Personal Growth

Better Quality of Life

Reduced Stress

Parental Questionnaire

  • Date Format: MM slash DD slash YYYY

  • All information on this form is considered strictly confidential within the guidelines of the clinic.

  • Date Format: MM slash DD slash YYYY

  • Please indicate how this has affected the child’s ability to function:

  • Symptoms and Issues you have Observed

  • Symptoms and Issues continued

  • Background Information

    (Please provide information for the person who is being seen.)
  • Biological/Adoptive Parents:

  • Indicate if A (adoptive), H (half), S (step)
  • NameAgeGrade/EducationPhysical/Emotional Health History 
  • Name of ParentName of Step-Parent/PartnerAgeOccupation 
  • (ex: grandparents or step-siblings that may live in the home for part of the week).
  • NameAgeRelationship to ChildCircumstance 
  • Safety

    Does the child have a history of abuse or trauma?
  • Has the child ever experienced:
  • History of Problem

  • Family Interaction

  • Family 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 
  • (such as ADHD, Autism, Anxiety, Learning Disabilities, Bipolar Disorder, etc.) for family members (include cousins, aunts/uncles, grandparents, etc.).”
    NameRelationship to ChildMedical Issue 
  • (such as alcoholism or drug addiction) in your immediate or extended family (include cousins, aunts/uncles, grandparents, etc.).
    NameRelationship to ChildSubstance Use Issue 
  • Developmental History

    Please provide the following information. If the child is adopted or a foster placement, provide as much information as possible.
  • What approximate age did the child develop in:
  • Single WordsSimple SentencesComplete Sentences
  • CrawlWalkRun
  • Bladder TrainingBowel Training
  • Please describe any emotional or behavioral difficulties:
  • Educational History

  • Psychological/Mental Health History

  • Clinic or TherapistDates of ServicesReason/Diagnosis 
  • Hospital/ClinicDates of ServicesReason/Diagnosis 
  • Medical History

  • Name of Medication and DosagePurposeLength of Use 
  • Does the child have a history of:
  • Social History

  • Employment History

  • PositionDutiesDates (from-to) 
  • Substance Use

  • Please identify the child’s current and historic substance use: Alcohol,Tobacco,Illicit Drugs, Misuse of Rx meds, Other
    SubstanceQuantityFrequencyDates Start / Stop 
  • Name of Program/ProviderInpatient/OutpatientDates (from-to) 
  • Client Expectations

  • This field is for validation purposes and should be left unchanged.