Background Information for Children
Parent Information for Who is Completing the Form
In Case of an emergency please notify:
Family Status
Family History
Developmental History
If yes, please complete the Developmental History Questionnaire. If no, please complete the following information:
Social History
Health Status and History
Mental Health Status and History
Education Status and History
Trauma/Abuse History
Legal History
Substance Use (0=no use, 1=occasional, 2=moderate, 3=heavy, 4=addiction, 5=currently in treatment)
Other Concerns
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