FAMILY HISTORY FORM

 

In order to ensure that our time together is effective, please fill this out as completely as you can, with as much detail as possible. If you have already answered a question in a previous part of this form, please say "see previous answer" or something similar ... you do not need to answer things twice! Also, if some of the questions do not pertain to your child, please write N/A as necessary.
Parent #1 Name
Parent #1 Name
Parent #2 Name
Parent #2 Name
Best Phone Number to call for follow-up calls *
Best Phone Number to call for follow-up calls
Child's Name
Child's Name
Date of Birth
Date of Birth
Please describe 2 different negative or problem behaviors that happened in the last week. In your description please include the following: 1) What happened right before the behavior occurred? 2) What was/were the actual behavior(s)? 3) What happened right after the behavior occurred (What did you or someone else do)? 4) How long did the incident last?