How does your child get along with each parent and with each brother and/or sister. SCHOOL: Describe your child’s function at school. Are there any problems? What are his/her school-related likes and dislikes? PEER RELATIONSHIPS: Describe how your child gets along with other children. Who are his/her best friends?
Please complete this form as honestly and completely as possible. All information that you provide us will be confidential as required by state and federal law. How long has this been going on? What made you come in at this time? What do you hope …
In the first two years, did your child experience: ___Separation from mother, ___Out of home care, ___Disruption in bonding, ___Depression of mother, ___Abuse, ___Neglect, ___Chronic pain, ___Chronic Illness, ___Parental Stress
Has your child ever been hospitalized for medical or mental illness? If so, list when, where, & reason: Do you suspect or know your child drinks alcohol or uses recreational drugs? If so, what kind & how often? Do you or anyone close to your child consider his/her substance use to be a problem? What types of food does he/she often eat?
• Suspected or actual physical and/or sexual abuse or neglect of a child or vulnerable adult • Information requested in a court order • Situation in which you are judged to be in imminent or immediate danger of harming self or others.
Toolbox of Forms - AACAP
A listing of forms and resources for AACAP members to assess and monitor care.
Describe your child/adolescent’s special areas of interest, hobbies and activities: _____ Chemical Use History (to be completed by child/adolescent) Does your child use or have any problems …
Please note that the information is important for your child’s care. Please fill out forms as completely as possible and have them ready before your first counseling session. CHILD INTAKE FORM (TO AGE 11) For Parent/Guardian to Complete Child’s …
It is strongly suggested that your child be available for the majority of time they are not in school to optimize the benefits of home- based ABA therapy. I hereby waive and release ABA STEPS LLC and its associates, directors, employees, and vendors from any and all …
Your therapist will complete an intake assessment to understand how the current difficulties may have developed and are maintained within the various contexts of your child’s life. The results of this assessment may be shared with you,
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