Child Intake Documents I And Ii Page 2

If your child is currently taking medications please list below:

Name of medication

Dosage

Prescribing physician

Does this child have a history of being abused, either physically, mentally, or through neglect? ( ) yes ( ) no

If yes, please list: 1. Date(s)

2. Location(s)

3. Name(s) of perpetrator(s)

4. Type of abuse:

Is legal action pending related to abuse? ( ) yes ( ) no

Place a check next to other legal actions that might impact, or have impacted, your child?

____Custody ____Adoption ____Visitation _____Parent in prison/jail ____Parent or sibling in rehab

If any of the above is checked, please describe briefly___________________________________________

Has your child had a traumatic experience other than described above? If so, please describe

Which approaches to discipline have been most successful?__________________________________________

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Parent category: Business