Child and Family Background Questionnaire

Lauren Hutchinson

Child and Family Background Questionnaire
Contact Information
Child's Name First Name   Last Name Prefers to be called Preferred Name
Current School and Location  Grade
Child's Date of Birth Date Child's Age
Home Address Street Address   Address Line 2   City

PARENT ONE (Person filing out this questionnaire):
First Parent's Name First Name   Last Name Prefers to be called Preferred Name
Mobile Phone Phone Number E-mail Email
Occupation (title, name of company, industry)

PARENT TWO
Second Parent's Name First Name   Last Name Prefers to be called Preferred Name
Mobile PhonePhone Number E-mail Email
Occupation (title, name of company, industry)
Child or Teen's gender identity:

Female Male Gender non-binary
Is your child or teen's gender identity different from gender assigned at birth?

No Yes
If yes, please tell me more about about this identity change (I am an ally for gender non-conforming children):

Family Information
Select one choice that best describes this child's primary household:

Parents living together and married Parents living together and unmarried Parents not together, lives with single parent Parents not together, lives with parent and stepparent Parents not together, lives with parent, stepparent, and stepfamily Lives with guardian other than parents Other
Please list all additional people currently living in this child's home (e.g. siblings, grandparents, nannies). If none, please enter "none" under Name. *
Is this child adopted or a foster child?
If yes, please indicate when child joined your family, age at adoption, whether the adoptions has been discussed with child, and whether child has contact with birth parents.
Please describe any major changes in your family's living situation or significant family stresses experienced over the past two years:
e.g. major move, death of a close family member, serious illness, family conflict, unemployment, trauma

Current Concerns
What brings you to counseling? What are your questions or concerns about your child or teen? Please be specific.
When did you first become concerned about these issues? What have you tried to address these concerns?
Does your child have any current diagnoses?
Examples might include ADHD, autism, learning disorder, anxiety, depression, PANDAS, epilepsy, other medical conditions. If yes, please indicate who diagnosed your child and approximate month/year or diagnosis.
Has your child had any previous evaluations? If so, what type? If yes, please provide copies of reports.

Neuropsychological/Psychoeducational Psychological (e.g/ for anxiety, depression) Educational/Learning Speech/Language Occupational Therapy Developmental Optometrist Auditory Processing Other
Has your child seen any other service providers for their areas of concern (medical providers will be asked about in next section)? If none, please put "none" under Name of Provider. *
What do you consider to be your child's greatest strengths and areas of interest? What do they love doing? Please list your child's activities, sports, hobbies, enthusiasms, passions, and deep interests. Include character strengths you see as well. Please tell me what makes your child or teen a unique and lovable human!
e.g. personality traits, academic interests (math, science, humanities), athletics, fine or performing arts, creativity, musical, STEM/technology (game design/coding, engineering), leadership, outdoors/nature, entrpreneurship, volunteerism/community service

Thank you so much for the valuable time you put in to filling out this form! I know it was a beast of a form, but because our gifted and 2e kids are so complex, their individuality and wellbeing deserves as much consideration as can reasonably be given to help determine next steps. Thank you!
This form completed by:

First Name Last Name
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

	Advanced or Developed Earlier than Peers	Typical	Behind or Developed Later than Peers
Motor Development (e.g. crawling, first steps)
Language development (e.g. first words, speaking in complete sentences)
Social Development (e.g. playing well with others)

	Yes/No	Relationship of family member
Epilepsy, seizures, Tourette's
Depression/Anxiety
ADHD or attention problems
Autism or suspected autism
Dyslexia or reading problems
Substance abuse or addiction

	Serious Problem	Below Peers	About Average	Above Peers	Way above Peers
Reading
Spelling
Written Expression
Handwriting
Mathematics
Science
Social Studies/History
Foreign Language
Technology
Arts
Study Skills and Test-taking
Organization and Planning
Academic Motivation

Lauren Hutchinson

Contact Information

Family Information

Current Concerns

Medical and Developmental History

School and Learning