The Wake • Kendall Group PLLC
Psychological & Educational Services

CLIENT INFORMATION

Name of client _________________________________________ Date of Birth_____________________

Age __________ School ___________________________________________ Grade _______________

Referred by ___________________________________________________________________________

Parents' Names ________________________________________________________________________

Address - Street ___________________________________ Telephone ( _____ ) ___________________

City ___________________________________________ State ___________ Zip ___________________

Parent's occupation ____________________________ Employer ________________________________

Telephone - Home ____________________ Work ______________________ Cell ___________________

Parent's occupation ____________________________ Employer ________________________________

Telephone - Home ____________________ Work ______________________ Cell ___________________

Names and ages of siblings (and schools they attend)

________________________________ ________________________________

________________________________ ________________________________

________________________________ ________________________________

Statement of Concerns

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Medical History - Please give dates and names of practioners who performed the most recent:

Physical _________________________________________ Eye Exam ______________________

Psychological Evaluation ___________________________________________________________

Educational Evaluation _____________________________________________________________