Microsoft word - parent of adolescent questionnaire

…private, independent practitioners PARENT OF ADOLESCENT QUESTIONNAIRE

Personal and Family Information

Name of adolescent

If your child was adopted, please answer the following questions:

At what age was the child adopted?
Does the child know he or she is adopted? If yes, at what age was the child told? Has your child had any contact with the biological Does the child mention the biological parents?
Please list people living in the home (include parents, siblings, anyone living in the home):

Relationship to child

Please list other immediate family members not living in the child’s home:

Relationship to child
If so, how old was the child when he or she began How would you characterize the stepparent’s relationship with the Parent of Adolescent Questionnaire How would you characterize the child’s relationship with others in the home:

Relationship to child
Quality of relationship

Educational Information

If so, please describe the circumstances What kinds of grades does the child earn? Has your child ever received special education programming? Has your child ever won any honors or been placed on the honor roll? Please describe your child’s school adjustment
Health Information

Date of last physical exam
Please list any illness or medical conditions Please list all medications and state the purpose for each Please list allergies (include allergies to medicine) Do you (or does your child) have any concern about the child’s weight or diet? Has your child ever been unconscious from a head injury? Parent of Adolescent Questionnaire Has you child ever been abused sexually or physically, neglected, the victim of a crime, or otherwise traumatized?
To your knowledge, does your child use (or has he/she tried):

Has any other member of the family had a drug or alcohol problem now or in the past? If so, please indicate who, the substance used, and whether the problem is ongoing: Has any member of the child’s immediate or extended biological family ever had a nervous or mental disorder? If so, please state the person’s relationship to the child and the nature of the problem Has your child ever received counseling before or had an evaluation?
Social and Recreational Information

Please list your child’s hobbies and interests:
Does your child have friend his or her age? Does your child have any particular friends of whom you do not approve? Which of your child’s activities do you and/or your spouse regularly attend? Has your family taken a vacation together with this child? Parent of Adolescent Questionnaire Please describe any past or present legal problems of situations that involved your child:
Presenting Problem

Please state the reason you are seeking treatment for your child
How sever is/are the problem(s) to you?

How sever is/are the problem(s) to your child?

What have you or your child tried to do to solve the problem?
Which areas in your child’s life do these problems affect?

Please check any symptoms your child is experiencing:

Please check any recent changes your child has experienced:

Parent of Adolescent Questionnaire Please check any recent changes your child has experienced (cont.):

Media Information

Does you child have a TV in his or her room? About how many hors a week does your child watch TV? Does he/she choose the programs he/she watches? About how many hours a week does your child play video games? What are some of the video games he/she plays? Does your child get your permission before seeing a movie? Which ratings of movies is your child allowed to see? Does your child have access to the internet at home? If so, please describe any restrictions to accessing the internet: I certify that I have (check one):

Custody of this child
Managing conservatorship of this child
Possessory conservatorship of this child
Joint custody or joint managing conservatorship with
Legal guardianship
Other: please describe
Signature of parent or guardian
Parent of Adolescent Questionnaire
I give permission to
to treat my child

in psychotherapy. I am the custodial parent or legal guardian of the child and I have the legal
authority to authorize treatment.

Without the consent of anyone else.
Only with the consent of
Address (number and street)
City, State, and Zip Code
Phone Number
I agree to provide any necessary documentation.

I understand that no child custody evaluation will be performed and that therefore my therapist
will not formulate an opinion regarding any custody issues, and that requiring the therapist to
testify regarding custody issues would be harmful to my child and the therapeutic relationship.

Printed name of parent or guardian
Relationship to child
Signature of parent or guardian

Thank you for selecting me as your child’s therapist. Please feel free to discuss any concerns you may
have about your child’s treatment. At any time that I am alone with your child, you are invited to
open the door and check on your child’s well-being. The ending of therapy is as important to
children as what takes place within it and I request that you talk with me about how therapy will
terminate before we actually end.

Parent of Adolescent Questionnaire MEDICATION LISTS & MEDICAL ALLERGIES

Date Began



Mood Stabilizer:

Sleeping Medications:



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