Personal Growth Better Quality of Life Reduced Stress Parent Questionnaire Date* MM slash DD slash YYYY HiddenAll information on this form is considered strictly confidential within the guidelines of the clinic. All information on this form is considered strictly confidential within the guidelines of the clinic.Child's First Name* Child's Last Name* DOB* MM slash DD slash YYYY Age* Your Name* Relationship to Client* How did you hear about us? Insurance Friend / Family Web / Social Media Newspaper Other Please describe the reason for this visit to our clinic:How distressing is this issue for the child? (on a scale of 1-10, with 1=not distressing, 10=most distressing): HiddenInstructionsPlease indicate how this has affected the child’s ability to function: Please indicate how this has affected the child’s ability to function:In Daily Life Not at All Minimally Moderately Significantly/Severely Academically Not at All Minimally Moderately Significantly/Severely Interpersonally/Socially Not at All Minimally Moderately Significantly/Severely Within the Family Not at All Minimally Moderately Significantly/Severely How long has the child been experiencing distress about this issue?What resources do you feel the child has to help them work through this issue?Symptoms and Issues you have ObservedPlease Select all that apply Anxious, worried Attitude issues Anger, aggression, or violence Bored Bullying by others Bullying to others Confused Cutting, burning, or hurting of self Counting or ordering of things Concentration of focus issues Conflicts with adults (parents, teachers, etc) Conflicts with others (friends, other kids) Crying or tearful Depressed Mood Difficulty being alone Disorganized Drug or alcohol issues Easily distracted Easily irritated Fatigued or tired often Fears (monsters, snakes, people, etc.) Guilt feelings/shame Hyperactive Impulsive Legal issues Living arrangement issues Lying frequently Lonely Money Issues Mood swings Motivation reduced or absent Overly worried about germs, organization Panic attacks Perfectionism Physical problems (stomach, headache) Self-esteem low Sexual identity concerns Sexual issues School or employment issues Shy or uneasy around others Unassertive Unwanted behaviors or thoughts Withdrawn or alone too much Symptoms and Issues continuedEnergy Levels Too much energy (beyond what is developmentally appropriate) Too little energy Sleep Problems Trouble falling asleep Trouble staying asleep Trouble sleeping too much/too little Eating Habits Binging (eating much more than is needed, or is normal, in a specific time period) Purging (making self vomit after eating) Restricting (not eating enough or not eating at all) Overeating (consistently, over time) Using laxatives to control weight Weight Changes Increase Decrease Please describe:Behavior Problems At Home At School/After school At Work With Friends/In social settings Background Information(Please provide information for the person who is being seen.)HiddenInstructions(Please provide information for the person who is being seen.)HiddenBiological/Adoptive Parents:Biological/Adoptive Parents:Name Age Education Occupation Dates of marriage and/or divorce for biological/adoptive parents: If the child is adopted or a foster placement, please answer the following: N/A If a kinship or relative adoption, what is your relationship to the child? When did the child join your family? What were the circumstances of the adoption/placement?If the placement is temporary, when is the child expected to return home? Does the child have contact with his/her biological parents? Yes No If yes, please explain:If the child was adopted from another country, please list the country of origin. Please describe any details about the situation the child was in prior to adoption.SiblingIndicate if A (adoptive), H (half), S (step) N/A HiddenInstructionsPlease fill out the Name, Age, Grade/Education and Physical Emotional Health History of each of your siblings in the corresponding fields below. Indicate if A (adoptive), H (half), S (step)NameAgeGrade/EducationPhysical/Emotional Health History If the child’s biological/adoptive parents are not together, please complete the following information for step-parents/partners. N/A HiddenInstructionsPlease list the Name of Parent, Name of Step Parent/Partner, Age, and Occupation in the fields provided below.Name of ParentName of Step-Parent/PartnerAgeOccupation Custody and Visitation Arrangements: N/A If yes please describeAre there any current legal proceedings related to custody involving the child? Yes No If yes, please describe:Currently live in: Single family home Apartment / Condo Townhouse / Condo Mobile Home Other List any others living in the home and the circumstances(ex: grandparents or step-siblings that may live in the home for part of the week). N/A HiddenInstructionsPlease fill in the Name, Age, Relationship to the Child and Circumstance for each additional person living in the home. (ex: grandparents or step-siblings that may live in the home for part of the week). Others living