Psychological Evaluation Form

Psychological, Personality and Aptitude Testing Services

Psychological Evaluation Form

Please complete and submit the form below to request a psychometric testing for an individual. Note: Parents and/or Guardian must fill out child consent form.

Dolly and Associates is pleased to prepare, identify, administer and interpret psychometric tests on your behalf. Please provide us with the following information. You can expect a response and quote normally within five business days. To best assist you, please fill in all fields. If you have any questions, please call us at 1-868-627-1845 or email [email protected]

9 DeVerteuil Street,
Woodbrook, Port Of Spain
Tel: 868-627-1845 / 625-7107
Client Identification
Is the Assessment for Adult or Child?*
Name of Person Completing this Form*
Prefix First Last
Please enter your name*
Prefix First Last
Relationship To Child*
Please define your relationship to the child*
Child's Name*
First Last
Child Age:*
Date of Birth*
DD slash MM slash YYYY
Family Child Is Currently Living With:*
Prefix First Last
Address Information
Address*
Street Address City Country
Email*
Phone*
Current Employment Status*
For How Long?*
Please provide child's educational background
Child's School Name*
Contact Person*
First Last
School Phone Number*
Grade Level*
Current Teacher(s) - Use + symbol to add more lines*
Preferred contact method to book appointment*
Best Time to Contact You*
Do we have your permission to leave you a message?
Referral Individual
Who referred you for psychological assessment?*
Please List Family Court Case #, if any
Referrer's Name*
Prefix First Last
Referrer's Email*
Referrer's Phone*
Is Child currently receiving services with another provider?*
Are you currently receiving services with another provider?*
Please provider name/agency*
Are you currently involved in any legal proceedings? (If so, please explain)*
Please describe the problems your child is now having, and what type of services you are seeking from us for these problems.*
Chief Complaint/Reason for Referral. Please describe your main reason(s) for seeking an assessment*
Please describe how this problem(s) interferes with your daily functioning. In what areas?*
History of chief complaint: Please describe how and when this problem(s) began. Be as specific as possible.*
Indicate Relationship of Parents/Guardians Living In The Home:*
Who has physical custody?*
- Mother
- Father
- Full Custody
- Joint Custody
Who has legal custody?
- Mother
- Father
- Full Custody
- Joint Custody
Mother's Name
First Last
Date of Birth
Please provide your professional and educational background
Occupation*
Employer*
Level of Education Attained*
Health Status
How would You Describe Your Health
Have you ever had work difficulties or trouble getting along with bosses or co-workers? (If so, please explain)*

Click + symbol to add more lines
How does your chief complaint relate to your work functioning?*

