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8/8/2019 rio General Para Padres

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General Parent Questionnaire

Note: Please complete all information on this questionnaire. All information is treated in

confi-

dence and will not be released without your permission.

Date ______________________ Form completed by____________________________________________

Childs full name _____________________________ [ ] Male [ ] Female Birthdate

________________

Address

______________________________________________________________________

______________

Street City County State Zip

Home phone ____________ Work phone ____________ (Mother) __________

(Father) ___________

Who referred the child?

_____________________________________________________________________Name Address

Childs primary physician

___________________________________________________________________

Insurance company ___________________________ Childs Social Security # ______-

______-______

FAMILY

Fathers name ____________________________________________________

Birthdate _______________

Address (if different from above)

___________________________________________________________

Occupation ____________________ Education level _________________ # of

dependents ________

Mothers name _____________________________________________ Birthdate

_________________

Address (if different from above)

________________________________________________________

Occupation ____________________ Education level _________________ # of

dependents ________

Date of marriage __________ Present marital status

________________________________________With whom does the child live? [ ] Birth parents [ ] Adoptive parents [ ] Foster parents

[ ] Other (specify) _________________________________________

If parents are separated or divorced: Date of separation/divorce

_______________________________

Who has physical custody? __________________ Who has legal custody?

_______________________

List all other persons living in the home:

Name Relationship to child Present health

_____________________________ ___________________________

________________________________

_____________________________ ___________________________________________________________


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_____________________________ ___________________________

________________________________

List any other people who care for the child a significant amount of time:

Name Relationship to child (grandmother, neighbor, etc.)

_______________________________________

_______________________________________________________________________________________

________________________________________________

_______________________________________

________________________________________________

CHILD

Pregnancy and birth: Any complications? [ ] Yes [ ] No; if yes, briefly explain:

__________________

______________________________________________________________________

_______________________

_____________________________________________________________________________________________

______________________________________________________________________

_______________________

Developmental milestones: (Ages) Sitting: ____ Walking: ____ Talking: ____ Toilet-

trained: ____

Medical problems: [ ] Yes [ ] No; if yes, briefly explain:

____________________________________

______________________________________________________________________

_______________________

______________________________________________________________________

_______________________

______________________________________________________________________

_______________________

Please list any jobs or chores your child has at How well does your child do these

home or at schoolfor example, feeding the dog, jobs/chores?

making the bed, safety patrol. [ ] None Poor Average Great

1. ________________________________________ 1 2 3 4 5

2. ________________________________________ 1 2 3 4 5

3. ________________________________________ 1 2 3 4 5

What are your childs strengths?

__________________________________________________________________________________________________________________________________

_______________________

How many close friends does your child have? [ ] None [ ] 1 [ ] 2 or 3 [ ] 4 or more

How many close friends in the neighborhood [ ] None [ ] 1 [ ] 2 or 3 [ ] 4 or more

does your child have?

How many times a week does your child do [ ] None [ ] 1 [ ] 2 or 3 [ ] 4 or more

things with them?

Compared to other children his/her age, how Poor Average Great

does your child get along with other children? 1 2 3 4 5

What are your childs favorite recreational or extracurricular activities?

__________________________


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______________________________________________________________________

_______________________

______________________________________________________________________

_______________________

Comments:______________________________________________________________________

___________

______________________________________________________________________

_______________________

______________________________________________________________________

_______________________

Who generally disciplines the child?

_________________________________________________________

What methods are used?

____________________________________________________________________

_____________________________________________________________________________________________

Do parents agree on methods of displine? [ ] Yes [ ] No; if no, please elaborate:

_______________

______________________________________________________________________

_______________________

______________________________________________________________________

_______________________

______________________________________________________________________

_______________________

______________________________________________________________________

_______________________


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Marque

condiciones y

familiares que han

padecido

si no

tratado

Padre

Madre

Abuelo

Abuela

Hermano

Hermana

Hijo

Hija

otro

Quien?

Alcoholismo

Alergias

Defectos nacimie

Cncer

Colitis

Depresin

Ataque corazn

Hipertensin

Hgado

RinMigraas

Desorden mental

Crecimiento

Retardo mental

Desorden aprend

Problema atencin

Suicidio/Intento

Otro

Miembro de la

familia

Vive? Edad Salud Actual Si murio, cual

fue la causa

Buena

Regular

Mala

Last physical exam date:

___________________________________________________________________

Doctors notes:

______________________________________________________________________

______

______________________________________________________________________

_______________________


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SCHOOL HISTORY

Has child been enrolled in a nursery or day care? [ ] Yes [ ] No At what age?

___________

Has child attended kindergarten? [ ] Yes [ ] No At what age? ___________

Has child begun elementary school? [ ] Yes [ ] NoAt what age did he/she enter first grade? ________ What is present grade placement?

_______

If your child has ever been to school (including nursery, kindergarten, and grade

school), com-

plete the following for all grades beginning with nursery and ending with current

placement.

Please indicate if your child repeated a grade or is in a special class (gifted/talented,

learning-

disabled, behavior-disordered, emotionally disabled, etc.).

Grade School Comments

_________________ ____________________________________________________________________________

_________________ _________________

___________________________________________________________

_________________ _________________

___________________________________________________________

_________________ _________________

___________________________________________________________

_________________ _________________

___________________________________________________________

_________________ _________________

___________________________________________________________

Current school performance (for children ages 6 and older):

[ ] Does not go to school

Falla Bajo el promedio Promedio Sobre el promedio

a. Lectura

b. Escritura

c. Aritmtica

d. Pronunciacin

Otros aspectos acadmicos (asignaturas, comprensin, etc.)

e.f.

g.

h.


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PARENTAL CONCERNS

What do you feel is your childs main problem?

_____________________________________________

______________________________________________________________________

________________________

______________________________________________________________________________________________

______________________________________________________________________

________________________

______________________________________________________________________

________________________

______________________________________________________________________

________________________

______________________________________________________________________

________________________

What do you feel caused your childs problem?______________________________________________

______________________________________________________________________

________________________

______________________________________________________________________

________________________

______________________________________________________________________

________________________

What have you been told by doctors, teachers, and/or others about your childs

problems? ___

______________________________________________________________________

________________________

______________________________________________________________________

________________________

______________________________________________________________________

________________________

Has your child had any other mental health evaluations or treatment?

_______________________

______________________________________________________________________

________________________

______________________________________________________________________

______________________________________________________________________________________________

________________________

What have you done to try to deal with your childs problem?

______________________________

______________________________________________________________________

________________________

______________________________________________________________________

________________________

______________________________________________________________________

________________________

Has any other member of your childs immediate family had mental health treatment?_______


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______________________________________________________________________

________________________

______________________________________________________________________

________________________

______________________________________________________________________

________________________Other comments:

______________________________________________________________________

_____

______________________________________________________________________

________________________

______________________________________________________________________

________________________

______________________________________________________________________

________________________

May we contact the childs primary physician? [ ] To receive information[ ] To give information

_________________________________________

(Signed) Parent or guardian

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