Dr.

Dr. Rance Harbor

Guiding young minds toward well-being

info@ranceharbor.com

Guiding young minds toward balance, confidence, and emotional well-being

Phone: (813) 308-9075

Intake Form:

K12 Form
College Form

College Form

 Rance L. Harbor, Ph.D.
Initial Intake for Diagnostic Interview


    Client Information


    Current Concerns

    (check all that apply)

































































    College & University Information




    Current Status:





    Major/Minor

    Field/Discipline (i.e., Psychology, Finance, Premed, etc.)

    Start Semester (i.e., Spring 26)

    Major (s)

    Major (s)

    Minor (s)

    Minor (s)

    Total Credits:

    Overall GPA:

    Anticipated Graduation Date:

    Do you have an Accommodation Plan with the University?


    Have you been on Academic Probation or Suspension?


    Have you had a Psychological Evaluation administered in last 3 years?


    Have you attended any colleges before your current college?


    Current Class Schedule

    Day (s)

    Time Start

    Time End

    Course

    Estimated Grade

    Recreation & Hobbies At College

    Activity, Hobby, or Clubs

    How Active?

    Family Information

    Significant Family Members in the home

    First Name

    Last Name

    Relationship

    Age (Approximately)

    Individual Leisure Interests (Free Time)

    Activity

    How Enjoyable?

    How Often?

    Family Activities

    Activity

    How Enjoyable?

    How Often?

    Developmental History

    Childhood Concerns


    Health Issue/Diagnosis

    Age of Onset

    Health Condition/Diagnosis

    Age of Onset

    Medical History

    Provider Information

    Specialty

    Name

    Date Last Visit

    Current Diagnoses

    Medical or Mental Health Diagnosis

    Initial Date

    How Serious

    None

    Some

    Moderate

    Very

    1234

    1234

    1234

    1234

    All Current Medications

    Name

    Dosage

    Estimated Date Began

    Brief Reason

    Outpatient Treatment

    Any Medical or Mental Health Outpatient Therapy?

    Dates

    Provider

    Hospitalizations

    Any Medical or Mental Health Hospitalizations

    Initial Date

    How Serious

    Mild

    Some

    Moderate

    Severe

    1234

    1234

    1234

    1234

    Education Information

    K-12 SCHOOL INFORMATION






    Did you have a 504, SSP, or any Accommodation Plan at your last school?


    Did you have an Individualized Special Education Plan (IEP) at your last school?


    Did you have any history of Discipline concerns?


    Did you have any history of Attendance concerns?


    Did you have any School Based or IEP Counseling?


    Have you had a Psychological Evaluation administered in last 3 years?


    Did you attend any Tutoring (at your school or outside of school)?


    Did you have any AP, AICE, or Dual Enrollment Classes in High School?


    High School History

    Grades (9-12)

    Year (2026-27, 2027-28)

    School Name

    City, State

    Average GPA

    Additional Information & Supporting Documents

    Please share any additional background or current status information here.

    Please attach any reports, transcripts, accommodation plans, letters or any additional supporting documents here

    Thank You!

    Your application and files have been successfully submitted. We will review your submission and get back to you shortly.