PARENT QUESTIONNAIRE
General Information
Name of Child
*
Date of Birth
/
Month
/
Day
Year
Date
Cell phone
Home phone
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian 1 Full name
*
Profession & place of work
Cell phone
*
Home phone
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian 2 Full name
Profession & place of work
Cell phone
Home phone
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please briefly describe general reasons for seeking out DBT Group for your child:
What changes do you hope to see as a result of DBT Group?
Family & Relationship Information
Who has custody of child:
Both parents
Mother only
Father only
Other
Who has medical decision making for the child if parents do not share custody?
List all people currently living in the household and relevant others who have lived there in the past (include name, age, relationship, and note if they no longer live in the home).
Please list any adoptions, previous marriages, separations, divorce, deaths, or major changes in the immediate family structure and approximate dates.
Describe any significant current family concerns/stressors.
Describe your child's relationship with:
Parent/Guardian 1 (specify)
Parent/Guardian 2 (specify)
Siblings
Peers
Adults in general
Significant others
Education History
Current School
Grade
Principal
School Counselor(s)
Please list all previous schools and dates attended.
What are your child's grades like now and in the past?
Please list your child's academic/extracurricular strengths.
Please list your child's academic/extracurricular difficulties.
How much homework does your child have at night? Are there any difficulties or issues starting, sticking with, or finishing homework?
Has your child ever repeated a grade or received special education services? If so, please provide details.
How does your child do socially at school?
Has your child ever been disciplined at school (i.e., suspensions, expulsions, etc.)? If so, please provide details.
Physical & Mental Health History
Individual Therapist's Name
Individual Therapist's Phone
How long has your child been seeing their current individual therapist and how often do they currently meet:
How does your child respond to individual therapy:
Has your child received previous outpatient mental health treatment (prior to current individual therapist)? If yes, please list names of providers and approximate dates.
Has your child received previous inpatient mental health treatment? If yes, please name the program/hospital and approximate dates.
Psychiatrist's Name
Psychiatrist's Phone
Other relevant medical providers:
Other relevant medical providers:
Current medications and dosages:
Please describe any issues during pregnancy/birth or developmental delays:
Please list relevant previous physical illnesses, injuries, hospitalizations:
Please list family mental and physical health history:
Behavioral/Emotional Concerns
Please briefly list any concerning behaviors you have observed in your child.
Has your child experienced anything you would consider traumatic (i.e., abuse, loss, victimization, significant changes, etc.)?
Has your child talked about or taken actions to harm self or others?
Describe any concerns about risk taking behaviors (i.e., with regard to substance use, sex, internet/social media, etc.).
Describe any significant patterns of worry, anxiety, fears, or shyness.
Describe any unusual behaviors, rituals, habits, etc.
Describe any significant fluctuations in mood.
What is your child's usual disposition?
What is the most effective form of discipline? Do caregivers agree on discipline?
How does child respond to discipline?
What activities does your child enjoy (sports, hobbies, interests, etc.)?
What are your child's strengths? What do you enjoy the most about your child?
Please provide any additional information that you think might be helpful.
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