Full Name: Preferred Name: Contact Email: Contact Phone: 1. How many days have you been unexpectedly absent or tardy from work/school in the last 30 days? 2. Do you have any current or history of medical conditions/illnesses? Has your child (or if child answering, have you...) 3. been very concerned about his/her weight? YesNo 4. moved in the last 2 years? YesNo 5. changed schools in the last 2 years? YesNo 6. been disciplined at school in the last year? YesNo 7. experienced a recent death of someone close? YesNo Does your child (or if child answering do you...) 8. drink or use drugs? YesNo 9. starve him/her, or make yourself throw up? YesNo 10. self-injure? YesNo 11. have any suicide thoughts or past attempts? YesNo 12. have any thoughts about hurting others? YesNo 13. tend to act or speak before thinking (poor impluse control)? YesNo 14. have problems in relationships with other people? YesNo 15. have sexual acting out behaviors? YesNo 16. have extreme irritability or outbursts? YesNo 17. have current or past trouble with the law? YesNo 18. have excessive fears, worries, or nervousness? YesNo 19. have difficulty falling or staying asleep? YesNo 20. feel down on him/her, or have low self-esteem? YesNo 21. have a short attention span? YesNo 22. have very low or high energy? YesNo Other issues needing to be discussed:
