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Questionnaire
Please fill out the information below so that I have a better understand of your families history and issues that you are experiencing at the present time.
Personal Info
Your Name
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Questionnaire
Q)
At what age was your child when you first noticed their behaviors were not the norm?
Q)
How old is your child now?
Q)
Is this child a biological child or an adopted child?
Q)
If adopted, what age were they adopted and from what area or country were they adopted from?
Q)
At what age did your child first live with you?
Q)
Did this child live elsewhere prior to living with you? If so give details on the places your child has lived and with whom? Give details in the order of first to last placement.
Q)
Was your child hospitalized or did your child experience trauma such as the deployment of a parent, parents divorcing, abuse, etc.? Did your child experience a time period when their primary caretaker was emotional unavailable during your child's first 5 years of life if so explain?
Q)
How long has child lived with you?
Q)
Describe the problems you are experiencing with your child now.
Q)
How do these problems make you feel?
Q)
How many siblings are in your family? Give names and ages.
Q)
Does this child have any biological siblings and how many reside with this child?
Q)
How many other children are adopted in your home?
Q)
How is the child's relationship with siblings?
Q)
Who is the primary caretaker in your home?
Q)
What person is this child closest to?
Q)
What methods of treatment have you sought out for your child and what has been the outcome?
Q)
If you are in therapy with your child who is your therapist, how often are your sessions and has this been benefiting your child and family?
Q)
Are you a single parent and do you have emotional support?
If you have a partner do you feel they understand the problems at hand? Do you feel understood and supported by your partner?
Q)
How do the other children in the home feel and how do they feel about this child?
Q)
What brings you to this training and what are you hoping to achieve?
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