Parent Questionnaire 1



What is the name of the child or adolescent?_______________________________


What is your name? _______________________________________


What is your relationship to the child? ___________________________________


What is today’s date? __________________________


Is the child male or female?_____________________


What is the child’s date of birth?_________________________________________


What is the name (or names) and relationships of other parents, stepparents, guardians, or other parental figures? Please include all.


Name: Relationship: Lives in current household, or not:


_____________ ________________ ______________________________


_____________ ________________ ______________________________


_____________ ________________ ______________________________


_____________ ________________ ______________________________




What is the mailing address at which the child resides?


Street Address:_____________________________________________________


City:____________________________ State:__________________ Zip:__________



What is the mailing address of any other parental figure(s) who are not at the address you just gave?


Street Address:_____________________________________________________


City:____________________________ State:__________________ Zip:__________




Please list phone numbers of family members, including yourself.


Name: Phone number:


________________ _________________________


________________ _________________________


________________ _________________________


Email addresses of family members, including yourself:

Name: Email address:


________________ _________________________


________________ _________________________


________________ _________________________




Who else lives in the household with the child – for example brothers or sisters -- and what are their dates of birth?


Name: Relation to child: Date of Birth


______________ _____________________ ________________________


______________ _____________________ ________________________


______________ _____________________ ________________________




What are the occupations of parents or caretakers?


Name: Occupation


______________ _____________________


______________ _____________________


______________ _____________________



What school does the child attend now?


What grade is the child in, in school?





Is the child in special education – that is, does the child have an IEP? If so, what designation? (By designation, we mean category such as specific learning disability, emotional disturbance, speech or language impairment, autism, hearing impairment, etc.)




Does the child have a “section 504” plan at school?



If there are special accomodations the child receives at school, what are they? (examples: one-on-one aide, extra time on tests, special ed teacher in classroom part of the time, pull-out into special ed classes part or all of the time, etc.)




What do you consider the child's race to be?




Is there any additional information on ethnic or cultural background of the child or the family that you would like to communicate to us?





How would you describe the presence or absence of religious affiliation or inclination of family members?





Who is the child’s primary care physician (e.g. pediatrician or family practice doctor?)





Who referred you, or how did you find out about this service?




We ask about family income and wealth so that when we someday write up our results for a journal, we can report the average economic status of our participants.

Please estimate the total monthly and/or yearly income of:


mother/female guardian:



father/male guardian:



total family income from all sources: .




Please estimate the family wealth. If you add up the value of all money, investments, house, and other important posessions, and subtract the total of all debts, what is the net value you get? (If the debts are larger than the assets, you will get a negative number.)



For the questions on education, please indicate the highest grade finished or highest degree received: e.g. 8th grade, high school diploma, associate’s degree, trade school, bachelor’s, master’s, doctorate, or otherwise.


What is the highest level of education obtained by the child's:


biological mother?


biological father?


female major caretaker (if not the biological mother)?


male major caretaker (if not the biological father?)



Is the family of low enough income to be eligible for food stamps, Medicaid, public housing, or any other kind of public assistance? If so, which?





In the space below, please write the problems you would like us to help solve, or the goals you would like us to help accomplish.









Mental Health Problems or Diagnoses

Please list any mental health diagnoses or problem labels that this child has been given, by whom, and when.


Past or Ongoing Mental Health Treatment

Please describe any past or ongoing mental health treatment of the child: dates, providers, interventions, and responses.








Past Medical History

Now please summarize any medical or surgical or other health problems the child has had. Please list types of problems, dates, providers, interventions, responses, results of assessments, etc.






Current Medications:


Please list all medications the child is on now, with doses:








Current Symptoms:

If the child has had any symptoms or complaints within the last couple of weeks, (for example, pain, dizziness, loss of appetite, fear, feeling down, etc.) please write below what those symptoms are:





Developmental History



Please circle any of the following exposures that were present during the time between conception and birth of this child.


drug exposure (if so, what?)


alcohol exposure


tobacco exposure


infectious illness of mother (if so, what?)


serious depression of mother


other illness or exposure


Was the child premature?

If so, by how much?



Were there problems during infancy? If so, what?



Did the child learn to walk by about a year of age? (If not, when?)



Was the child starting to talk by about a year of age? (If not, when?)



How old was the child when you first heard a complaint or concern voiced by a teacher about his or her behavior, if there have been any complaints or concerns voiced?



Family psychiatric history

What psychiatric problems have there been for


mother:


father:


siblings:


other family members:







Think about family history of: alcohol problems, other drug problems, depression, anxiety, attention problems, impulse control problems, learning difficulties, anger control problems, violence, bipolar disorder, obsessive-compulsive problems, schizophrenia, tic or Tourette’s disorder, conduct problems, delinquency, criminality. Include problems family members had in childhood, even if those problems have since resolved.

Of the child’s first degree relatives, that is biological mother, biological father, or siblings, and of the person with the most severe psychiatric or behavioral or emotional problem, at the time it was most severe, how severe or impairing or troublesome was this problem?


0=no problem

2=mild problem

4=somewhat impairing or troublesome

6=definitely impairing or troublesome, but for a limited time or to a llimited degree

8=very impairing or troublesome, by virtue of severity or length of time or both

10=extremely impairing or troublesome for a long time








Of the child’s higher degree relatives, that is aunts and uncles who are siblings of parents, grandparents, and first cousins, please answer the same question regarding psychiatric, behavioral, or emotional problems.


0=no problem

2=mild problem

4=somewhat impairing or troublesome

6=definitely impairing or troublesome, but for a limited time or to a llimited degree

8=very impairing or troublesome, by virtue of severity or length of time or both

10=extremely impairing or troublesome for a long time



Family medical history


What medical problems (other than psychiatric problems) are present in:


mother


father


siblings


other family members


Family stressors


What stressful events or life changes have happened for the child or for the family as a whole, or any individual in the family? How much of an impact do you think these have had?













Parent's support


Does the parent who has the major responsibility for the child have at least one other adult who is supportive and helpful and in a good relationship with the major caretaker? Please say anything else you can about how supported the major caretaking parent is. If there is more than one major caretaker, please comment on the support level of both or all.





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