Adolescent Parent Report

Name of Child:  ________________________________        Date: _________
Name of Guardian: _____________________________
Relationship to Child: ___________________________
Child’s Date of Birth: ___________        Age: ____
Referred by: ________________________

Presenting Problems Checklist:
_ Very unhappy                  _ Impulsive                        _Fire setting
_Irritable                              _Stubborn                        _Stealing
_Temper outbursts              _Disobedient                    _Lying
_Withdrawn                          _Infantile                          _Sexual Trouble
_Daydreaming                      _Mean to others              _School performance
_Fearful                                _Destructive                    _Truancy
_Clumsy                                _Trouble w/ law               _Eating problems
_Overactive                          _Running away                _Short attention span
_Self mutilation                     _Sleep problems             _Sickly
_lacks initiative                     _Shy                                _Drug use
_Undependable                    _Strange behavior           _Alcohol use
_Peer conflict                       _Phobic                            _Anxious
_Grief                                  _depressed                       _Suicide talk
_Defiant                              _Hurting animals                _Homicide talk

Description of Chief Complaint:
      








What Occurred to Seek Therapy at This Time?





Child’s Name: _________________________________        Date: __________

Are the problems:                  _very serious          _serious                _not serious

What are your expectations of your child?








What changes would you like to see in your child?








What changes would you like to see in yourself?







What changes would you like to see in your family?







Child’s Name: ________________________________        Date__________

What strengths do you see in your child?





What preferences do you have?





Any additional Comments:


















___________________________
Parent/Guardian printed name                                


___________________________                        ______________
Parent/Guardian Signature                                   Date