Child & Adolescent Clinical Questionnaire for Parents

AUBREY K. EWING PH.D. & ASSOCIATES, P.A.
1230 So. Federal Hwy, Boynton Beach, FL 33435

CHILD & ADOLESCENT CLINICAL QUESTIONNAIRE FOR PARENTS

The Child & Adolescent Clinical Questionnaire is intended to be completed by parents of children and adolescents for whom you are seeking counseling or other psychological services. It asks you to provide information about why you are making an appointment for your child, her/his general emotional and physical health, pertinent history, and what about your child is of greatest concern to you. The questionnaire helps your doctor/therapist get a head-start on the evaluation and treatment planning process.

This information will become part of your child's confidential record with this office and will not be released to anyone without your written permission. Your answers to these questions are considered protected health information (PHI) and are relayed to our office by a secure, HIPAA compliant process. We are committed to ensuring your child's privacy and protecting our confidential relationship.
Child's name
Your email address to which we can confirm receipt of this questionnaire
example@example.com
Date of birth

MonthDayYear
Date
Age
Gender
Pediatrician
School
Grade in school
Teacher's name
Who referred your child for services
Name of parent completing this form - relationship (Mom, Dad, guardian, other)
Your occupation
Your marital status
Name of spouse/partner (other person responsible for your child)
Spouse/partner's occupation
Please describe your child's current family/living circumstances:
Please name all people living with your child, their ages, and relationships to the child, beginning with yourself.
PRIMARY CONCERNS
What is the primary reason for having your child seen at this time?
List the three behaviors or symptoms that concern you the most about your child. Start with the most troubling first and work your way down.
When did you first notice your child having these behaviors or symptoms?
What are you most worried might happen if things continue as they are?
Did your child ever have similar behavioral or emotional problems that concerned you when she/he was younger? If so, please describe these problems, when they occurred, and what was done about them.
Has your child ever seen another professional for help with behavioral or emotional problems? If so, please give the name of the professional and when they were seen:
Has your child ever been prescribed medication to help with behavioral or emotional problems?
If yes, how recently?
Please list all the medications your child has taken in the past (not current meds):
List any medical problems for which your child is currently being treated. Please indicate if a problem has been ongoing requiring regular or periodic care.
List any past hospitalizations you have had for medical, surgical, chemical dependency, or psychiatric reasons.
List any medications to which your child is allergic or that they could not take due to intolerable side effects.
Please list all medications your child is currently taking. Include birth control, vitamins, and over the counter drugs. Please identify the prescribing doctor.
FAMILY HISTORY

Have any of your child’s biological relatives on either parent's side of the family had any of the following? Please indicate which side of the family and the family member involved.
Nervousness or panic

Mother' sideFather' sideOther
Depression

Mother's sideFather's sideOther
Obsessive-compulsive problems

Mother' sideFather' sideOther
Bipolar disorder (manic depressive illness | cycling mood)

Mother' sideFather' sideOther
Suicide

Mother' sideFather' sideOther
Alcohol or drug problems

Mother' sideFather' sideOther
Police record (arrests, jail)

Mother' sideFather' sideOther
Schizophrenia

Mother' sideFather' sideOther
Intellectual disability (mental retardation, Down's Syndrome, other)

Mother' sideFather' sideOther
Developmental conditions (Autism Spectrum Disorder, Asperger's, other)

Mother' sideFather' sideOther
Learning disoder (specific LD, dyslexia, other)

Mother' sideFather' sideOther
Attention problems (ADD, ADHD)

Mother' sideFather' sideOther
Tourette's or other tic problems

Mother' sideFather' sideOther
Other conditions or more detail about answers above
HISTORY OF BEHAVIORAL OR EMOTIONAL EVENTS AND PROBLEMS
Please click the box in front of the questions to follow if they apply to your chld:

had to repeat a grade in school
If yes, which grade(s) has he/she repeated
Indicate if your child has had any of the following types of testing

Psychoeducational testing at school or privatelyGifted testingPsychological or neuropsychological testing for the purpose of identifying a mental health, psychological, developmental, or neurological problem
If yes, where and by whom was your child tested?
What school or facility | Who did the testing
What were the dates of the testing
Year, grade, or child's age
Please click the box in front of all that apply to your child:

was in at least one special education class or an SE curriculumwas told by a teacher or other professional your child has a learning disabilityhas been in accelerated classes for smart kidshas skipped a grade in school
Does your child experience any of the following at school or at home (check all that apply)?

