Dr. Rance Harbor, Ph.D.

Date Form Completed:

Client Information

Client Name:

DOB:

Gender:

Age:

Primary Address:

City:

Zipcode:

Cell Phone:

Email Address:

Primary Business Contact

Scheduling Contact

Name:

Phone:

Email Address:

The Scheduler and the Billing contact are the same

Billing Contact

Name:

Phone:

Email Address:

Current Concerns

(check all that apply)

Sadness and/or Depression
Grief Issues
Social Anxiety
Performance Anxiety
Test Anxiety
Frustration and/or stress
Difficulty falling asleep and/or remaining asleep
Difficulty waking in the morning
Difficulty with eating

Reading
Math
Written Language/Spelling

Vaping
Tobacco use
Marijuana use
Alcohol use
Prescription Drug abuse

Anger Management Difficulties - Verbal
Anger Management Difficulties - Physical
Difficulty with Authority
Argumentative
Oppositional
Not following rules at home
Not following rules at school
Difficulty getting along with parents
Difficulty getting along with peers
Difficulty getting along with siblings
Homework
Classwork
Arriving home on Time
Planning and Organization

Group Projects
Presentations/Projects

Difficulty completing group projects
Difficulty with Presentations projects

Attention/Focus
Hyperactivity
Easily Distracted

Test Taking
Poor Test Taking

Poor Long-Term Retrieval Memory
Poor Short-Term Memory

Poor school attendance

Poor/Low Self-esteem

Remaining on Task
Starting a Task/Assignment
Completing a Task/Assignment
Excessive energy
Impulsivity
Bloodwork/Shots

Skipping classes
School Discipline History
Difficulty with Teachers
Difficulty with Administrators
Disassembles/Steals
Leaving on Time for School or Events

Only Online/Virtual Friends
Watching TV
Video Games (Computer/Xbox/PS4, etc.)
Tablet/Phone Games

Social Media
YouTube
TikTok
Other

Texting
Facetime
Phone Conversations

Time alone in Room
Stealing from parents/family/others

Other

Family Information

Significant Family Members Living with Client

First Name

Last Name

Lives with Client Full/Part Time

Phone

Email Address

Significant Family Members Not Living with Client

First & Last Name

Relationship

Age

Individual Leisure Interests (Free Time)

Activity: Reading, Listening to Music, Playing Instrument, Crafts Drawing/Painting, Writing, Yoga, Gym, Running, etc.

How Enjoyable?

How Often?

Family Activities

Activity: Table-Top Games, Video Games, TV, Movies, Concerts, Fishing, Hiking, Camping, Skiing, Tennis, Pickle Ball, Cooking

How Enjoyable?

How Often?

Developmental History

Prenatal Health History

No Complications
Complications include:

Health Condition/Diagnosis

Trimester Identified

Health Condition/Diagnosis

Trimester Identified

Alcohol Use

1
2
3

Rh Incompatibility

1
2
3

Fetal Disease

1
2
3

Rx Drug Use

1
2
3

Gestational Diabetes

1
2
3

Type I Diabetes

1
2
3

Hypertension

1
2
3

Type II Diabetes

1
2
3

Infections

1
2
3

Tobacco Use

1
2
3

Low Oxygen

1
2
3

Toxemia

1
2
3

Non-Rx Drug Use

1
2
3

Other:

1
2
3

Spinal Disease

1
2
3

Other:

1
2
3

Pregnancy

No Complications
Complications include:

Health Issue/Diagnosis

Age of Onset

Health Issue/Diagnosis

Age of Onset

Asphyxia/NIB (No Oxygen)

Low Apgar Score

Anoxia

Premature Birth

Breech Delivery

Neonatal Asphyxia

Failure to Progress

Placenta Previa

Forceps

Rapid Labor

Hemorrhage

Respiratory Distress Syndrome

Incubator Care

Nuchal Cord (Umbilical)

Jaundice

Uterine Rupture

Late Term/Post Term

Other:

Low Birth Weight

Other:

Childhood Concerns

No Significant Health Issues
Significant Health issues:

Health Issue/Diagnosis

Age of Onset

Health Condition/Diagnosis

Age of Onset

ADHD

Fetal Alcohol Syndrome

Allergies

Gastrointestinal Difficulties

Asthma

Head Injury

Autism (ASD)

Hepatitis

Brain Tumor

Loss of Consciousness

Cancer

Meningitis

Convulsions

Seizures

COVID-19

Sickle Cell Anemia

Diabetes

Strep Throat

Ear Infections

Tic Disorder

Epilepsy

Other:

Failure to Thrive

Other:

Medical History

Provider Information

Specialty

Name

Date Last Visit

Health Screening

Topic

Yes / No

If Yes, Date of Most Recent

Outcome

Yes
No

PassedNeeds Assistance

Yes
No

PassedNeeds Assistance

Yes
No

PassedNeeds Assistance

Current Diagnoses

Medical or Mental Health Diagnosis

Initial Date

How Serious

None

Some

Moderate

Very

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

Education Information

K-12 SCHOOL INFORMATION

Name of School Last Attended

City:

County:

Current Grade Level:

Repeated Any Grades?

Skipped Any Grades:

School Counselor:

ESE/Special Education Coordinator:

Does your child have a 504, SSP, or any Accommodation Plan at their last school?

Yes
No

Does your child have an Individualized Special Education Plan (IEP)?

Yes
No

Does your child have any history of Discipline concerns?

Yes
No

Does your child have any history of Attendance concerns?

Yes
No

Does your child have any School Based or IEP Counseling?

Yes
No

Has your child had a Psychological Evaluation administered in last 3 years?

Yes
No

Does your child attend any Tutoring (at school or outside of school)?

Yes
No

Does your child have any AP, AICE, or Dual Enrollment Classes in High School?

Yes
No

SCHEDULE

Period

Course

Teacher

Estimated Current Grade

School Related Extra-Curricular

Activity, Hobby, or Clubs

Instructor/Coach/Sponsor

How Active?

Non-School Related Extra-Curricular

Activity, Hobby, or Clubs

Instructor/Coach/Sponsor

How Active?

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

+ Attach Document or Note

Dr.

Dr. Rance Harbor

Intake Form:

K12 Form

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

Client Information

Primary Business Contact

Scheduling Contact

Billing Contact

Current Concerns

Family Information

Significant Family Members Living with Client

Significant Family Members Not Living with Client

Individual Leisure Interests (Free Time)

Family Activities

Developmental History

Prenatal Health History

Pregnancy

Childhood Concerns

Medical History

Provider Information

Health Screening

Current Diagnoses

All Current Medications

Outpatient Treatment

Hospitalizations

Education Information

K-12 SCHOOL INFORMATION

SCHEDULE

School Related Extra-Curricular

Non-School Related Extra-Curricular

Additional Information & Supporting Documents

Dr.

Dr. Rance Harbor

Intake Form:

K12 Form

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

Client Information

Primary Business Contact

Scheduling Contact

Billing Contact

Current Concerns

Family Information

Significant Family Members Living with Client

Significant Family Members Not Living with Client

Individual Leisure Interests (Free Time)

Family Activities

Developmental History

Prenatal Health History

Pregnancy

Childhood Concerns

Medical History

Provider Information

Health Screening

Current Diagnoses

All Current Medications

Outpatient Treatment

Hospitalizations

Education Information

K-12 SCHOOL INFORMATION

SCHEDULE

School Related Extra-Curricular

Non-School Related Extra-Curricular

Additional Information & Supporting Documents

Thank You!

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