RICHARD COSTA, LCSW PARENT QUESTIONNAIRE In order for me to be able to fully evaluate your child/adolescent, please fill out the following questionnaire to the best of your ability. I realize that there may be information that you do not remember or have access to; do the best you can. Thank you! IDENTIFYING INFORMATION ON CHILD/ADOLESCENT Name_______________________________ First Appointment Date_________________ Birth Date_________________________ Age______________ Sex__________________ School_____________________________ Grade__________________________________ Religion___________________________ Parent(1)______________________________ Race______________________________ Parent(2)_______________________________ Address____________________________________________________________________ City_________________________________ State____________ Zip________________ Home Phone # ____________ Parent(1) Work #________ Parent(2) Work #________ Who is child/adolescent currently living with?_____________________________ Insurance Subscriber Name:_________________________________________________ Insurance Subscriber Date of Birth:______________ SSN:____________________ Child's SSN:_________________________________ Name of Insurance Provider:________________________________________________ Insurance ID Number: _____________________________ Group No.______________ REASON FOR SEEKING HELP AT THIS TIME (Please give a summary of your main concerns and why you are seeking assistance at this time.) ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ _________________________________________________ PRIOR ATTEMPTS TO CORRECT PROBLEMS/PRIOR PSYCHIATRIC HISTORY (Please include contacts with other professionals, medications, types of treatment, etc.) Why did you seek previous help? What did you hope to have happen? What were the results? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ____________________________________________________________ MEDICAL HISTORY: Current medical problems/medications:________________________________________________ _____________________________________________________________________________________ Past medical problems/medications:___________________________________________________ _____________________________________________________________________________________ Doctors or clinics seen regularly:___________________________________________________ _____________________________________________________________________________________ Prior hospitalizations (place, cause, date, outcome):________________________________ _____________________________________________________________________________________ Present Height:_______________________ Present Weight:______________ FAMILY HISTORY: Parents Responsible for Child: (Please include name and relationship of all parents, i.e.,.; Birth, step, adoptive, foster, legal guardian) Parent (1) _________________________________________________________________________ Parent (2) _________________________________________________________________________ Parent (3) _________________________________________________________________________ Parent (4) _________________________________________________________________________ Parent (5) _________________________________________________________________________ Parent (6) _________________________________________________________________________ Family Structure: (Who lives in the current household with the child/adolescent, please give relationship to the child/adolescent): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Family Development: (include marriages, significant relationships, separations, divorces, deaths, traumatic events, losses, etc.): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Parent (1) History: Age ______ Outside work _________________________________________ School: highest grade completed: ______________ Learning problems (specify) _________________________________________________________ Behavior problems (specify) _________________________________________________________ Marriages ___________________________________________________________________________ Medical problems ____________________________________________________________________ Childhood atmosphere (family position, abuse, illnesses, etc.)_______________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Does parent regularly drink? ___ smoke? ___ Use prescribed or non-prescribed drugs?____ Which drug(s)?_______________________ If so, does the habit hurt: relationships? ______ jobs? _____ When did the habit begin: ___________________________________________________________ Has the parent ever sought psychiatric treatment? Yes ____ No ____ If yes, for what purpose? ___________________________________________________________ _____________________________________________________________________________________ Have any of the parent's blood relatives her had any learning problems or psychiatric problems including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify) ___________________________________ _____________________________________________________________________________________ Parent (2) History: Age ______ Outside work _________________________________________ School: highest grade completed: ______________ Learning problems (specify) _________________________________________________________ Behavior problems (specify) _________________________________________________________ Marriages ___________________________________________________________________________ Medical problems ____________________________________________________________________ Childhood atmosphere (family position, abuse, illnesses, etc.)_______________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Does parent regularly drink? ___ smoke? ___ Use prescribed or non-prescribed drugs?____ If so, does the habit hurt: relationships? ______ jobs? _____ When did the habit begin: ___________________________________________________________ Has the parent ever sought psychiatric treatment? Yes ____ No ____ If yes, for what purpose? ____________________________________________________________ _____________________________________________________________________________________ Have any of the parent's blood relatives ever had any learning problems or psychiatric problems including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify) ___________________________________ _____________________________________________________________________________________ ___________________________________________________________________ (If applicable) Parent (3) History: Age ______ Outside work _________________________________________ School: highest grade completed: ______________ Learning problems (specify) _________________________________________________________ Behavior problems (specify) _________________________________________________________ Marriages ___________________________________________________________________________ Medical problems ____________________________________________________________________ Childhood atmosphere (family position, abuse, illnesses, etc.)_______________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Does parent regularly drink? ___ smoke? ___ Use prescribed or non-prescribed drugs?____ If so, does the habit hurt: relationships? ______ jobs? _____ When did the habit begin: ___________________________________________________________ Has the parent ever sought psychiatric treatment? Yes ____ No ____ If yes, for what purpose? ___________________________________________________________ _____________________________________________________________________________________ Have any of the parent's blood relatives her had any learning problems or psychiatric problems including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify) ___________________________________ _____________________________________________________________________________________ (If applicable) Parent (4) History: Age ______ Outside work _________________________________________ School: highest grade completed: ______________ Learning problems (specify) _________________________________________________________ Behavior problems (specify) _________________________________________________________ Marriages ___________________________________________________________________________ Medical problems ____________________________________________________________________ Childhood atmosphere (family position, abuse, illnesses, etc.)_______________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Does parent regularly drink? ___ smoke? ___ Use prescribed or non-prescribed drugs?