Follow-up Assessments Packet - Caregiver
Welcome, Caregiver. Your Clifford Beers clinician would like to assess your progress in treatment to ensure you're getting the most out of your care.
Please fill out the following information to the best of your ability. Before answering any questions, please read through the instructions and pay close attention to the date range you should be answering for (for example, "past 6 months"). Read all questions and response choices carefully (the response choices may change). Answer the questions as honestly as you can.
Be sure to hit "Submit" at the end to send us your answers. Contact your clinician if you have any questions.
What is the name of your Clinician?
What is your child's First Name?
What is your child's Last Name?
What Grade is your child currently in?
Too Young for School
2 Year College/University
4 Year College/University
High School Graduate
Unknown/Decline to Answer
Not in School
What is your child's Date of Birth?
What was your child's Sex Assigned at Birth?
What is your child's Race?
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Decline to Answer
What is your relationship to the child receiving services?
What Age is your child? (This will determined which assessments you are asked to answer.)
0-4 years old
5-17 years old
Are you ready to go to the next section?
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This form was created inside of Clifford Beers Guidance Clinic.