Child’s Name/Birthdate/Age
Person completing this form
Today's Date
Relationship to child
Your phone number/Please indicate YES or NO if we can leave a message at this number
Your address and how long have you lived at this address?
Who does the child live with?
Emergency contact name and address
Are you
Are you court ordered for child impact/parenting classes or are you seeking classes voluntarily
If court ordered what have you been ordered to do?
If court ordered please put name of person, address, and fax number
Tell me about the abilities and achievements that make you most proud of your child.
If any tell me about the actions and problems that make you most concerned for your child.
Please describe a typical weekday for your child: What does s/he do? Who does s/he interact with? What is the quality of those interactions?
Please share a bit about your philosophy, principles and beliefs about parenting.
Tell me about any special factors, such as family culture, languages, parenting and custodial arrangements, which would be helpful for me to know about:
Has there been any recent stresses and crises that have occurred in the family in the last few years. For any stress you list, describe how you think it may have affected your child. Example: Include a parent who must work unusually long hours in the list of stresses. Also, include any anticipated future stresses.
What do you think is your greatest strength as a parent (each parent)?
What do you think is your greatest limitation as a parent (each parent)?
please describe the periods of time you spend with your child that provide you with the most satisfaction as a parent.
Do you co-parent?
Please share about the periods of time that are the most difficult for you as a parent.
What experiences have been the most helpful to you as a parent?
Your child’s special skills, talents and interests (hobbies, sports, recreational, musical, TV, toy preferences, etc):
Early Development
Age 0-2: please complete all that apply.
Age 3-5: please complete all that apply:
Health/Medical History: List any current or past medical problems and medications your child is taking.
Your child's medical doctor
Your Health/Medical History: List any current/past medical problems/medications
Mental Health History: If any-Please list all mental health diagnoses:
School: Is your child homeschool or attend school?
Name of school and what grade is your child in
Is there anything else I should know that doesn’t appear on this form, but might be important for me to know about?
Your Printed Name is your electronic signature