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Parent Questionnaire
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Email
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Your email
Parent Name(s)
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Your answer
Phone number
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Your answer
Occupation(s)
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Child Name and Age
Your answer
Child Name and Age
Your answer
Child Name and Age
Your answer
Child Name and Age
Your answer
List main concerns in order of importance
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List main goals in order of importance
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Does your family have a regular weekday routine?
Yes
No
Sometimes
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Please briefly explain your weekday routine as a family
Your answer
Does your family have a regular bedtime routine?
Yes
No
Sometimes
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Please briefly explain your bedtime routine with your child(ren).
Your answer
Do you experience any bedtime/night time struggles with your child? If so please explain.
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Does your family have a regular weekend routine?
Yes
No
Sometimes
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Please briefly explain what weekends look like for your family.
Your answer
Who is the primary caregiver for your child(ren)?
Your answer
If married, do you feel you and your spouse are on the same page in terms of raising your child(ren)?
Your answer
If parenting time (custody) is shared, do you feel that you are on the same page as the other parent in terms of raising your child(ren)?
Your answer
Are there any other caregivers involved in raising/caring for your child(ren)?
Your answer
Are there any concerns other caregivers, teachers, or relatives have brought to your attention about your child(ren)?
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Has your child been diagnosed with any medical condition or learning challenge such as dyslexia, torticollis, acid reflux, ADHD, etc.?
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What parenting strategies have you tried so far?
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What parenting strategies have worked well?
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What hasn't worked so well, and why?
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Do you feel your child has a balanced diet?
Yes
No
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