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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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: 1 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) 2 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) 3 (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): __________________________________________ 4 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: __________________________________________________________________ 5 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 _________________________________________ ____________ _____________________________________________________________________________ ____________ 6 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:_____________________ 7