Background Questionnaire for Children
Form to be completed by parent
Name of Person filling out this form: *
Your answer
Person(s) filling out this form: *
Required
Today's Date *
Your answer
Child's Name *
Your answer
Child's Age *
Your answer
Child's Date of Birth *
Your answer
Child's Street Address, City and Zip Code *
Your answer
Gender *
School and Grade *
Your answer
Mother's Name and Age
Your answer
Mother's Occupation and Education
Your answer
Father's Name and Age
Your answer
Father's Occupation and Education
Your answer
Stepmother's Name and Age
Your answer
Stepfather's Name and Age
Your answer
Martial status of parents:
If parents are separated, divorced, or widowed, how old was the child when this occurred?
Your answer
List of all people living in the household - relationship to child, gender, and age
Your answer
List the name, gender, age and relationship to child of siblings, parents, or other significant people living outside the home
Your answer
Dominant language spoken in the home, and other languages, if any
Your answer
Was the child adopted?
If adopted, at what age did the adoption occur; and does the child know?
Your answer
Who referred you here?
Your answer
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