Form: New Patient Registration | Pro Psychology Group

1 Orchard Road, Suite 100. Lake Forest, CA. 92630

Child's Name

Address

Parent’s or Guardian’s Home Phone

Parent’s or Guardian’s Work Phone

SPATIAL SKILLS

Confusion telling right from left

Has difficulty with puzzles

Problems drawing or copying

Doesn’t know his/her colors

Difficulty dressing (not due to physical difficulty)

Problems finding his/her way around places he/she has been to before

Difficulty recognizing objects

Seems unable to recognize facial or body expressions of disapproval or emotions

Gets lost easily

PROBLEM SOLVING

Confusion telling right from left

Has difficulty with puzzles

Problems drawing or copying

Doesn’t know his/her colors

Difficulty dressing (not due to physical difficulty)

Problems finding his/her way around places he/she has been to before

Difficulty recognizing objects

Seems unable to recognize facial or body expressions of disapproval or emotions

Gets lost easily

SPEECH, LANGUAGE, AND MATH SKILLS

Confusion telling right from left

Has difficulty with puzzles

Problems drawing or copying

Doesn’t know his/her colors

Difficulty dressing (not due to physical difficulty)

Problems finding his/her way around places he/she has been to before

Difficulty recognizing objects

Seems unable to recognize facial or body expressions of disapproval or emotions

Gets lost easily

SPEECH, LANGUAGE, AND MATH SKILLS

Confusion telling right from left

Has difficulty with puzzles

Problems drawing or copying

Doesn’t know his/her colors

Difficulty dressing (not due to physical difficulty)

Problems finding his/her way around places he/she has been to before

Difficulty recognizing objects

Seems unable to recognize facial or body expressions of disapproval or emotions

Gets lost easily

SPEECH, LANGUAGE, AND MATH SKILLS

Confusion telling right from left

Has difficulty with puzzles

Problems drawing or copying

Doesn’t know his/her colors

Difficulty dressing (not due to physical difficulty)

Problems finding his/her way around places he/she has been to before

Difficulty recognizing objects

Seems unable to recognize facial or body expressions of disapproval or emotions

Gets lost easily

NEW PATIENT REGISTRATION FORM

Barbra McDowell, Ph.D.
Professional Psychology Group, Inc.

Pediatric Neuropsychology
Clinical Psychologist
PSY 15622

NEW PATIENT REGISTRATION FORM

Barbra McDowell, Ph.D. Professional Psychology Group, Inc.

Pediatric Neuropsychology Clinical Psychologist PSY 15622

Barbra McDowell, Ph.D.
Professional Psychology Group, Inc.

Pediatric Neuropsychology
Clinical Psychologist
PSY 15622