Booking

YOUTH BECOMING ENGAGED INC.

CHILD AND ADOLESCENT INTAKE QUESTIONNAIRE - PARENT FORM

Step 1 of 6

Basic Child & School Information

Child's Name *

Date *

Birthdate *

Current Age

Address *

Home Phone

Mom's Cell

Dad's Cell

Current School

School Name *

School Address *

School Phone Number *

Grade *

Main Teacher/Principal *

Family Information

FATHER

Name

Age

Highest Education Level

Relationship Type:

Biological Adoptive Step Foster

MOTHER

Name

Age

Highest Education Level

Relationship Type:

Biological Adoptive Step Foster

Address and phone number if different from child's

Other Treating Clinicians

REFERRED BY

Name

Phone Number

Address

Therapist

Name

Phone Number

Address

Primary Care

Name

Phone Number

Address

OTHER

Name

Phone Number

Address

Current Psychiatric Medication

List all current psychiatric medication, name, dose, reason or purpose, and result/effect

Medication Name

Dosage

Reason/Purpose

Tell Us About Yourself

Why do you want to be a part of Youth Becoming Engaged?

What type of impact do you want to have on your community now and in the future?

What do you wish you could change about yourself?

What do you wish you could change about your community?

What do you hope to learn and gain from being a part of Youth Becoming Engaged INC?

What triggers you, and who can help de-escalate you when you are feeling upset?

Do you have any positive peer relationships? What makes them positive? If not, what makes them not so positive?

Is giving back to the community important to you? Why or why not?

What is your definition of leadership? Give examples of who you think has leadership qualities.

What makes you a leader? Give examples of how you have led someone with positive and negative leadership.

Past Psychological or Psychiatric Concerns

Has your child ever been treated for any other psychological or psychiatric problems at any other time? Please describe other mental health problems and what interventions have been made. What have been the results of these interventions?

Is there anything else we should know about your child's mental health?

Your Child's Social History

1. Does your child prefer to play alone or with others?

2. Does your child have any good friends? If yes, who are they and what do they do together?

3. What are your child's hobbies?

4. What is your child best at doing? What is he/she least good at?

5. Does your child ever feel guilt or remorse for wrong doings? If yes, how does he/she show it?

6. Does your child feel guilty even when what he/she has done isn't that terrible?

7. How well does your child seem to like him/herself? What does he/she like best about him/herself?

8. Does your child make negative statements about him/herself? What are they?

9. Does your child feel like a "loser"?

10. Does your child get picked on or teased? If yes, what about or why? How does he/she handle it?

11. How does your child handle peer pressure?

12. Who is your child most likely to confide in?

13. Which parent is your child closest to?

14. How does your child get along with Mom?

15. How does your child get along with Dad?

16. How does your child get along with siblings?

Is there anything else we should know about your child's social history?

Family Social History

1. Have there been any recent stresses in the family? Please explain.

2. Has anyone recently left the family or died? Please explain.

3. Has anyone recently joined the family? Please explain.

4. Have there been any recent employment changes or job losses? Please explain.

5. Have there been any recent financial changes (good or bad)? Please explain.

6. How many times has your family moved during your child's lifetime? Please explain your moves and reasons for moving. How did your child adapt to moving?

Booking

YOUTH BECOMING ENGAGED INC.

CHILD AND ADOLESCENT INTAKE QUESTIONNAIRE - PARENT FORM

Basic Child & School Information

Current School

Family Information

FATHER

MOTHER

Other Treating Clinicians

REFERRED BY

Therapist

Primary Care

OTHER

Current Psychiatric Medication

Tell Us About Yourself

Past Psychological or Psychiatric Concerns

Your Child's Social History

Family Social History

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