• 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!

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

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    Pick a Date

  • 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


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  • Current Concerns

  • Please identify the severity of any current problems your child as. Leave blank if 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

  • Prenatal and Developmental History


  • Education

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  • Physical Health

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  • Mental Health

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  • Family History

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  • Final Thoughts

  • Should be Empty: