Focused therapies and interventions dedicated to the well being of children and families.

Child Questionnaire

Child's Name: *
Age: *
Date of Birth: *
Gender: Male   Female
Birth Mother's Name: *
Birth Father's Name: *
Siblings:
Name:                              Age:     Gender:
Your relationship with the child: Birth Parent
Other Family Member
Please explain:
Social Worker
Foster Parent
Other
Please explain:
Child's School:
Grade:
Has the child ever has any psychological or psychiatric evaluations no   yes
If Yes, provide the name, date and reason for the evaluation, and the name and phone number of the person who performed the evaluation
Has the child recieved psychotherapy or counselling no   yes
If Yes, provide the dates, reasons and the name and phone number of the therapist
What are your child's presenting problems
 Anger Management   Poor Self-Image   Grief Sexual Abuse 
 Impulse Control   Parent-Child Conflict   Loss and Separation 
 Other 
Please explain:
Briefly describe the on set of the presenting problems:
Your First Name *
Your Last Name *
Your Daytime Phone Number
E-mail Address: *