Parent Form

Parent Questionnaire:

Please fill out the following questionnaire to the best of your ability/knowledge. If a question does not pertain to your child (ie. history or arrest, drug use, etc.) NA or NO if acceptable).

Child’s full Name:*
DOB:*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Grade:*
School Attending:*
1. What has brought you into counseling services?*
2. Please provide a history of your child's presenting problems: (Events, precipitating factors, or incidents leading to need for services):*
3. Please provide the frequency, duration, and severity of symptoms:
4. Was there a clear time when symptoms worsened?*
5. Is there any significant mental health history on either side of the family?*
* 6. Current Family and Significant Relationships, please provide for each person you list: Name/Age/Quality of Relationship:*
7. Childhood/Adolescent History: Any concerns with the child's developmental milestones, past behavioral concerns, sudden changes of environment, history of abuse, school history, and social functioning?*
8. Significant social relationships*
9. Are there any cultural or ethnical considerations I need to be aware of during treatment with your child or family?*
10. Are there any Spiritual/Religious considerations I need to be aware of during treatment with your child or family?*
11. Does your child or anyone in your family have any current or past legal problems or arrests?*
*12. Please provide child's current grade and school. How long have they been there?*
14. What does your child enjoy to do for fun? Do they participate in any sports, activities, or groups outside of the school?*
15. Does your child have any serious physical or medical issues? Do they take medication?*
16. Does your child have any history of substance abuse? Is there any history of substance abuse in your family?*
Please provide any Counseling/Prior Treatment History for any mental health or substance issues:*
17. Any other information you wish to share that you may find pertinent or important that was not covered here?*