Parents’ Questionnaire for Child and Adolescent Assessments – Part 1 – Luzio & Associates Behavioral Services, Inc.

Luzio & Associates Behavioral Services, Inc.
Parent's Questionnaire
For Child and Adolescent Assessments

Child's Name

Date

Age

Date of Birth

Right or Left Handed?

Address

Primary Care Doctor

Your Name

Relation to child

Is the child adopted?

Age at Adoption

Is the child aware of the adoption?

Circumstances of the adoption:

CURRENTPROBLEMS

What problems are you seeking help for?

When these problems were first noticed and how long concerned about them?

Are the problems getting worse, better or staying the same?

What seems to have helped?

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Has your child ever been in trouble with the law?

If so, Describe:

Check all of the following behaviors which you consider to be a problem at the present time.

Often becomes quite upset when leaves home, reluctant or refuses to go to school or elsewhere because of fear of separation Worries a lot about something bad happening to major attachment figure Reluctant or refuses to go to school or elsewhere because of fear of separation Afraid or reluctant to be alone or refuses to go to sleep without being near major attachment figure Repeated nightmares about the theme of separation Repeated complaints of physical symptoms (headaches, stomach aches, nausea, etc.) when separation from major attachment figure occurs or is anticipated

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Were all of these behaviors present before age 7?

Where do these behaviors cause problems? (List all settings)

Check all of the following behaviors you have observed in the child in the past 6 months.

Excessively anxious and worried, occurring more days than not, about a number of events of activities and has difficulty controlling the worry Restless or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Difficulty sleeping or staying asleep, or restless sleep

List of all previous psychological treatment, inpatient, outpatient, psychological testing or therapy that the child has had:

List child's medical conditions (past & current):

List all medications the child is currently taking and drug previously given, especially for any psychological and behavioral problems:

Does your child have any medication allergies? If so, describe.

What are your child's favorite activities?

How often does the child comply with requests and commands?

If other, describe:

Who usually disciplines the child?

How effective are the methods you use with the child?

FAMILY DATA

Mother

Father

Step-Parent

Quality of relationship with current or previous spouse/partner (problems, violence, etc.)?

List all people that live with the child now.

List all people who have lived with the child in the past.

How well does the child get along with other people in the home?

List the changes in the child's living arrangements (family moves, divorces, changes of custody, etc.)

Note any family involvement with legal system and/or child services agency:

Note any abuse history to child (physical, sexual or neglect):

Describe any psychological problems (i.e. depression, anxiety, suicide, attention disorder, etc...) regarding the child's relatives (parents, grandparents, brothers, sisters, etc.):

Did the child's mother have any academic or behavioral problems in school? (If so, describe.)

Did the child's father have any academic or behavioral problems in school? (If so, describe.)

Luzio & Associates Behavioral Services, Inc.Parent's QuestionnaireFor Child and Adolescent Assessments

Luzio & Associates Behavioral Services, Inc.
Parent's Questionnaire
For Child and Adolescent Assessments