Click + symbol to add more lines
Have you been told that you had behavioral problems?
Did you get into physical fights?
Have you ever been suspended or expelled?
Have you had an assessment for any psychological condition?
By Whom*
When*
Diagnosis*
Note: if you have been evaluated previously, please provide a copy of the report.
Father's Name
First Last
Household Relationships
Does either parent’s job require him/her to be away from home long hours or extended periods? _*
How long have you been married?*
- Less than 1 Year
- 1 to 5 Years
- 5 to 10 Years
- More than 10 Years
How long have you been divorced/separated?*
- Less than 1 Year
- 1 to 5 Years
- 5 to 10 Years
- More than 10 Years
Has either parent been married before or since?*
Please list the name(s) of the stepparents
Prefix First Last
Provide dates of previous marriage(s), names, and ages of children from these marriages. Click + symbol to add more entries*
Date of Marriage Child's Name Child's Age Male or Female School
Is there a birth parent living outside the home*
Birth Parent Name*
Where do they live?*
How much contact does the child have with the parent not having custody, with stepsiblings, etc.?*
Name of Siblings
Name Age Relationship Living in Home (Y/N) School Grade
Please indicate any special needs of concerns regarding the other children living in your home:
Please indicate any concerns you have regarding the child for whom you are seeking services and these siblings relationship(s):
List any other people who currently, or in the child’s lifetime, have lived in your home.*
Name Age Relationship to Child # Years Living in Home From - To
Are there any other people that have a significant role in how this child is raised.*
Please identify and grade child's behavioral symptoms
Child Behavioural Problems
Attendance*
- Frequently absent
- Frequently tardy
- Unexplained gaps of time between classes
- Frequent attempts to excuse from class
- No attendance problems
Attitude*
- Mood changes from day to day
- Very defensive
- Sensitive/Feelings easily hurt
- Worries excessively
- Never satisfied with performance
Performance*
- Grades decreasing
- Assignments late
- Assignments poorly completed
- Not working up to potential/low motivation
- No performance problems
Self Control*
- Impatient/Difficulty waiting turn
- Outspoken/Often talks out
- Easily shifts from one activity to another
- Difficulty accepting change
Relating to Friends/Peers:*
- Challenges/Problems
- Overreacts to minor events
- Critical of others
- Withdraws from others
- Argumentative
Compliance:*
- Argumentative with others
- Defiant towards others/authority
- Often blames others for mistakes
- Often defensive or easily annoyed
- Excessively submissive to others
Please identify and grade child's behavioral symptoms*
Areas of Problem Behaviors Frequency of Behavior Intensity of Behavior
Schedule Appointment
Have you used our services before?*
Name of counselor you worked with previously?*
Do you have a preferred location for your appointment?*
- Woodbrrok
- Sangre Grande
- San Fernando
- Tobago
Briefly describe your issue in a few sentences:*
Patient's/Guardian Name*
Patient's/Guardian Signature*
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The Legal Stuff
Informed Consent For Psychological Services
Terms of Service
Informed Consent For Psychological Services

I hereby voluntarily apply for and consent to behavioral and/or psychological services by Dolly and Associates Ltd. This consent applies to myself, ward, or patient named below. Since I have the right to refuse services at any time, I understand and agree that my continued participation implies voluntary informed consent. I understand that the potential benefits of undergoing these services may include obtaining a professional opinion, reduction of my symptoms, and an increased understanding of myself, my family, and/or my child. I understand that potential risks may include predictive validity of assessments (when applicable), possible disagreement with the opinions offered to me, and possible emotional distress when addressing my situation. I understand that alternative procedures include services provided by another professional. I understand that I may ask for a referral to another professional if I am not satisfied with the progress of my treatment. I understand and agree that my disclosures and communications are considered privileged and confidential except to the extent that I authorize a release of information, or under certain other conditions – some of which are listed below: (1) where abuse or harmful neglect or children, the elderly, or disabled or incompetent individual is known or reasonably suspected; (2) where the validity of a will of a former patient is contested; (3) where such information is necessary for the professional to defend against a malpractice action brought by the client; (4) where such information is necessary for the professional/corporation to pursue payment for services rendered; (5) where an immediate threat of physical violence against a readily identifiable victim is disclosed to the professional; (6) where the client, by alleging mental or emotional damages in litigation, puts his/her mental state at issue; (7) pursuant to a Court order, open DCFS investigation, National Security Investigation or otherwise allowed or compelled under the law, and (8) where the client is examined pursuant to a court order. I hold Dolly and Associates Ltd. harmless for releasing information under the above conditions.
Agreement*
- I agree to the above Terms & Conditions
Date*
DD slash MM slash YYYY
Patient's/Guardian Signature

Please sign here

Save and Continue Later

Date of Marriage	Child's Name	Child's Age	Male or Female	School

Name	Age	Relationship	Living in Home (Y/N)	School	Grade

Name	Age	Relationship to Child	# Years Living in Home	From - To

Areas of Problem Behaviors	Frequency of Behavior	Intensity of Behavior

Psychological Evaluation Form

Psychological Evaluation Form

Client Identification

Address Information

Referral Individual

Health Status

Household Relationships

Child Behavioural Problems

Schedule Appointment

The Legal Stuff

Terms of Service