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