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Trainee Information
Trainee Name
Trainer
Date of Birth
Date
Sex
Male
Female
Personal Information
Trainee grew up in (check all that apply)
Birth Family
Adoptive Family
Foster Family
Number of Siblings (including trainee)
- Select a value -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Trainee's place in family birth order.
- Select a value -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Is there a history of?
Separated from birth mother < age 2
Distant or absent parents early in life
Neglect
Abuse
other
Other Trauma
Schooling completed
- Select a value -
None
Some school
High School
Undergraduate degree
Graduate degree
Graduate degree
Occupation
Which is the trainee's dominant hand?
- Select a value -
Left hand
Right hand
Some of each
Medications
Antidepressants
- Select a value -
0
1
2
3
4
5
>5
Anti-anxiety
- Select a value -
0
1
2
3
4
5
>5
Anticonvulsants
- Select a value -
0
1
2
3
4
5
>5
Antipsychotics
- Select a value -
0
1
2
3
4
5
>5
Stimulants
- Select a value -
0
1
2
3
4
5
>5
Mood stabilizers
- Select a value -
0
1
2
3
4
5
>5
Do you now or have you in the past drunk alcoholic beverages?
- Select a value -
Occasionally in the past
Regularly in the past but no longer
Currently drink
No
Alcohol Frequency
- Select a value -
1-12 x/year
1-4 x/month
1-2 x/week
3-4 x/week
>3-4 x/week
Do you now or have you in the past used recreational drugs?
- Select a value -
Yes, experimented in the past
Yes, used regularly in the past but no longer
Currently use
No
Recreational Drugs Frequency
- Select a value -
1-12 x/year
1-4 x/month
1-2 x/week
3-4 x/week
>3-4 x/week
Conditions
Have you sustained a head injury?
- Select a value -
Yes, with loss of consciousness
Yes, with symptoms following injury
Yes, multiple times
No
Do you now or have you ever had seizures?
- Select a value -
Had in the past, no longer have them
Currently have, controlled by medication
Currently have, uncontrolled
No
Check applicable boxes below
Autistic spectrum
Nonverbal
Language delay
Parkinson's disease
Please list any drugs (prescribed or recreational) regularly taken or leave blank.
Physical
Autonomic
Migraines
0
1
2
3
4
5
Not a problem
Must change
Irritable bowel
0
1
2
3
4
5
Not a problem
Must change
Panic Attacks
0
1
2
3
4
5
Not a problem
Must change
Allergies or asthma
0
1
2
3
4
5
Not a problem
Must change
Tinnitus
0
1
2
3
4
5
Not a problem
Must change
Cold hands/feet
0
1
2
3
4
5
Not a problem
Must change
Dull chronic pains
0
1
2
3
4
5
Not a problem
Must change
Tics/involuntary movements or vocalizations
0
1
2
3
4
5
Not a problem
Must change
Tremors
0
1
2
3
4
5
Not a problem
Must change
Experiences racing heartbeat
0
1
2
3
4
5
Not a problem
Must change
Sharp shooting pains
0
1
2
3
4
5
Not a problem
Must change
Fibromyalgia
0
1
2
3
4
5
Not a problem
Must change
Chronically fatigued
0
1
2
3
4
5
Not a problem
Must change
Hot flashes or chills
0
1
2
3
4
5
Not a problem
Must change
Sensitivity to touch or light or sound
0
1
2
3
4
5
Not a problem
Must change
Closes off to sensory awareness
0
1
2
3
4
5
Not a problem
Must change
Does not like to be touched or held
0
1
2
3
4
5
Not a problem
Must change
Sleep
Has trouble falling asleep
0
1
2
3
4
5
Not a problem
Must change
Wakes often during the night
0
1
2
3
4
5
Not a problem
Must change
Hard to awaken/never feel rested
0
1
2
3
4
5
Not a problem
Must change
Wakes at night and can't sleep again
0
1
2
3
4
5
Not a problem
Must change
Moves around a lot while sleeping
0
1
2
3
4
5
Not a problem
Must change
Grinds teeth in sleep
0
1
2
3
4
5
Not a problem
Must change
Wets the bed
0
1
2
3
4
5
Not a problem
Must change
Sleep walks
0
1
2
3
4
5
Not a problem
Must change
Nightmares or night terrors
0
1
2
3
4
5
Not a problem
Must change
Night sweats
0
1
2
3
4
5
Not a problem
Must change
Social
Social
Misses cues in social situations
0
1
2
3
4
5
Not a problem
Must change
Difficulty forming or sustaining relationships
0
1
2
3
4
5
Not a problem
Must change
