Form available to fill out online or download, print and fill out. Download available bottom of this page.
Read the list below and circle Yes or No when thinking about your child If subject does not apply please select "No"
Has your child ever told you that they “hate” you? If so, please consider:
Most of the time during the past four weeks, has your child appeared/reported feeling: If subject does not apply please select "No"
Please list, if appropriate, any psychiatrist, psychologist, or counselor your child has seen in the past:
If your child has or is taking prescription medication for behavioral /mental health issues, please complete the next section by history from earliest to latest to current:
Please provide the names of any blood relatives that have been treated for emotional or behavioral issues. This would include issues with mood, anxiety, depression, ADHD, chemical dependencies, postpartum, schizophrenia, etc. Please describe the treatments they received and their response to them.
IF YES to any of the above questions, please identify
Please think about the prescription medications in your home. Does your child have access to them?
Has your child experienced “consequences” from substance abuse, either from you or the legal system?
Is there a history of substance abuse within the family?
During pregnancy did mom:
Please describe your child’s temperament as a baby, toddler (circle “High” or “Low”):
Is your child a survivor of emotional, sexual, or physical abuse?
Does your child have any current medical problems?
Has your child experienced any serious illness within the past year?
Does your child have any known allergies?
Please describe any medications, vitamins, supplements or home remedies your child is taking:
Is your child home schooled?
In terms of discipline, what has your child experienced from school? If "Yes" Please write a brief explanation in following text area. If "No" Please type No
Academically, how would you describe your child’s performance:
Socially, how would describe your child’s school and neighborhood experience
Has your child ever been assessed for a 504 Plan or an I.E.P.?
When it comes to homework responsibility, please consider the following when answering Yes or No: Does your child:
Who else lives in your child’s home (siblings, step-siblings, grandparents, aunts or uncles, friends, etc.)?
I sincerely appreciate you taking the time, effort, and energy to provide me with such thoughtful and insightful responses to all of these questions. By completing this questionnaire ahead of time, you have provided me with invaluable information about your child and your family.
Respectfully, Bob Schuppel
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