Parent Questionnaire for child or adolescent
If you have child under the age of 18 seeing a clinician for the first time at The Wellness Room, please complete this questionnaire before their first appointment.
Name of Child: *
Your answer
DOB: *
Your answer
Name parent/guardians (for minor child): *
Your answer
Are you as parents divorced, separated or still married?
If you are divorced or separated, do you have sole legal or joint legal custody?
If joint custody, please list contact information of other parent below.
Your answer
Address: *
Your answer
City/town/zip *
Your answer
Adolescent phone(if applicable):
Your answer
Parent/Guardian phone: *
Your answer
Religion/Spiritual practice: *
Your answer
Emergency contact for child (must be over 18): *
Your answer
I understand that The Wellness Room, LLC will contact my emergency contact only in case of an emergency. The Wellness Room, LLC may be required to share limited clinical information with my emergency contact (sign below) *
Your answer
Please select any family concerns you have:
Name, address and telephone number of child's pediatrician: *
Your answer
Permission to speak with child's pediatrician? (please sign below) *
Your answer
What are your goals for your child's time in therapy? *
Your answer
What you and/or they tried to solve the concerns that bring the child into therapy? *
Your answer
What do you imagine will be the first sign that our work with your child is successful? *
Your answer
How will we know your child is done with therapy? *
Your answer
Please list any other services/agencies/professionals involved with your child's care (please specify role and list names and phone numbers): *
Your answer
Please list prior therapists, psychiatrists, or mental health treatments and their names and approximate dates of service. *
Your answer
Please list any physical, mental health issues, or substance use/abuse (past or present) for family members. *
Your answer
Please list all medication and/or herbal supplements your child is currently using or has used in the past. *
Your answer
Please use this space to share anything else important you think we should know about you, your family, and/or your child. *
Your answer
Signature *
Your answer
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