PACE Parent Questionnaire

PACE Parent Questionnaire
Parent/guardian Name

First NameLast Name
Student Name*

First NameLast Name
Student DOB*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Grade
School
What are your teen's strengths?
What does your teen appear to be most successful with?
What is your teen motivated by?
Please indicate any concerns you might have about your teen:
Please indicate any pertinent medical history of your teen
Too few friendsTalks to friends about their problemsIs overly shyMakes friends easilyEnough friendsDoesn't talk to friends about problemsFinds it very difficult to open up to othersFinds it hard to keep friends
Laundry (wash, dry, fold)Vacuuming/Mop/Sweep floorsClean mirrors/windowsCleaning dishes/kitchenTake out trashCookingOther
Please indicate specific social skills that you would like your teen to work on.
As a parent/guardian, please indicate which challenges you are having in your relationship with
Parent: ANYTHING ELSE YOU WANT US TO KNOW?
Teen: What are the main things your would like to discuss in groups?
Parent: How did you hear about PACE?
Should be Empty: