Parent Questionnaire - Edwards Psych 2024

Name of Child

Date of Birth

Date

Cell phone

Home phone

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian 1 Full name

Profession & place of work

Cell phone

Home phone

Email

example@example.com

Address (if different from child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian 2 Full name

Profession & place of work

Cell phone

Home phone

Email

example@example.com

Address (if different from child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please briefly describe general reasons for seeking out therapy for your child:

What changes do you hope to see as a result of therapy?

Who has custody of child?

Both parentsMother onlyFather onlyOther

Who has medical decision making for the child if parents do not share custody

List all people currently living in the household and relevant others who have lived there in the past. Include name, age, relationship, and note if they no longer live in the home.

Please list any adoptions, previous marriages, separations, divorces, deaths, or major changes in the immediate family structure and approximate dates.

Describe any significant current family concerns/stressors.

Describe your child's relationship with:

Parent/Guardian 1 (specify)

Parent/Guardian 2 (specify)

Siblings

Peers

Adults in general

Significant others

Current School

Grade

Principal

School Counselor(s)

Please list all previous schools and dates attended.

What are your child's grades like now and in the past?

Please list your child's academic/extracurricular strengths.

Please list your child's academic/extracurricular difficulties or growth areas.

How much homework does your child have at night? Are there any difficulties or issues starting, sticking with, or finishing homework?

Has your child ever repeated a grade or received special education services? If so, please provide details.

How does your child do socially at school?

Has your child ever been disciplined at school (i.e., suspensions, expulsions, etc.)? If so, please provide details.

Pediatrician Name

Phone

Psychiatrist Name

Phone

Other relevant medical providers

Current medications and dosages

Please describe any issues during pregnancy/birth or developmental delays.

Please list relevant previous physical illnesses, injuries, or hospitalizations.

Has your child received previous outpatient mental health treatment? If yes, please list names of providers and approximate dates.

Has your child received previous inpatient mental health treatment? If yes, please name the program/hospital and approximate dates.

Please list relevant family mental and physical health history.

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Please briefly list any concerning behaviors you have observed in your child.

Has your child experienced anything you would consider traumatic (i.e., abuse, loss, victimization, significant changes, etc?

Please briefly list any concerning behaviors you have observed in your child.

Has your child experienced anything you would consider traumatic (i.e., abuse, loss, victimization, significant changes, etc.)?

Has your child talked about or taken actions to harm self or others?

Describe any concerns about risk taking behaviors (i.e., with regard to substance use, sex, internet/social media, etc.).

Describe any significant patterns of worry, anxiety, fears, or shyness.

Describe any unusual behaviors, rituals, habits, etc.

Describe any significant fluctuations in mood.

What is your child's usual disposition?

What is the most effective form of discipline? Do caregivers agree on discipline?

How does your child respond to discipline?

What activities does your child enjoy (i.e., sports, hobbies, interests, etc.)?

What are your child's strengths? What do you enjoy most about your child?

Please provide any additional information that you think might be helpful.

General Information

Family & Relationship Information

Education History

Physical & Mental Health History

Behavioral/Emotional Concerns