Misses non-verbal meaning of communication
0
1
2
3
4
5
Not a problem
Must change
Inability to feel others' emotions
0
1
2
3
4
5
Not a problem
Must change
Needs to be the center of attention
0
1
2
3
4
5
Not a problem
Must change
Does not accept authority
0
1
2
3
4
5
Not a problem
Must change
Argumentative
0
1
2
3
4
5
Not a problem
Must change
Inappropriate social interactions/behaviors
0
1
2
3
4
5
Not a problem
Must change
Poor eye contact
0
1
2
3
4
5
Not a problem
Must change
Issues related to mood
Stress
Overreacts to pressure
0
1
2
3
4
5
Not a problem
Must change
Can't quiet the mind
0
1
2
3
4
5
Not a problem
Must change
Speaks very fast
0
1
2
3
4
5
Not a problem
Must change
Talks excessively
0
1
2
3
4
5
Not a problem
Must change
Expects perfection of self/others
0
1
2
3
4
5
Not a problem
Must change
Physically tense
0
1
2
3
4
5
Not a problem
Must change
Speaks quietly or slowly
0
1
2
3
4
5
Not a problem
Must change
Frequent tension headaches
0
1
2
3
4
5
Not a problem
Must change
Anxiety
Often worried/anxious
0
1
2
3
4
5
Not a problem
Must change
Relatively constant anxiety
0
1
2
3
4
5
Not a problem
Must change
Tends to expect the worst
0
1
2
3
4
5
Not a problem
Must change
Judges self negatively
0
1
2
3
4
5
Not a problem
Must change
Shy or withdrawn in social situations
0
1
2
3
4
5
Not a problem
Must change
Trembling/twitching/shakiness
0
1
2
3
4
5
Not a problem
Must change
Feels on edge
0
1
2
3
4
5
Not a problem
Must change
Easily startled
0
1
2
3
4
5
Not a problem
Must change
Avoids places where he/she might be anxious
0
1
2
3
4
5
Not a problem
Must change
Frequent thoughts of danger
0
1
2
3
4
5
Not a problem
Must change
Sees self as unable to cope
0
1
2
3
4
5
Not a problem
Must change
Thoughts of something terrible happening
0
1
2
3
4
5
Not a problem
Must change
Depression
Energy levels are low
0
1
2
3
4
5
Not a problem
Must change
Feels helpless or hopeless
0
1
2
3
4
5
Not a problem
Must change
Cries easily
0
1
2
3
4
5
Not a problem
Must change
Apathetic or indifferent
0
1
2
3
4
5
Not a problem
Must change
Flat emotional response to positive events
0
1
2
3
4
5
Not a problem
Must change
Seems lazy
0
1
2
3
4
5
Not a problem
Must change
Weight loss or gain
0
1
2
3
4
5
Not a problem
Must change
Decreased sexual desire
0
1
2
3
4
5
Not a problem
Must change
Easily tired
0
1
2
3
4
5
Not a problem
Must change
Trouble swallowing/lump in the throat
0
1
2
3
4
5
Not a problem
Must change
Less interest or pleasure in usual activities
0
1
2
3
4
5
Not a problem
Must change
Withdraws from or avoids people
0
1
2
3
4
5
Not a problem
Must change
Finds it harder than usual to do things
0
1
2
3
4
5
Not a problem
Must change
Sees self as worthless
0
1
2
3
4
5
Not a problem
Must change
Difficulty making decisions
0
1
2
3
4
5
Not a problem
Must change
Suicidal thoughts or plans
0
1
2
3
4
5
Not a problem
Must change
Recurrent thoughts of death
0
1
2
3
4
5
Not a problem
Must change
Low self esteem
0
1
2
3
4
5
Not a problem
Must change
Self-critical thoughts
0
1
2
3
4
5
Not a problem
Must change
Feels guilty or ashamed
0
1
2
3
4
5
Not a problem
Must change
Anger
Has an explosive temper
0
1
2
3
4
5
Not a problem
Must change
Explosive emotional reactions to minor events
0
1
2
3
4
5
Not a problem
Must change
Irritable/impatient
0
1
2
3
4
5
Not a problem
Must change
Reacts with physical violence
0
1
2
3
4
5
Not a problem
Must change
Feels bitter/negative
0
1
2
3
4
5
Not a problem
Must change
Anger outbursts after slow build-up
0
1
2
3
4
5
Not a problem
Must change
Easily agitated
0
1
2
3
4
5
Not a problem
Must change
Aggressive anger or irritability
0
1
2
3
4
5
Not a problem
Must change
Outbursts of rage without cause
0
1
2
3
4
5
Not a problem
Must change
Perceives events negatively
0
1
2
3
4
5
Not a problem
Must change
Fear
Often afraid
0
1
2
3
4
5
Not a problem
Must change
Paranoid thoughts
0
1
2
3
4
5
Not a problem
Must change
Afraid in situations when others are not
0
1
2
3
4
5
Not a problem
Must change
Issues related to cognition
