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mark@berkowitztherapies.com
(204) 475-9997
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mark@berkowitztherapies.com
(204) 475-9997
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Child Questionnaire
Child Questionaire
Child's Name
Age
Date of Birth
Gender
Male
Female
X
Please Specify if "X" was selected
Birth Fathers's Name
Birth Mother's Name
Siblings
- None -
1
2
3
4
5
6
Your relationship with the child
Birth Parent
Other Family Member
Social Worker
Foster Parent
Other
Child's School
Grade
- Select -
N
KG
1
2
3
4
5
6
7
8
9
10
11
12
Has the child ever has any psychological or psychiatric evaluations
Yes
No
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
Yes
No
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
Last Name
Your Daytime Phone Number
E-mail Address
Text Input
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