MCO CI

Child Interview Form
Please fill out this form to the best of your ability. You may skip any question that does not apply to you and write "DK" if you don't know.

Note to Parent: Please do not fill this out for the child. The Examiner will address incomplete forms in the interview.
Name *
Today's Date

Month Day Year
Date
Date of Birth *

Month Day Year
Date
Age
Sex *

Male Female
Parent(s) Name *

School
What grade are you in this year or if you are on summer vacation, what grade will you be in when school starts?
Have you ever failed a grade?

Yes No
If Yes, which one(s)?
I am in

regular classes special classes
What kind of grades do you usually make?
How do you feel about school, overall?
What is your favorite subject?
What is your least favorite?
Have you ever gotten into trouble at school for your behavior?

Yes No
If so, for what?
How many times have you been suspended or expelled from school?
Sent to detention?
In School Suspension (ISS)?

Treatment
Have you had any counseling or therapy before?

Yes No
If Yes, did you find it helpful?

Yes No
Do you take any medicines to help you pay attention, think better, or feel less sad?

Yes No
If so, do you find them to be helpful?

Yes No
Why do you think you were brought to this office?
Do you have any concerns you would like to discuss?
Should be Empty: