continued... Child & Adolescent Client Information Questionnaire

Please circle any of the following issues which pertain to your child:

  Shyness Depression Health problems

  Fears Separation Stomach trouble
 
  Friends Anger Bowel troubles

  Self-control Unhappiness Appetite

  Stress Relaxation Headaches

  Memory Energy Insomnia

  Making decisions Loneliness Nightmares

  Inferiority feelings Concentration Tiredness

  Learning Temper Sleep

  Peers Problems with authority Drug use

  Lying Grief Alcohol use

  School attendance Fire setting Sexual issues

  Cutting self Stealing Suicidal thoughts

Please list the members of your family and all others in your home: (Name, age, & relationship)

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