Parent Questionnaire

Helping your young person requires us to understand what they’re going through. This questionnaire helps us formulate with you an understanding of why your child is having their difficulties in this way at this time. Try and be as descriptive as possible. We will learn about them more at your assessment.

Your information will be kept only for the purposes of the assessment and stored in your child’s clinical record. Information sharing with other clinical providers can occur with your consent. Please refer to the consent and financial agreement document provided to you or our privacy policy for more information.

Your Name(Required)

Child's Name(Required)

Child's Age(Required)

Please describe your child’s current personality in five words or more:

Please tell us some good things about your child, their hobbies, their interests and things they are interested in.

Please tell us who lives in the home your child lives in?

Please tick the concerns you have about your child:

Sadness

Suicidal Ideation

Self Harm

Anxiety

Anger

ADHD

Eating Problems

Hallucinations

Learning Difficulties

Other concerns:

Please describe how the issues impact your child’s life:

Most concerning issue:

Next concerning issue:

Other concerning issues:

Can you describe the first time you noticed these issues becoming a concern?

How long have the difficulties been occurring?

Has something made it worse recently?

Tell us about the treatments that you have tried so far? (Please include all therapies and medication names and dosages if you can).

Are there other professionals involved in your child’s care? Please also provide your GPs name and contact details.

Are there other medical or health concerns for your child?

Please list any medications they are currently taking:

Please tell us about the impact of your child’s difficulties on their relationships.

Describe how your child’s problems affect the relationship between each PARENT:

Describe how your child’s problems affect the relationship between their SIBLINGS:

Describe how your child’s problems affect the relationship they have with their FRIENDS:

Describe how your child’s problems affect the relationship they have with THEMSELVES:

Help us understand the background of your child’s difficulties.

About The Family

Can you tell us about other members of the family (including extended family) who have the same or other mental health issues?

Are there any other important facts we should know about the maternal or paternal sides of the family? (eg. Learning difficulties, medical or mental health issues)?

About your child's early life

Were there any medical or other concerns relating to the pregnancy and birth of your child?

How would you describe the challenges you found as a mother/father in your child’s first year?

What was your child like when they were a baby? How would you describe their sleeping or feeding habits?

What was their development like eg. the usual milestones of walking, talking, socialising?

Was there any evidence of anxiety early on?

Please indicate if any of the following concerns were experienced by your child at school or in their earlier years:

Please provide more information if you wish:

Have there been any significant events (positive or negative) that may have impacted your child’s emotional development?

What goals do you have for your child and family's mental health treatment?

Where To Find Us

Woodend (Head Office)

Sunbury (Melbourne)

Mildura

Parent Questionnaire

Please describe how the issues impact your child’s life:

Please tell us about the impact of your child’s difficulties on their relationships.

Help us understand the background of your child’s difficulties.

Where To Find Us

Get Help For Your Family

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