ADHD Child Assessment Intake Form
Child Information
Full Name
Date of Birth
Age
Gender
School Name
Grade
Parent / Guardian Information
Parent/Guardian Name
Relationship to Child
Contact Number
Email
Referral Information
Referred By
Reason for Referral
Medical & Developmental History
Primary Concerns/Presenting Problems
Past Medical or Psychological Diagnoses
Medications Currently Taken
Allergies
Significant Medical History
Developmental Milestones
Were there any difficulties during pregnancy, birth, or infancy?
At what age did your child reach major milestones (e.g., sitting, walking, speaking)?
Family History
Any family history of ADHD or related conditions?
Other relevant family medical or psychological history
Current Issues & Concerns
Describe current behavioral, emotional, or academic concerns
When did these concerns begin?
What strategies have you tried?
Strengths or positive qualities