Attention
Drifts off into thoughts when working
0
1
2
3
4
5
Not a problem
Must change
Easily distracted from tasks
0
1
2
3
4
5
Not a problem
Must change
Puts off starting assigned tasks
0
1
2
3
4
5
Not a problem
Must change
Doesn't finish assigned tasks until the deadline
0
1
2
3
4
5
Not a problem
Must change
Can't finish assigned tasks
0
1
2
3
4
5
Not a problem
Must change
Difficulty completing tasks with multiple steps
0
1
2
3
4
5
Not a problem
Must change
Works very slowly to be sure things are right
0
1
2
3
4
5
Not a problem
Must change
Self-Control
Stubborn
0
1
2
3
4
5
Not a problem
Must change
Acts/speaks impulsively
0
1
2
3
4
5
Not a problem
Must change
Speaks quickly or loudly or interrupts
0
1
2
3
4
5
Not a problem
Must change
Impatient/seeks stimulation/easily bored
0
1
2
3
4
5
Not a problem
Must change
Tends to have quick emotional responses
0
1
2
3
4
5
Not a problem
Must change
Fidgety/restless/hyperactive
0
1
2
3
4
5
Not a problem
Must change
Handwriting is sloppy
0
1
2
3
4
5
Not a problem
Must change
Tends to be clumsy/accident prone
0
1
2
3
4
5
Not a problem
Must change
Can't control use of substances
0
1
2
3
4
5
Not a problem
Must change
Driven to repetitive/compulsive behaviors
0
1
2
3
4
5
Not a problem
Must change
Rigid thought; gets stuck on an idea
0
1
2
3
4
5
Not a problem
Must change
Phobias or irrational fears
0
1
2
3
4
5
Not a problem
Must change
Obsessive thoughts or fears
0
1
2
3
4
5
Not a problem
Must change
Addictive behaviors
0
1
2
3
4
5
Not a problem
Must change
Oppositional/defiant
0
1
2
3
4
5
Not a problem
Must change
Dominant or demanding in relationships
0
1
2
3
4
5
Not a problem
Must change
Argues frequently; doesn't give in
0
1
2
3
4
5
Not a problem
Must change
Eating disorders
0
1
2
3
4
5
Not a problem
Must change
Eats too little
0
1
2
3
4
5
Not a problem
Must change
Eats too much
0
1
2
3
4
5
Not a problem
Must change
Holds a grudge or dislikes change
0
1
2
3
4
5
Not a problem
Must change
Self injury/cutting
0
1
2
3
4
5
Not a problem
Must change
Pulls out hair
0
1
2
3
4
5
Not a problem
Must change
Inappropriate sexual behavior
0
1
2
3
4
5
Not a problem
Must change
Creativity
Concrete thinking
0
1
2
3
4
5
Not a problem
Must change
Doesn't do well with tasks involving novelty
0
1
2
3
4
5
Not a problem
Must change
Avoids creative tasks
0
1
2
3
4
5
Not a problem
Must change
Doesn't enjoy fiction, arts
0
1
2
3
4
5
Not a problem
Must change
Has difficulty seeing context
0
1
2
3
4
5
Not a problem
Must change
Learning
Has a hard time listening for detail
0
1
2
3
4
5
Not a problem
Must change
Has a hard time reading for detail
0
1
2
3
4
5
Not a problem
Must change
Rushes tasks; makes silly mistakes
0
1
2
3
4
5
Not a problem
Must change
Makes careless math errors
0
1
2
3
4
5
Not a problem
Must change
Can't get math concepts
0
1
2
3
4
5
Not a problem
Must change
Doesn't stay on track when speaking/writing
0
1
2
3
4
5
Not a problem
Must change
Reverses letters/numbers
0
1
2
3
4
5
Not a problem
Must change
Dyslexia
0
1
2
3
4
5
Not a problem
Must change
Stutters
0
1
2
3
4
5
Not a problem
Must change
Memory
Quickly forgets what is read/heard
0
1
2
3
4
5
Not a problem
Must change
Quickly forgets tasks or learned material
0
1
2
3
4
5
Not a problem
Must change
Can't remember past events
0
1
2
3
4
5
Not a problem
Must change
Forgets faces/names
0
1
2
3
4
5
Not a problem
Must change
Old memories keep intruding into thoughts
0
1
2
3
4
5
Not a problem
Must change
Cannot recall periods of time from the past
0
1
2
3
4
5
Not a problem
Must change
Thinking
Hyperfocuses or has difficulty changing tasks
0
1
2
3
4
5
Not a problem
Must change
Difficulty balancing multiple tasks or assignments
0
1
2
3
4
5
Not a problem
Must change
Highly detail oriented or structured
0
1
2
3
4
5
Not a problem
Must change
Productive but gets worn down by workload
0
1
2
3
4
5
Not a problem
Must change
Hears voices inside head
0
1
2
3
4
5
Not a problem
Must change
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