____ If so, does the habit hurt: relationships? ______ jobs? _____ When did the habit begin: ___________________________________________________________ Has the parent ever sought psychiatric treatment? Yes ____ No ____ If yes, for what purpose? ___________________________________________________________ _____________________________________________________________________________________ Have any of the parent's blood relatives her had any learning problems or psychiatric problems including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify) ___________________________________ _____________________________________________________________________________________ Siblings (names, ages, problems, strengths, relationship to child/adolescent) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ __________________________________________ Family Stresses (please list current factors that are a source of stress in the family: ______________________________________________________________________________________ ____________________________________________________________________________________ CHILD'S OR ADOLESCENT'S DEVELOPMENTAL HISTORY: Prenatal events: Parent's attitude toward pregnancy _________________________________________________ Conception ease _______ planned ______ unplanned _______ Pregnancy complications (bleeding, excess vomiting, medication, infections, x-rays, smoking, alcohol/drug use, etc.)____________________________________________________ Birth and Postnasal period: Birth weight ________ Length _________ Labor duration ____________ Delivery: Vaginal ____ Cesarean section ______ Problems ___________________________ Mother's health after delivery _____________________________________________________ Post delivery depression? _______ If yes, how long? ________________________________ Primary caretaker for child, first year? __________________ Thereafter? ____________ Feeding history: Breast or bottle ___________________ Age weaned ___________________ Food allergies: ____________________________________________________________________ Current eating problems: ___________________________________________________________ Excessive dieting, overeating, purging? ____________________________________________ ____________________________________________________________________________________ Sleep Behavior: Sleepwalking, nightmares, recurrent dreams, current problems ( getting up or going to bed): _______________________________________________________ ____________________________________________________________________________________ Separations: from parents: age, duration, reaction to: _____________________________ ____________________________________________________________________________________ Any problems with fine or gross motor coordination? ________________________________ Any problems with language development (vocabulary, articulation, comprehension)? ____________________________________________________________________________________ Any problems with gender identity? _________________________________________________ Any problems with toilet training? _________________________________________________ Any problems with social development (What was the quality of attachment to mother and father? Was the child able to separate from parents easily at 2-3 years of age? Could child play cooperatively with others by the age of 4? What was the quality of early peer interactions?) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Emotional development: Early temperament _____________________________________________________________________________________ Current personality _________________________________________________________________ Mood ________________________________________________________________________________ Habits ______________________________________________________________________________ Fears/phobias _______________________________________________________________________ Ability to express feelings _________________________________________________________ Behavior/Discipline: Responsibilities and chores _________________________________________________________ Compliance vs non-compliance ________________________________________________________ Lying/stealing ______________________________________________________________________ Rule breaking _______________________________________________________________________ Consequences ________________________________________________________________________ Methods of discipline _______________________________________________________________ Other problems ______________________________________________________________________ Physical/Sexual Abuse _____________________________________________________________________________________ _____________________________________________________________________________________ Drug/Alcohol History ________________________________________________________________ ________________________________________________________________________________ Do you suspect any problems with gang or peer relationships? ________________________ _____________________________________________________________________________________ __________________________________________________ School History: Current grade ____ School contact (teacher or other staff): _________________________ Number of schools attended ____________ average grades ______________________________ Attendance problems: ________________________________________________________________ _____________________________________________________________________________________ Has he or she been held back a grade?:__________________________________________ Homework problems ________________________________________________________________________________ Behavior problems ___________________________________________________________________ Specific learning disabilities ______________________________________________________ Quality of relationship with teachers _______________________________________________ How does he/she get along with peers? _______________________________________________ Regarding friends, does he/she have: many ____ few ___ none ___ Are friends generally: older ___ younger ___ same age ___ or mixed ages ____ His/her strengths: ______________________Motivational level: ________________ Interests and strengths (as viewed by caretaker): Number of television and video hours per week and program choices ___________________ _____________________________________________________________ Number of computer hours per week and program choices:_________________________ Hobbies and interests (how is free time spent: ______________________________________ ________________________________________ Jobs and work experience ____________________________________________________________ Requested resources and privileges (what does he or she want to look forward to): ________________________________________________________________________________ Overall strengths of child: ________________________________________________________ ____________________________________________________________________________________ ____________________ Legal History: Has he/she ever been in trouble with the law? _______________________________________ If so, how many times (give approximate dates) ______________________________________ What was the court disposition? _____________________________________________________ Is the child/adolescent currently on probation? ________________________________________________________________________________ If yes, who is the Probation Officer? ______________________Phone: ____________ Is there any legal action currently pending? ___________________________________ ________________________________________________________________________________ REGARDING TREATMENT What has your child/adolescent been told about the purpose of the appointment? ________________________________________________________________________________ ________________________________________________________________________________ How does he or she feel about coming in? _______________________________________ _________________________________________ What do you hope we will accomplish in our work together? ______________________ ________________________________________________________________________________ __________________________________________________________ Name of person who completed this form: _____________________________________________ Signature:_____________________________________Date: __________________________ (parent/step parent/foster parent/guardian)