in homeNameAgeRelationship to ChildCircumstance Has the child ever been placed outside the home (shelter, foster home, or group home)? Yes No If yes, please provide details:Has the child ever been arrested or placed on probation? Yes No If yes, please provide details:SafetyDoes the child have a history of abuse or trauma?Physical Yes No Please describe any increase or decrease:Sexual Yes No If yes, when and please provide details:Emotional Yes No If yes, when and please provide details:Verbal Yes No If yes, when and please provide details:Neglect Yes No If yes, when and please provide details:Domestic Abuse Yes No If yes, when and please provide details:Other Yes No If yes, when and please provide details:Has the child ever experienced:HiddenHas the child ever experienced:Suicidal Thoughts Yes No If yes, when? please provide details.Suicidal Attempts Yes No If yes, when? please provide details.Self Harm Yes No If yes, when? please provide details.Is the child involved in any legal proceedings related to the safety issues listed above? Yes No If yes, please describe:Are there current or past child protection issues? Yes No If yes, please describe:History of ProblemWhen and how did you first notice the problem?What kinds of changes have you seen in the child (such as changes in academics, sleep, or eating patterns)?Please describe any changes or incidents (such as moving, a death in the family, change of schools, birth of a sibling, death of a pet, financial/legal problems, etc.) which seem to have affected the child.What was the child’s reaction to the above changes or incidents?How have you tried to resolve the problem? Please list things that have worked as well as things that have not worked.Family InteractionWhat do you do together as a family?How does your family express feelings?How often are there conflicts in your family?What are the conflicts typically about?How are these conflicts resolved?Who is typically in charge of discipline in your family?What type of discipline is used in your family?Family HistoryWhat is your family cultural background (ethnic or racial origin)?What is your family religious background?Please list any cultural or religious traditions that are important in your family.HiddenInstructionsPlease enter your family medical history, (such as diabetes, cancer, hearing/vision problems, sensory integration disorder, etc.) for family members (include cousins, aunts/uncles, grandparents, etc.). Please fill in the name, relationship to child and medical issue for each entry. Please list any medical history(such as diabetes, cancer, hearing/vision problems, sensory integration disorder, etc.) for family members (include cousins, aunts/uncles, grandparents, etc.).NameRelationship to ChildMedical Issue HiddenInstructionsPlease enter your family mental health history (such as ADHD, Autism, Anxiety, Learning Disabilities, Bipolar Disorder, etc.) for family members (include cousins, aunts/uncles, grandparents, etc.).” Please fill in the name, relationship to child and medical issue for each entry. Please list any mental health history(such as ADHD, Autism, Anxiety, Learning Disabilities, Bipolar Disorder, etc.) for family members (include cousins, aunts/uncles, grandparents, etc.).”NameRelationship to ChildMedical Issue HiddenInstructionsPlease enter your family substance use history (such as alcoholism or drug addiction) in your immediate or extended family (include cousins, aunts/uncles, grandparents, etc.). Please fill in the name, relationship to child and medical issue for each entry. Please list any substance use history(such as alcoholism or drug addiction) in your immediate or extended family (include cousins, aunts/uncles, grandparents, etc.).NameRelationship to ChildSubstance Use Issue Developmental HistoryPlease provide the following information. If the child is adopted or a foster placement, provide as much information as possible.HiddenInstructionsPlease provide the following information. If the child is adopted or a foster placement, provide as much information as possible.Was the child full term? Yes No If no please explainThe child was born C-section Vaginal Induced Early/Premature How did you react to news of the pregnancy?Were there any complications during the pregnancy or birth? Yes No If yes, please provide details:What approximate age did the child develop in:HiddenInstructionsWhat approximate age did the child develop in Speech, please list for Single words, Simple sentences, and Complete sentences. SpeechSingle WordsSimple SentencesComplete SentencesHiddenInstructionsWhat approximate age did the child develop in Mobility, please list for Crawling, Walking, and Running. MobilityCrawlWalkRunHiddenInstructionsWhat approximate age did the child develop in Toilet training, please list for Bladder trained, Bowel trained. Toilet TrainingBladder TrainingBowel TrainingPlease list any problems with toilet trainingPlease list any problems with toilet training after the child had mastered it.Please describe any emotional or behavioral difficulties:HiddenPlease