Neuropsychological Intake Form

Neuropsychological Intake Form

Medical History

Neurological Problems


Current Medical Problems

If you filled out another form given to you by DBH with this same info, you can skip this section.

Current Medications

Diagnostic Tests

(MRI, CT, PETscan, EEG, MEG, etc)

Cognitive Rehabilitation Therapy

(Speech Therapy or Occupational Therapy)

Relevant Family History

Social and Education History



Graduate School


Any negative employment evaluations:

Substance Use/Abuse

How many years?
(e.g., 1 pack/day)

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