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  • Parent Questionnaire

  • This HIPAA-compliant questionnaire provides us with important information that will be carefully considered in your child’s evaluation or treatment. Please provide as much detail as you feel is necessary.

    We do not recommend using a cell phone to complete this questionnaire, as many items will not display well. Please use a computer or tablet instead.

    You will not be able to save your progress, so please complete it in one session. It can take from 10-30 minutes to complete, depending on the level of detail you provide. Thank you!

  • How did you hear about us?*

  • Note: The patient's parent or court-appointed guardian should complete this form. 

  • Child's Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Child's Biological Sex*
  • Relationship to child*

  • Parents are:*

  • You have indicated that this child's parents are separated or divorced. Because of the sensitive nature of mental health services, we require one of two things to proceed with the appointment:

    1. A copy of the most recent child custody order. Must be received at least three days prior to the appointment. Custody orders may be emailed to info@etheridgepsychology.com or faxed to (888) 887-6361.

    2. Written consent from both parents at least three days prior to the appointment. The consent forms may be found here: Intake and Informed Consent

  • Does anyone other than the parents have legal guardianship over this child?*
  • Reason for this appointment*
  • Purpose of Evaluation (check all that apply)*

  • Reason for Psychotherapy (check all that apply)*

  • Current Concerns

  • Since the symptoms/concerns began:

  • Please rate your child on the following problems and symptoms.

    None: Not present or not a problem

    Mild: Occasionally a problem or not really a problem; not significantly interfering with functioning

    Moderate: Symptom is bothersome but may not be present every day and not significantly interfering with functioning

    Severe: Symptom is distressing and/or seriously disrupting relationships, school, work, sleep, or other area of functioning

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  • Personal Information

  • Was this child adopted?*
  • Please list the child's siblings.

  • Prenatal and Developmental History

  • Was this child born after a full term pregnancy?
  • Temperament as an infant (check all that apply):
  • Developmental delays:

  • Education

  • School Calendar
  • Elementary School Grades:
  • Middle School Grades:
  • High School Grades:
  • Please answer the following questions, leaving blank if answer is "no":
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  • Check any areas in which your child struggles at school:

  • Physical Health

  • Please answer the following questions about this child (leave blank if answer is "no"):
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  • Mental Health

  • Has this child ever:
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  • History of psychosocial stressors in child's life:
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  • Family History

  • Please indicate if this child's relatives have had any of the following:
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  • Final Thoughts

  • Should be Empty: