Download Form 7. Parent Questionnaire - Clinical Neuroscience Counseling

PARENT QUESTIONNAIRE
In order for us to be able to fully assess your child, please fill out the following questionnaire.
We realize there may be information that you do not remember or have access to, please do the best you can.
Thank you!
PATIENT IDENTIFICATION
Child Name:__________________________________
First Appointment Date:_________________
Date of Birth: _________________________________
Age:__________ Gender: _________
Address: ______________________________________________________________________________
City: ________________________________
State: ___________
Zip: _________________
Who is the child currently living with? ________________________________________________________
Who referred your child to our office? ________________________________________________________
PURPOSE OF THE CONSULTATION
Please give a brief summary of the main problems
WHAT ARE YOUR GOALS FOR COUNSELING AT THIS TIME?
How can this therapist help your child, yourself or your family?
____________________________________
______
____________________________________________________________________________________
MEDICAL HISTORY:
Current medical problems/medications: _________________________________________________________
_________________________________________________________________________________________
Past medical problems/medications:
Doctors/clinics seen regularly:
Present Height:
Present Weight:
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Any history of head trauma? (describe):
Ever any seizures or seizure like activity?
________________________
Any periods of spaciness or confusion?
______________________________
Prior hospitalizations (place, cause, date, outcome):
________________________
Allergies/drug intolerances (describe):
____________
FAMILY HISTORY:
Family Structure (who lives in the current household with the child, please give relationship to the child):
FAMILY DEVELOPMENT: (include marriages, separations, divorces, deaths, traumatic events, losses, etc.)
CURRENT MARITAL SITUATION/SATISFACTION OF PARENTS:
NATURAL MOTHER’S HISTORY: Name:_____________________Age: ____ Occupation:
School: highest grade complete:
______
____________
Learning problems (specify):
____________
Behavior problems (specify):
____________
Marriages:
____________
Medical Problems:
____________
Childhood atmosphere (family position, abuse, illnesses, etc):
Has mother ever sought psychiatric treatment? Yes ____ No _____
If yes, for what purpose?
Mother’s alcohol/drug use history:
____________
Have any of mother’s blood relatives ever had any learning problems or psychiatric problems including such
things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify)
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NATURAL FATHER’S HISTORY: Name:__________________ Age: ____ Occupation:
School: highest grade complete:
______
____________
Learning problems (specify):
____________
Behavior problems (specify):
____________
Marriages:
____________
Medical Problems:
____________
Childhood atmosphere (family position, abuse, illnesses, etc):
Has father ever sought psychiatric treatment? Yes ____ No _____
If yes, for what purpose?
Father’s alcohol/drug use history:
___________
Have any of father’s blood relatives ever had any learning problems or psychiatric problems including such
things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify)
(If Applicable)
STEP, ADOPTIVE OR GUARDIAN MOTHER’S HISTORY: Name:___________________ Age: ____
Occupation:
______
______ Highest grade completed:
Learning problems (specify):
____________
Behavior problems (specify):
Marriages:
_____ Medical Problems:
___________
____________
____________
Childhood atmosphere (family position, abuse, illnesses, etc):
Has she ever sought psychiatric treatment? Yes ____ No _____
If yes, for what purpose?
Step/Adoptive Mother’s Alcohol/drug use history:
Have any of her blood relatives ever had any learning problems or psychiatric problems including such things
as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify)
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(If Applicable)
STEP, ADOPTIVE or GUARDIAN FATHER’S HISTORY: Name:_______________________ Age: ____
Occupation:
____________
School: highest grade complete:
Learning problems (specify):
______________________________
Behavior problems (specify):
______________________________
Marriages:
________ Medical Problems:
Childhood atmosphere (family position, abuse, illnesses, etc):
Has he ever sought psychiatric treatment? Yes ____ No _____
If yes, for what purpose?
Step/Adoptive father’s alcohol/drug use history:
________________________
Have any of his blood relatives ever had any learning problems or psychiatric problems including such things as
alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify)
CHILD’S SIBLINGS: (names, ages, problems, strengths, relationship to patient)
CHILD’S FAMILY STRESSES: (please list current factors that are a source of stress in the family)
CHILD’S DEVELOPMENTAL HISTORY:
Prenatal Events:
Parent’s attitude toward pregnancy:
Conception—ease _________
______
planned ________________ unplanned_______________
Pregnancy complications (bleeding, excess vomiting, medication, infections, x-rays, smoking, alcohol/drug use,
etc):
__________________________________________
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Birth and Postnatal period:
Birth weight _______ Length ____________ Any jaundice? Yes _________ No
____
Any birth or delivery complications?
Mother’s health after delivery
____________
Post delivery blues? ________ If yes, how long?
Primary caretaker for child, first year:
____________
______________ Thereafter
__________________
Current eating problems:
____________
__________________________________________________________________________________________
Sleep behavior: sleepwalking, nightmares, recurrent dreams, current problems (getting up, going to bed)
Separations from mother and/or father: age, duration, reaction to
Motor development: Does your child have any physical development concerns?
__________________________________________________________________________________________
Current level of activity:
____________
Social development Concerns:
Early interactions with other children: ___________________________________________________________
Current interactions with other children: ___________________________________________________
Special interests: ___________________________________________________________
____________
Relationships to family members: ____________________________________________
____________
Hobbies/interests: __________________________________________________________
____________
__________________________________________________________________________________________
Toilet training:
Age reached bowel/bladder control: day ___________ night ____________
Any concerns: __________________________________________________________________
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Sexual development:
Gender identity __________________________Any problems _______________________________________
Behavioral/Discipline:
Compliance vs. non-compliance:
_______________________________________________________________________
____________
Lying/stealing _________________________________ Rule breaking ____________________
Methods of discipline ______________________________________________________
______
____________
Other problems _________________________________________________________________________
Emotional development:
Early temperament __________________________________________________________________________
Current personality _____________________________________________________________ ____________
Habits _______________________________________________________________________ ____________
Fears/phobias _________________________________________________________________ ____________
Special objects (blankets, dolls, etc) ________________________________________________ ____________
Physical/Sexual abuse:
__________________________________________________________________________________________
__________________________________________________________________________________________
Drug/Alcohol History:
_____________________________________________________________________________ ____________
__________________________________________________________________________________________
School History:
Name of School:_____________________________________________Current grade ___________________
School contact (Teacher/Counselor): ______________________________________
Number of schools attended _________ Average grades _____________________________________
Homework problems ___________________________________________________________ ____________
Specific learning disabilities ______________________________________________________ ____________
Strengths ____________________________________________________________________ ____________
Motivation ____________________________________________________________________ ____________
What have teachers said about the child/teen _________________________________________ ____________
_____________________________________________________________________________ ____________
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Overall Strengths—as viewed by parents:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Overall Strengths – as viewed by the child/teen:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Printed Name of Person Completing this form:_____________________________________
Relationship to Child (Please circle) Mom,
Dad,
Guardian,
Signature:_______________________________________
Other:___________________________
Date:_____________________
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