Neurobehavioral History Forms


The Neurobehavioral History forms are well reviewed and popular intake forms. They provide a comprehensive and organized method of gathering important clinical information that should be part of every assessment. These comprehensive forms are particularly critical in medico-legal situations where the thoroughness of your assessment should be documented. 

They are used to assess individuals with conditions such as brain injury, neurologic disease and developmental disorders and provide an excellent tool to thoroughly evaluate patient’s with mental health disorders as well. The forms make the initial part of your assessment efficient when they are mailed before the first appointment. 

The adult form is 12 pages and the child form is 8 pages. Short form versions (4 pages) are available for a rapid assessment of an adult or a child. 

Biological Family Medical History Grid Example from adult form

Sections (varies between adult and child forms):

  • Patient Demographics
  • Referral Information
  • Healthcare Providers
  • Presenting Problems
  • Medical History
  • Review of Systems
  • Seizures
  • Serious Injuries
  • Hospitalizations
  • Consultations and Tests
  • Pain
  • Mental Health History
  • Substance Use History
  • Life Stresses
  • Adverse Childhood Experiences
  • Early History
  • Education
  • Employment
  • Military
  • Family History (displayed above)
P.O. Box 594     Westtown, PA 19395        Phone: 610 566-0501       Fax: 610 566-0502     NEW email: