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Luzio & Associates Behavioral Services, Inc.
Parent's Questionnaire
For Child and Adolescent Assessments
Child's Name
Date
Preferred Name
Age
Date of Birth
Primary Care Doctor
Your Name
Relation to child
Check all of the following behaviors you have observed in the child in the past 6 months.
Often loses temper
Often argues with adults
Often actively defies or refuses adult requests or rules
Often deliberately annoys other people
Often blames others for own mistakes or misbehavior
Often touchy or easily annoyed by others
Often angry and resentful
Often spiteful or vindictive
Often bullies, threatens or intimidates others
Often initiates physical fights
Has used weapon that can cause serious physical harm (bat, brink, knife, gun, etc.)
Has been physically cruel to people
Has been physically cruel to animals
Has stolen while confronting a victim
Has forced someone into sexual activity
Has deliberately destroyed others' property
Has broken into someone else's house, building or car
Often lies to obtain goods or favors or to avoid obligations ("cons" others)
Has stolen items of nontrivial value without confronting a victim (shoplifting, etc.)
Often stays out at night despite parental prohibitions, beginning before age 13
Has run away from home overnight at least twice (or once without returning for a lengthy period of time)
Often truant from school, beginning before age 13 years
Has been in trouble with the law
Check all of the following behaviors you have observed in the child in the past 12 months.
Often bullies, threatens or intimidates others
Often initiates physical fights
Has used weapon that can cause serious physical harm (bat, brink, knife, gun, etc.)
Has been physically cruel to people
Has been physically cruel to animals
Has stolen while confronting a victim
Has forced someone into sexual activity
Has deliberately destroyed others' property
Has broken into someone else's house, building or car
Often lies to obtain goods or favors or to avoid obligations ("cons" others)
Has stolen items of nontrivial value without confronting a victim (shoplifting, etc.)
Often stays out at night despite parental prohibitions, beginning before age 13
Has run away from home overnight at least twice (or once without returning for a lengthy period of time)
Often truant from school, beginning before age 13 years
Has been in trouble with the law
Check all of the following behaviors you have observed in the child in the past 6 months.
Often does not give close attention to details or makes careless mistakes
Often has difficulty sustaining attention
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish things
Often has difficulty organizing tasks and activities
Often avoids or dislikes tasks that require sustained mental effort
Often loses things
Often easily distracted by extraneous stimuli
Often forgetful in daily activities
Often fidgets with hands or feet or squirms in seat
Often leaves seat in classroom or in other situations in which remaining seated is expected
Often runs about or climbs excessively when it is inappropriate
Often has difficulty playing quietly
Often "on the go" or often acts as if "driven by a motor"
Often talks excessively
Often blurts out answers before questions have been completed
Often has difficulty awaiting turn
Often interrupt or intrudes on others
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
Check all of the following that your child has now:
Depressed mood nearly every day
Low interest or no pleasure in things he/she used to enjoy
Greatly decreased or increased appetite
Not able to sleep or sleeping too much
Restlessness or feel like you're being slowed down
Feeling tired all of the time, lack of energy
Low self esteem
Feeling hopeless, helpess or worthless
Poor concentration
Thoughts about hurting yourself or others
My child has had inpatient or outpatient therapy services in the past.
YES
NO
If so, please state where and when.
My child has medical problems?
YES
NO
Describe:
FAMILY DATA
Mother
Father
List all people who live with the child now:
List all people who have lived with the child in the past.
The child's mother or father had academic or behavioral problems in school?
YES
NO
Describe:
DEVELOPMENTAL HISTORY
Any complications with mother or child during pregnancy, labor, or delivery?
YES
NO
Describe:
When did your child achieve the following milestones?
Smiling (range: 2-6 months)
EARLY
ON-TIME
LATE
Sitting up (range: 6-8 months)
EARLY
ON-TIME
LATE
Crawling (range: 7-10 months)
EARLY
ON-TIME
LATE
Fear of Strangers (range: 7-10 months)
EARLY
ON-TIME
LATE
Walking Independently (range: 10-16 months)
EARLY
ON-TIME
LATE
Use meaningful words (range: 12-24 months)
EARLY
ON-TIME
LATE
Using short sentences (range: 24-36 months)
EARLY
ON-TIME
LATE
Were you ever told that your child is "mentally hanicapped" or "retarded" or "developmentally delayed"?
YES
NO
My child has experienced sexual abuse
YES
NO
My child has experienced physical abuse
YES
NO
My child has thoughts or attempts of suicide
YES
NO
EDUCATIONAL HISTORY
What school does the child attend?
What grade is the child in?
Has the child ever been held back in a grade?
YES
NO
If so, what grade?
Is the child in Special Education?
YES
NO
Does the child have an IEP or 504 Plan?
YES
NO
If so, what for and how long?
Check any of the following that your child has difficulty completing in daily life:
Morning activities:
Getting out of bed on time
Completing morning routine tasks (i.e., brushing teeth, washing face, etc.)
Eating breakfast
Getting dressed
Getting to school (i.e., catching bus, walking, leaving on time etc.)
Interacting with family members during morning routine.
School activities:
Completing classwork
Eating lunch
Having appropriate social interactions with other children
Having appropriate social interactions with teachers/school officials
After School:
Going to friend's home, daycare, after school program
Doing homework
Engaging in extracurricular activities (i.e. sports, clubs, etc.)
Watching excessive amoutns of television or playing video games
Engaging in physical activity such as exercising
Participating in mealtime
Completing household chores
Completing hygiene activities (i.e. bathing, showering, brushing teeth, etc.)
Inteacting appropriately with family members (parents and siblings)
Getting to bed
Signature
Relationship to client:
Send
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