often leave things unfinishedis easily distractedhas difficulty concentrating on reading or homeworkhas difficulty sitting stillfeels restless or fidgetyis impulsive--I sometimes act without thinking or considering consequencesoften misplaces or loses thingsis easily forgetful and needs frequent reminders
The following describe traits my child has or things my child has done (click all that apply):

is usually stubborn or self-willedhas trouble conforming to rules or regulationstends to do the opposite of what he/she is toldargues with you or his/her teacherloses her/his temper easily, sometimes breaks/throws thingshas shoplifted or stolen somethinghas skipped school without permission or a legitimate reasonhas run away from home overnightoften tells lies to deceive you or teacherhas set fires that were potentially dangeroushas injured or killed a pet or small animal just for amusementhas broken or destroyed someone else's property (something of value or importance)has a reputation for starting fightshas displayed a knife, gun, or other weapon in a threatening way toward someonehas tried to steal things by threatening someonehas tried to force another person to engage in a sexual act
The following apply to my child/teen:

smokes cigarettes regularlydrinks or has experimented with beer, wine, or other alcoholic beverageshas used alcoholic beverages to excesshas missed school (or was asked to leave) because of drinkinghas missed work (or was asked to leave) because of drinkinghashas smoked marijuana (pot, weed, grass)has used amphetamines (crystal meth, ice, speed, ADHD medication) to get highhas used cocaine (coke, crack, rocks)hasused hallucinogens (LSD, PCP, peyote, mescaline)has used heroin, opiates (junk, smack, horse, H, fentanyl)has abused prescription medication (roxys, oxys, pain, sleep, etc.)has abused sedatives, tranquilizers (downers, bars, Xanax)is regularly using some of the above substances now
Provide details about alcohol or other substance use/abuse (amount, frequency, etc.) that will clarify the extent of your child's use
My child has had a period of two weeks or longer (now or in the past) when she/he:

seemed to be sad, depressed, moody, or irritabledidn’t feel much like eating or lost weightfelt like eating more than usual or gained extra weighthad trouble falling asleep or staying asleepslept more than usual or had trouble waking upwithdrew from family and friends, talking less than usuallost interest in things he/she usually likes to dofelt tired all the time but wasn’t physically sickfrequently complained of aches headaches, stomachaches, etcfelt guilty over things he/she really wasn’t to blame forfelt worthless and thought they would be better off deadcouldn’t concentrate on work/school as welltalked about or tried to kill myselfthought a lot about death or dyingis now feeling sad, blue, moody, or irritablehas experienced at least five of the items checked in this section continuously for the past two weeks or longer
My child has had a period of at least one week or longer (now or in the past) when she/he:

was so overly happy or “high” that she/he got into troublebecame more overactive than usual to the extent that it made others concernedtalked faster or more constantly than usualhad thoughts were going very fast (racing) in my headthought they had special powers to do remarkable thingsslept a lot less than usual without appearing or feeling tiredwas unable to concentrate on things as usualdid extravagant things they later regretted (grand promises, travel, sex, spent money)
Please click the statements below that describe your child. My child:

is an anxious persontends to worry alotsometimes thinks too much about health concerns or illnessworries about being away from his/her parentshas complained about headaches or stomachaches before schoolworries that something will happen to him/her or to his/her parentsneeds to have a parent close to him/her to fall asleephas experienced an anxiety attack without apparent reason
If you answered "yes" to the question above, how often does your child have panic or anxiety attacks?
During an anxiety attack my child (click all that apply):

has have trouble catching her/his breathher/his heart races too fasther/his face becomes flushed or their hands begin to sweat
Please click all of the following that are true about your child:

sometimes seems to have unusual and troublesome thoughts that he/she can’t put out of their mind (getting hurt, health, germs, bugs, etc)has special habits or rituals that seem excessive or unnecessary (counting things, touching, hand washing, or similar)checks and rechecks excessively on things already done, like turning off a light, or closing a doorhas wet the bed since age fivehas wet him/herself during the day since age five?continues to wet the bed nowsince he/she was potty trained, has soiled him/herselfhas continued to soil on him/herself nowtends to get highly upset when things are not in their exact placehas certain numbers or sequences have special meaning to them
thinks he/she is too fat or is preoccupied with the issue of weight?has lost excessive weight intentionallyhas exercised with the intent to lose weighthas lost more than ten pounds intentionallyhas gone on excessive eating bingeshas made him/herself vomit after binges or mealshas used diet pills or laxatives to lose weight
has sudden, jerky movements, which are repetitive, like neck jerks, eye blinking, mouth twitches, shoulder shrugs, or ticshas now or in the past had a habit of making repetitive sounds such as sniffs, grunts, throat clearing, barking or similarhas now or in the past had a habit of rocking her/his body or moving their fingers and hands in a repetitive way
Has your child ever had thoughts or sensory experiences that confused them such as (click the boxes that apply):

thinking someone was out to get them?thinking that others could control their thoughts?hearing voices others could not hear that seemed real and were saying strange things?seeing things, having visions that others don’t see?
Click the box in front of each statement below that describes your child:

my child is indifferent to or does not seem to like affection such as hugs, kisses, sitting close to you or othersmy child seems uninterested in or relates in a peculiar manner to other kids his/her agemy child uses unusual or peculiar language with othersmy child seems more interested in things than in peoplemy child sometimes displays repetitive movements such as hand or arm movements (flapping), clapping, twirling, etc.my child gets highly upset with even small changes in her/his routine or when things are out of placemy child has habits of hurting herself/himself (biting, hitting, cutting)
Thank you for taking the time to answer these important questions. This information is helpful to the doctor/therapist in understanding your needs and how to best be of help to you and your child.
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