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Parent Questionnaire

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Please answer the following questions as thoroughly and as honestly as possible. All information disclosed will remain confidential and I will approach your concerns in a subtle, professional manner. In order to turn your son/daughter into a responsible, confident, risk-taking young adult I need to first understand where they are at this point. Thank you.

Child Name*

Age

Grade

Cell Phone

Email

Parent's Names (Mom)*

Cell Phone

Email

Parent's Name (Dad):*

Cell Phone

Email

Emergency Contact Name (if parents can’t be reached)*

Cell Phone*

Section 1: Family Dynamic & Parent Expectations

What is the makeup of your household (married/divorced, siblings, others)?

Describe the family dynamic. How are the relationships between your child and other members of the household?

Who is part of your child’s support system (who is in their lives)?

Rate your child’s behavior at home on a scale of 1-10.

(Poor)

1

2

3

4

(Neutral)

6

7

8

9

10

(Commendable)

Explain your selection

Rate your child's work ethic on a scale of 1-10.

(Minimal)

1

2

3

4

(Neutral)

6

7

8

9

10

(Maximal)

Explain your selection

How would you describe your parenting style? Please rate the level of structure/rule enforcement.

(Enabling)

1

2

3

4

(Neutral)

6

7

8

9

10

(Too tough/strict)

Explain your selection

What is the most important thing I should know about your child?

What are your greatest concerns?

Section 2: School/Social Dynamic & Activities

Rate your child’s behavior at school on a scale of 0-10.

(Poor)

1

2

3

4

(Neutral)

6

7

8

9

10

(Commendable)

Explain your selection

How are their grades and relationships with their teachers?

How are their relationships with their peers? What are their friends like?

What sports/physical activities does your child engage in? What are their strengths and weaknesses?

Section 3: Health & Personality

How would you describe your child’s overall physical health?

How would you describe your child’s overall emotional health

Rate your child's self-esteem on a scale of 0-10.

(Low)

1

2

3

4

(Neutral)

6

7

8

9

10

(High)

Explain your selection

Does your child have any injuries/medical conditions and/or is prescribed medication at this time?

Are there any counseling services or relevant medications being prescribed at this time?

What is your child passionate about?

What would you like your child to gain from this program?

Is there anything else I should know about your child?

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