Family Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete. Child s Name: DOB: Age:
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1 Family Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete Child s Name: DOB: Age: School: Grade: Race/Ethnic Origin: Religious Preference: Family Members and Other Persons in Household Name Age Relationship To Child Grade Or Occupation Living In Household? If different from above, please give: Biological mother s name: Biological father s name: Problem Description Please state the problems for which you want help for this child: Therapist/Program Problem: Therapist/Program Problem: Previous mental health counseling and/or treatment: Date: Date:
2 Page 2 Emotional/Behavioral/Chemical Issues Has your child recently or currently experienced the following? Recent Suicidal thoughts Difficulty sleeping Suicide plans Depression, loneliness, or hopelessness Suicide attempts and/or Crying often self-inflicted injury Frightening dreams or thoughts A tendency to be shy or Often annoyed by little things sensitive Difficulty completing tasks A strong dislike of criticism Violent or destructive behavior A frequent loss of temper Difficulty remembering Difficulty expressing feelings Difficulty concentrating Nervousness, anxiety, or worry Mental Confusion Difficulty relaxing Difficulty with eating Difficulty making decisions Has your child ever been in court or picked up by the police?. Do you think your child has tried cigarettes, sniffing, alcohol or drugs? Child s Development 1. Were there any complications with the pregnancy or delivery of your child? 2. Did your child have health problems at birth? 3. Did your child experience any developmental delays (e.g. toilet training, walking, talking)? t sure 4. Did your child have any unusual behaviors or problems prior to age 3? t sure 5. Has your child experienced emotional, physical, or sexual abuse? t sure
3 Page 3 Peer Relations 1. Is your child socially: outgoing shy depends on the situation. 2. Is your child involved in any organized social activities ( e.g. sports, scouts, music)? 3. What activities does your child prefer to do? 4. Do you feel uncomfortable about any of your child s activities or toys? School History 1. Has your child ever been held back a grade? 2. What are the grades your child receives at school? 3. Do you feel your child is doing the best he/she can at school? 4. Are there any behavior problems at school? 5. What is your child s best subject? Worst subject? 6. How many schools has your child attended? Discipline 1. How do you discipline your child? Describe: Father: Mother: Other adults in family:
4 Page 4 2. Are there differences between father and mother with regard to discipline? Have these differences been a source of strain in the family? 3. Who usually disciplines the child? 4. Does the child prefer one parent over the other? If yes, whom? Medical History Check the age(s) at which this child had any of the following health problems. If the child has never had the problem, check the box in the Never column. If the health problem is still continuing or is a current concern, check the box in the Current Concern column. More than one category may be checked. High fever (over 103 ) Seizures (convulsions) Rashes or skin problems Meningitis Asthma Food allergies Other allergies Pneumonia Anemia (low blood count) Heart problems Kidney or urinary problems Bowel problems Trouble with vision Trouble with hearing Lack of weight gain Poisoning or medication overdose Serious injury Hospitalization Surgery Never O-6 Months 7-12 Months Since 6 Current Concern Other important illnesses (list):
5 Page 5 Medication used over a long period of time (list): Current medication: In general, this child s heath has been: Name of physician: excellent (is rarely sick, when sick recovers very quickly) good (is not often sick or injured, illnesses are fairly short-lived) fair (frequently sick or injured, illnesses often linger or recur) poor (chronically ill) Child s Strengths Please mark those strengths that you have observed in your child: Outgoing Self-confident Seems happy Friendly Enjoys new experiences or activities Even disposition or steady moods Expresses feelings Affectionate Kind or sympathetic to others Shares Can compromise Follows rules easily Is forgiving Stands up for self when appropriate Tolerates criticism Recovers easily after disappointment Is appropriately cautious Creative Plays gently with smaller children or animals Good sense of humor Often True Sometimes True Seldom True Cannot Say
6 Page 6 Anxiety disorders ADHD or ADD Mental retardation Seizure disorder Depression Schizophrenia Other psychiatric disorder Learning difficulties Behavioral problems Alcoholism or drug dependence Family Illnesses/Disorders Mother s Family Biological Mother Biological Father Father s Family Inherited conditions (e.g. Huntington s Chorea, Sickle Cell Anemia): Other significant family illness: Parent s History Biological Father: Birth date: Ethnic origin: Place of Employment: Date of marriage: give dates: Occupation: If separated, divorced, widowed, previously married, please specify and Education (Check appropriate categories and specify year and degree reached in each category): Technical College Graduate Other Elementary High School Training School (Specify) Biological Mother: Birth date: Ethnic origin: Place of Employment: Date of marriage: give dates: Occupation: If separated, divorced, widowed, previously married, please specify and Education (Check appropriate categories and specify year and degree reached in each category): Technical College Graduate Other Elementary High School Training School (Specify)
7 Page 7 Parent s Marital/Significant Other Relationship 1. Would you describe your present marital/significant other relationship as (check one): smooth with occasional difficulties with frequent difficulties failure 2. Describe any significant relationship problems now, or in the past: 3. Have you sought outside help with regards to relationship problems? If yes, please give details: 4. Does any parent/caregiver have difficulties with nervousness, anxiety, or depression? 5. Does any parent/caregiver have difficulties with anger, e.g. losing temper easily, verbally abusive, being violent when angry? LH: 2003
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