Parent Questionaire
Please help us to better understand your child's behavioral health needs. Transparency allows your child to get the help and services they need. All information disclosed is confidential. (This form must be completed along with the consent form & the ROI)
Child Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Male
Female
Does your child have
IEP/504 Plan
Intellectual Learning Disabilities
Depression
Anxiety
Easily Distracted
Easily Angered
Impulsivity
Tantrums/Raging
Poor Socialization
Isolating
Sibling Violence
Destruction of Property
Poor Academic Performance
ADHD
Running Away
Playing with fire
Hospitalized/Facility for behavioral health needs
Please list any medical or behavioral diagnosis. You may also let us know any additional information you would like us to know about your child.
If your child does not have any diagnosis just put "NA"
Does your child receive any prescription medication?
Please Select
Yes
No
Any reports of abuse? (physical, verbal, neglect, or sexual)
Please Select
Yes
No
Any behavioral concerns reported by the school?
Yes
No
CSB/CPS Involvement?
Yes
No
Please list your child's strengths (what they are good at)?
Are you satisfied with your relationship with your child?
Please Select
Yes
No
Need improvement
Do you feel you are capable of dealing with your child's problems ?
Please Select
Yes
No
Need improvement
How much family stress or pressure do you feel right now in your life
Please Select
Mild
Moderate
Severe
None
Please select all behaviors your child has experienced in the last 30 days
Arguing with others
Getting into fights (hitting, kicking, pushing)
Yelling, swearing, or screaming at others
Fits of anger
Refusing to do things teachers or parents ask
Causing trouble for no reason
Using drugs or alcohol
Breaking rules or breaking the law(out past curfew, stealing)
Skipping school or class
Lying
Can't seem to sit still, having too much energy
Hurting self (cutting or scratching, taking pills)
Talking or thinking about death
Feeling worthless or useless
Feeling lonely and having no friends
Feeling anxious or fearful
Worrying that something bad is going to happen
Feeling sad or depressed
Nightmares
Eating Problems
How is your child doing in the following areas (Consider your child's age when responding) Please select any areas of concern:
Getting along with family and friends
Developing age-appropriate relationships with boys and girls
Getting along with adults outside the family (teachers, principal)
Hygiene
Controlling emotions and staying out of trouble
Participating in recreational activities such as sports, swimming, bike riding etc
Completing household chores (cleaning room, other chores)
School attendance and getting passing grades
Feeling good about self
Making good decisions
Concentrating, paying attention, and completing tasks
Doing things without supervision or restrictions
Accepting responsibility for actions
Ability to express feelings
Gaming time and social media
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Parent/Guardian Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: