Parent information questionnaire (clients under 18) Parent information Questionaire (clients under 18) Additional Information regarding your AdolescentPurpose: This questionnaire helps me understand your child’s background, personality, and current functioning so that therapy can be as effective and supportive as possible. Please complete the sections you feel comfortable with. There are no right or wrong answers - your honest impressions are most helpful.1. General InformationChild’s full name(Required)Date of birth(Required) MM slash DD slash YYYY Age(Required)Current gradeType of schooling Mainstream Special needs Homeschool Online school Other Type of schooling - other (please specify)(Required)Name of school (if applicable)Who does your child live with?Names and ages of siblings2. Family and Significant Life Events2.1 Have there been any major changes or stressful events in your child’s or family’s life? (e.g., divorce, loss, illness, relocation, trauma, financial strain) Yes No If yes, please describe briefly(Required)2.2 How do you think these events have affected your child?2.3 My child is currently under significant stress Not at all Slightly Somewhat Very much 3. Your Child’s Personality, Likes, and Dislikes3.1 How would you describe your child’s personality?3.2 What are your child’s strengths?3.3 What are your child’s likes / enjoyable activities?3.4 What are your child’s dislikes / avoidances?4. Sleeping Habits4.1 Usual bedtime4.1 Wake-up time4.2 Sleep concerns Difficulty falling asleep Frequent waking Nightmares Early waking None 4.3 Recent changes in sleep? Yes No 5. Appetite and Eating HabitsPlease complete the sections below as accurately as possible.Typical meal pattern (e.g., 3 meals, snacks, skips breakfast, grazes, etc.)Appetite level (e.g., low, average, high)Food preferences / strong dislikesSensitivity to textures, smells, or specific foodsAny history of restrictive or overeating patternsRecent changes in appetite or eating habitsFamily mealtime environment (e.g., eats with family, alone, in front of screens)Please rate (Eating)My child eats regular meals Never Occasionally Often Always My child seems comfortable around food and eating Never Occasionally Often Always My child shows signs of picky eating Never Occasionally Often Always My child’s appetite seems affected by mood or stress Never Occasionally Often Always 5. Friendships and Social Interactions5.1 How easily does your child make and keep friends? Very easily Somewhat With difficulty Prefers to be alone 5.2 Who are your child’s closest friends or social connections?5.3 Has your child experienced bullying, exclusion, or conflict? Yes No If yes, please describe(Required)6. Enjoyable Activities and Coping6.1 What activities make your child feel happy or calm?6.2 What activities does your family enjoy together?6.3 What helps your child cope when upset or stressed? (Please rate)My child talks about feelings or problems Never Occasionally Often Always My child tends to keep their feelings to themselves Never Occasionally Often Always 7. Health and Medical Background7.1 Please include any illnesses, accidents, or operations - even minor ones - as these can have an impact on the nervous system and overall functioning.7.1 Details (use this format: Approx. age | Illness | Falls/physical accidents | Operations/medical procedures | Comments)7.2 Any chronic health issues? (e.g., asthma, allergies, headaches, hormonal changes)Medication list (use this format: Medication | Dosage | Purpose | Duration | Current?)8. Psychological or Therapeutic History8.1 Has your child ever received a diagnosis from a psychiatrist or psychologist? Yes No If yes, please specify(Required)8.2 Has your child received therapy, counselling, or academic support before? Yes No If yes, when and with whom?(Required)8.3 What was helpful or unhelpful about those experiences?8.4 Are there any reports or assessments (psychological, medical, or school-based) you could share? Yes No Unsure 9. School or Learning Environment9.1 Please describe your child’s learning environment Mainstream school Special needs school Homeschool Online school Other Learning environment - other (please specify)(Required)9.2 How would you describe your child’s academic performance? Above average Average Below average Variable 9.3 How does your child feel about their learning environment? Enjoys it Mixed feelings Dislikes it Highly anxious about it Please rate (School)My child is motivated to learn Not at all Occasionally Often Always My child completes schoolwork on time Not at all Occasionally Often Always Teachers/tutors have expressed concerns Not at all Occasionally Often Always If concerns, please specify(Required)My child experiences academic stress Not at all Occasionally Often Always 9.4 If academic stress is present, when was this noticed?(Required)10. Additional InformationIs there anything else you’d like me to know about your child or what you hope therapy can help with? Contact Us Name Email Address What do you need support with? Your age Your ageAdolescent - 12- 18Student - 18+Adult - 23 - 31Adult - 31 - 61Adult - 61+ Tell us which days and times would suit you? 10 + 5 = Send Phone 078 869 3602 E-mail [email protected] Address Unit 2 Tonquani House 6 Gardner Williams Avenue Paardevlei, Firgrove Rural, 711019 Mark St, Stellenbosch Central, Stellenbosch, 7600 Instagram Follow Ustherapywithelonie HPCSA registration number: 0137782 Practice Number: 072 7725 Resources Solution Focused Therapy (SFT) | Ego-state Therapy | Resource Therapy | Eye Movement Integration Therapy | Brain Working Recursive Therapy | The Gottman Method
