Intake Form for Neurofeedback Patients
Linda Cooke, LCSW
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
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Angola
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Burundi
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Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
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Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Cell Phone
-
Area Code
Phone Number
Landline Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
E-mail
Handedness
Left
Right
Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Parent/Guardian of minor information (if applicable)
Name(s)
Primary Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Cell phone
-
Area Code
Phone Number
Cell phone #2 (optional)
-
Area Code
Phone Number
Landline phone
-
Area Code
Phone Number
Work phone
-
Area Code
Phone Number
Referral source info (if referred to this office by someone other than yourself)
Referral source phone
-
Area Code
Phone Number
Physician/other health care professional information
Health professional's name
Phone Number
-
Area Code
Phone Number
Diagnosis
Medication Information
(complete as applicable)
Please list your current medications, doses, frequency of doses, and length of time you've used each medication
Briefly list other approaches you have tried for this condition (medication, behavior therapy, counseling, alternative medicine, etc.)
What benefits do you hope to gain from neurofeedback?
DEVELOPMENTAL HISTORY
Please indicate your (or your child's) history in relation to the following:
Prenatal History
Prenatal stress or injury
Yes
No
Unknown
Prenatal drug/alcohol exposure
Yes
No
Unknown
Birth Trauma (forceps, breach, etc)
Yes
No
Unknown
Anesthesia, pain, medications
Yes
No
Unknown
Premature/Late delivery
Yes
No
Unknown
Anoxia (oxygen deprivation at birth)
Yes
No
Unknown
Medical problems after birth
Yes
No
Unknown
Details
Birth weight
Adopted at age
Growth and development
Activity Level
Typical
More
Less
Details
Motor/coordination development
Typical
More
Less
Details
Infections/allergies
Typical
More
Less
Details
Emotional Development
Typical
More
Less
Details
Handedness Development
Typical
More
Less
Details
Behavioral Concerns
Typical
More
Less
Details
Appetite/digestion
Typical
More
Less
Details
Language/speech development
Typical
More
Less
Details
Head injury (even minor falls, etc)
Yes
No
Unknown
Details
Coma (loss of consciousness)
Yes
No
Unknown
Details
Accidents
Yes
No
Unknown
Details
High fever
Yes
No
Unknown
Details
Serious illness
Yes
No
Unknown
Details
Surgery
Yes
No
Unknown
Details
CNS infection
Yes
No
Unknown
Details
Sexual abuse
Yes
No
Unknown
Details
Physical abuse
Yes
No
Unknown
Details
Emotional/psychological abuse
Yes
No
Unknown
Details
Drug overdose/poisoning
Yes
No
Unknown
Details
Anoxia
Yes
No
Unknown
Details
Stroke
Yes
No
Unknown
Details
Pschological stress/life changes
Death in family
Yes
No
Unknown
Details
Divorce/remarriage
Yes
No
Unknown
Details
Move/relocation
Yes
No
Unknown
Details
Job change
Yes
No
Unknown
Details
Family member chronic illiness
Yes
No
Unknown
Details
Alcoholism/drug addiction in family
Yes
No
Unknown
Details
SYMPTOM CHECKLIST
Please indicate if the client and/or family members (parents, grandparents, siblings, aunts/uncles, children) currently experience or have history of any of the following symptoms. Check all that apply.
Feeling Tense
Current Self
Current Family
History Self
History Family
Depressed
Current Self
Current Family
History Self
History Family
Always on the go
Current Self
Current Family
History Self
History Family
School/work problems
Current Self
Current Family
History Self
History Family
Impulsivity
Current Self
Current Family
History Self
History Family
Hyperactivity
Current Self
Current Family
History Self
History Family
Attention problems
Current Self
Current Family
History Self
History Family
Behavior problems
Current Self
Current Family
History Self
History Family
Sleep problems
Current Self
Current Family
History Self
History Family
Legal trouble
Current Self
Current Family
History Self
History Family
Headaches
Current Self
Current Family
History Self
History Family
Feeling anxious
Current Self
Current Family
History Self
History Family
Tremors
Current Self
Current Family
History Self
History Family
Suicidal ideas
Current Self
Current Family
History Self
History Family
PMS
Current Self
Current Family
History Self
History Family
Phsycial/sexual abuse
Current Self
Current Family
History Self
History Family
Over-ambition
Current Self
Current Family
History Self
History Family
Unable to relax
Current Self
Current Family
History Self
History Family
Can't make decisions
Current Self
Current Family
History Self
History Family
Communication problems
Current Self
Current Family
History Self
History Family
Problems at home
Current Self
Current Family
History Self
History Family
Financial problems
Current Self
Current Family
History Self
History Family
Any chronic illness
Current Self
Current Family
History Self
History Family
Feeling lonely
Current Self
Current Family
History Self
History Family
Frequent illness
Current Self
Current Family
History Self
History Family
Repetitive thoughts
Current Self
Current Family
History Self
History Family
Shy with people
Current Self
Current Family
History Self
History Family
Allergies
Current Self
Current Family
History Self
History Family
Asthma
Current Self
Current Family
History Self
History Family
Seizures
Current Self
Current Family
History Self
History Family
Chronic pain
Current Self
Current Family
History Self
History Family
Food sensitivity
Current Self
Current Family
History Self
History Family
Head injury
Current Self
Current Family
History Self
History Family
Memory Problems
Current Self
Current Family
History Self
History Family
Temper tantrums
Current Self
Current Family
History Self
History Family
Rages
Current Self
Current Family
History Self
History Family
Verbal aggression
Current Self
Current Family
History Self
History Family
Physical aggression
Current Self
Current Family
History Self
History Family
Stubbornness
Current Self
Current Family
History Self
History Family
Addictions
Current Self
Current Family
History Self
History Family
Bowel disturbances
Current Self
Current Family
History Self
History Family
Chronic fatigue/FMS
Current Self
Current Family
History Self
History Family
Inferiority feelings
Current Self
Current Family
History Self
History Family
Dizziness
Current Self
Current Family
History Self
History Family
Fainting spells
Current Self
Current Family
History Self
History Family
Heart palipitations
Current Self
Current Family
History Self
History Family
Stomach trouble
Current Self
Current Family
History Self
History Family
Poor appetite
Current Self
Current Family
History Self
History Family
Picky eater
Current Self
Current Family
History Self
History Family
Nightmares
Current Self
Current Family
History Self
History Family
Alcohol/Drug problem
Current Self
Current Family
History Self
History Family
Feeling panicky
Current Self
Current Family
History Self
History Family
Migraine headaches
Current Self
Current Family
History Self
History Family
Tension headaches
Current Self
Current Family
History Self
History Family
Other symptoms not included in above list (please specify)
Please list the FIVE current problems listed above which are the most distressing to you or your child
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