describe any emotional or behavioral difficulties:As an infant:As a toddler:As a preschooler:During elementary school:During middle school:During high school:Are/were normal separations tolerated before school age? Yes No If no, please describe:Please describe any developmental eating problems.Please describe any developmental sleeping problems.Educational HistoryWhat school/daycare/preschool is the child currently enrolled in? At what age did the child begin school? What grade is the child currently in? Has the child repeated or skipped any grades? Yes No If yes, please explain:What kinds of grades does the child typically receive? Have there been any changes to academic performance? Yes No If yes, please describe:What are the child’s favorite subjects?What are the child’s least favorite subjects?Did the child receive a 3-year-old assessment from the school district? Yes No If yes, what were the outcomes?Does the child receive any support services (such as Special Education, IEP, 504 plan, Title 1)? Yes No If yes, please describe:Has the child been assessed for any learning disabilities (LD, EBD, Non-verbal learning disorder)? Yes No If yes, please describe:Have there been any academic, behavioral, or emotional problems with peers or teachers? Yes No If yes, please describe:Has the child ever been given detention, suspended, or expelled from school? Yes No If yes, please describe:Psychological/Mental Health HistoryHas the child received services from the school counselor/psychologist/social worker? Yes No If yes, please describe:Current or Previous Counseling/Therapy N/A HiddenInstructionsPlease fill in the Clinic or Therapist, The Dates of Service, and the Reason/DiagnosisClinic or TherapistDates of ServicesReason/Diagnosis Psychiatric Hospitalizations/Partial Hospital Program/Intensive Outpatient Program N/A HiddenInstructionsPlease fill in the Hospital/Clinic, The Dates of Service, and the Reason/DiagnosisHospital/ClinicDates of ServicesReason/Diagnosis Medical HistoryPrimary Care Physician Clinic Date of last visit and outcome(s):Psychiatrist Clinic Date of last visit and outcome(s):Medical Concerns in the previous year:Has the child ever received OT (Occupational Therapy), PT (Physical Therapy), or Speech Therapy? Yes No If yes, please explain:Has the child ever received social security income? Yes No If yes, please explain:Medications N/A HiddenInstructionsPlease list the Name of the Medication and Dosage, the purpose and Length of use in the provided fields. Name of Medication and DosagePurposeLength of Use Does the child have a history of:HiddenDoes the child have a history of:Head Injury Yes No If yes, please describe:Concussion Yes No If yes, please describe:Surgeries Yes No If yes, please describe:Car Accident Yes No If yes, please describe:Chronic Illness Yes No If yes, please describe:Seizures Yes No If yes, please describe:Allergies Yes No If yes, please describe:Disabilities Yes No If yes, please describe:Has the child ever been injured while playing any sports (football, hockey, soccer, skiing, cheerleading, etc.)? Yes No If yes, please describe:Social HistoryHow many close friends does the child have at this time? Frequency of contact If the child has been worried about friends’ actions/behaviors, please describe.Recreation, hobbies, interests:Organized activities/sports (such as Girl/Boy Scouts, community baseball, gymnastics, YMCA):What do you feel the child does well?Employment History N/A Does the child have a job, either in school or outside school? Yes No Typical Hours: Current Employer/Job Position:HiddenInstructionsPlease fill in Position, Duties and Dates for each employment.Previous Employment:PositionDutiesDates (from-to) Substance Use N/A HiddenInstructionsPlease identify the child’s current and historic substance use: Alcohol,Tobacco,Illicit Drugs, Misuse of Rx meds, Other. Please fill in Substance, Quantity, Frequency and Dates for each use.ListPlease identify the child’s current and historic substance use: Alcohol,Tobacco,Illicit Drugs, Misuse of Rx meds, OtherSubstanceQuantityFrequencyDates Start / Stop Please describe the child’s consumption of caffeine (coffee, soda, energy drinks, etc.).Has the child experienced any undesirable results (DUI, DWI, school failure, etc.) from substance use? Yes No If yes please describe:Has the child attended (past or present) a self-help group, such as AA, NA, or Alateen? Yes No If yes please describe:CD Treatment History: N/A HiddenInstructionsPlease fill out the Name of Program/Provider, Inpatient/Outpatient, and Dates for each treatment.Name of Program/ProviderInpatient/OutpatientDates (from-to) Client ExpectationsHow do you feel about seeking help for the child at this time?What goals do you have for therapy for the child?What research have you done related to the reason for this visit?How long do you expect the child to continue therapy?How often would you like the child to attend therapy?What else do we need to know that we have not asked?PhoneThis field is for validation purposes and should be left unchanged. Δ
