JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Child Information
Cizelle Louw | M.A. KLIN. SIELK. (UNIV STELL) | Clinical Psychologist | Pr Nr 8616825 PS0026964
Sign in to Google
to save your progress.
Learn more
Please take note: information you provide here is protected as confidential information.
A) PERSONAL INFORMATION OF PARENT
Name and Surname of Parents
Your answer
Date of birth of Child
MM
/
DD
/
YYYY
Marital Status of Parents
Never married
Domestic Partnership
Separated
Divorced
Married in community of Property
Married without community of Property
Widower / Widow
Please list children/age
Your answer
List the members of your current household:
Person 1 (Name, Gender, Age, Relationship with you)
Your answer
Person 2 (Name, Gender, Age, Relationship with you)
Your answer
Person 3 (Name, Gender, Age, Relationship with you)
Your answer
Person 4 (Name, Gender, Age, Relationship with you)
Your answer
Person 5 (Name, Gender, Age, Relationship with you)
Your answer
Person 6 (Name, Gender, Age, Relationship with you)
Your answer
Person 7 (Name, Gender, Age, Relationship with you)
Your answer
Home phone number
Your answer
May we leave a message?
Yes
No
Cell/Other Phone:
Your answer
May we leave a message?
Yes
No
Email
Your answer
May we email you? (Please note: Email correspondence is not considered to be a confidential medium of communication.)
Yes
No
Referred by ...
Friend/family
GP
Psychiatrist
Google
Another psychologist
Clear selection
Career of Parents - Job description:
Your answer
B) GENERAL HEALTH INFORMATION
Is your child currently taking any prescription medication?
Yes
No
Please list and provide dates:
Your answer
Please list any specific sleep problems that your child might be experiencing:
Your answer
How many times a week does your child generally exercise?
Your answer
What types of exercise does your child participate in:
Your answer
Please list any difficulties your child experience with appetite or eating patterns:
Your answer
Does your child use alcohol? How often, if yes?
Your answer
How often does your child use drugs?
Daily
Weekly
Monthly
Infrequently
Never
Name the specific drug/s
Your answer
C) MENTAL HEALTH INFORMATION
Has your child ever been prescribed psychiatric medication?
Yes
No
Please list and provide dates:
Your answer
Does your child suffer from any of the following
Depression
Bipolar Mood Disorder
Panic attacks
Weight Changes
Difficulty concentrating
Body aches/pains
Perfectionism
Difficulty sleeping
Nightmares
Anxious/tense
Lonely/isolated
Inferiority feelings
Thoughts of suicide
Hearing voices
Low energy
Frustration
Rage
Feelings of hopelessness
Obsessions/compulsions
Family mental health history:
In the section below indicate if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.)
Alcohol/substance abuse (Yes/No - If YES, then who?)
Your answer
Anxiety (Yes/No - If YES, then who?)
Your answer
Domestic Violence (Yes/No - If YES, then who?)
Your answer
Eating Disorders (Yes/No - If YES, then who?)
Your answer
Bipolar Disorder (Yes/No - If YES, then who?)
Your answer
Obsessive Compulsive Disorder (Yes/No - If YES, then who?)
Your answer
Schizophrenia (Yes/No - If YES, then who?)
Your answer
Suicide attempts (Yes/No - If YES, then who?)
Your answer
Attention Deficit Disorder (Yes/No - If YES, then who?)
Your answer
Is your child currently in a romantic relationship?
Yes
No
If yes, for how long?
Your answer
On a scale of 1 – 10, how would you rate this relationship? 1 = poor 10 = excellent
Your answer
What significant life changes or stressful events have you experienced recently?
Your answer
D) INFORMATION FOR THERAPEUTIC PURPOSES
Do you consider yourself to be spiritual or religious?
Yes
No
If yes, describe your faith or belief
Your answer
If yes, is it important to you that it forms part of the therapeutic process
YES
NO
MAYBE LATER
Clear selection
What are your central issues/problems with your child?
Your answer
What are the factors (or circumstances) that seem related to the issue (or contributed to the problem)?
Your answer
What measures have been used so far in an attempt to solve the key issues with your child?
Your answer
What do you consider to be some of your child’s strengths?
Your answer
And your family as a whole’s strengths?
Your answer
Mother’s strengths:
Your answer
Father’s strengths:
Your answer
Other members of household:
Your answer
What is your goal for therapy?
Your answer
How and how soon do you anticipate the problem to be solved?
Your answer
How do you think therapy will help you as a parent to deal with the problem?
Your answer
How do you think therapy will help your child to deal with the problem?
Your answer
How would you know that you have indeed resolved this problem? A "sign" that your child has turned a corner.
Your answer
What made you decide that now is the right time for therapy?
Your answer
Our biggest dream for our child is ...
Your answer
The difference that reaching this dream will make is ...
Your answer
We are here at this point regarding our dream ...
Still a very long way to go
1
2
3
4
5
6
7
8
9
10
We have arrived
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
