Wild Rose Public Schools

Family Background Questionnaire

Child’s Name: Today’s Date:

Birth Date: Age: Sex: □ Male □ Female

Home Address:

Phone:

School:

Person completing this form: □ Mother □ Father □ Stepmother □ Stepfather □ Guardian □ Other

Mother’s Name: Education: Occupation:

Father’s Name: Education: Occupation:

Stepparent’s Name: Education: Occupation:

Marital Status of Parents: □ Married □ Separated □ Divorced □ Widowed

If separated or divorced, how old was the child when the separation occurred?

Primary language spoken in the home:

Other languages spoken in the home:

Was the child adopted? □ Yes □ No If yes, at what age? Does the child know? □ Yes □ No

If referred for this assessment, who referred you here?

PRESENTING PROBLEM

Briefly describe your child’s current difficulties:

How long has this problem been of concern to you?

When was the problem first noticed?
What seems to help the problem?

What seems to make the problem worse?

Have you noticed changes in the child's abilities? □ Yes □ No

If yes, please describe:

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Have you noticed changes in the child's behaviour? □ Yes □ No
If yes, please describe:

Has the child been evaluated or treated for the current problem or similar problems? □ Yes □ No
If yes, when and with whom?
Is the child being treated for a medical illness? □ Yes □ No
If yes, for what condition is the child being treated?
Is the child on any medication at this time? □ Yes □ No
If yes, please note the kind of medication:
Has the child previously received counselling? □ Yes □ No
If yes, when and with whom?
Has the child previously undergone a formal psychological assessment? □ Yes □ No
If yes, when and were there any diagnoses?

What specific questions would you like answered by this assessment?

BEHAVIOURAL/EMOTIONAL CONCERNS

Place a check next to any behaviour or problem that your child currently exhibits.

Inattention:
□ Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
□ Often has difficulty sustaining attention to tasks or play activities
□ Often does not seem to listen when spoken to directly
□ Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the
workplace (not due to oppositional behaviour or failure to understand instructions)
□ Often has difficulty organizing tasks and activities
□ Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as
schoolwork or homework)
□ Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
□ Is often easily distracted by extraneous stimuli
□ Is often forgetful in daily activities

How long have these been of concern to you?

Impulsivity:
□ Often blurts out answers before questions have been completed
□ Often has difficulty awaiting turn
□ Often interrupts or intrudes on others (e.g., butts into conversations or games)

How long have these been of concern to you?

Hyperactivity:
□ Often fidgets with hands or feet or squirms in seat
□ Often leaves seat in classroom or in other situations in which remaining seated is expected

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□ Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be
limited to subjective feelings of restlessness)
□ Often has difficulty playing or engaging in leisure activities quietly
□ Is often “on the go” or often acts as if “driven by a motor”
□ Often talks excessively

How long have these been of concern to you?

Oppositional Behaviours:
□ Often loses temper □ Is often angry or resentful \
□ Often actively defies or refuses to comply with adults’ □ Often argues with adults
requests or rules
□ Often deliberately annoys people
□ Often blames others for his or her mistakes or
□ Is often touchy or easily annoyed by others
misbehaviour
□ Is often spiteful or vindictive

How long have these been of concern to you?

Inappropriate Conduct:
□ Often bullies, threatens, or intimidates others □ Often initiates physical fights
□ Has used a weapon that can cause serious physical harm □ Has been physically cruel to people
to others (e.g., a bat, brick, knife, gun)
□ Has been physically cruel to animals
□ Has stolen while confronting a victim (e.g., mugging,
□ Has forced someone into sexual activity
purse snatching, armed robbery)
□ Has deliberately destroyed others’ property
□ Has deliberately engaged in fire setting with the intention of
(other than by fire setting)
causing serious damage
□ Often lies to obtain goods or favours or to
□ Has broken into someone else's house, building, or car
avoid obligations (i.e., “cons” others)
□ Has stolen items of non-trivial value without confronting a
□ Often stays out at night despite parental
victim (e.g., shoplifting, but without breaking & entering,
prohibitions, beginning before age 13 years
forgery)
□ Is often truant from school, beginning
□ Has run away from home overnight at least twice while
before age 13
living in parental or parental surrogate home (or once
without returning for lengthy a period)

How long have these been of concern to you?

Depression:
□ depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feel sad or empty)
or observations made by others (e.g., appears tearful). Note: in children and adolescents, can be irritable mood
□ Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as
indicated by either subjective account or observations made by others)
□ Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 percent of body weight in a
month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected
weight gains
□ Difficulty falling asleep or waking up
□ Physical restlessness (observable by others, not merely subjective feelings of restlessness or being slowed down)
□ Fatigue or loss of energy nearly every day
□ Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not
merely self-reproach or guilt about being sick)
□ Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or
as observed by others)
□ Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or suicide
attempt or a specific plan for committing suicide

How long have these been of concern to you?

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Anxiety:
□ Excessive worrying or anxiety (apprehensive expectation), □ Difficulty concentrating or mind going
occurring more days than not for at least 6 months, about a blank
number of events or activities (such as school performance) □ Irritability or anger
□ Finds it difficult to control the worry □ Muscle tension
□ Feelings of restlessness or being on edge □ Sleep disturbances (difficulty falling or
□ Being easily fatigued staying asleep, or restless unsatisfying
sleep)

How long have these been of concern to you?

ACADEMIC CONCERNS

At what age did your child begin kindergarten? What is his or her current grade?

Is your child in a special education class? □ Yes □ No

If yes, what type of class?

Has your child been held back a grade? □ Yes □ No

If yes, what grade and why?

Has your child ever received special tutoring or therapy at school? □ Yes □ No
If yes, please describe:

Has your child’s school performance become poorer recently? □ Yes □ No

If yes, please describe:

Has your child missed a lot of school? □ Yes □ No

If yes, please indicate reasons:

DEVELOPMENTAL HISTORY

Were there any problems during the pregnancy? □ Yes □ No

If yes, what kind?

Was this a first pregnancy? □ Yes □ No

If no, how many times was the mother previously pregnant?

During pregnancy, did the mother drink alcoholic beverages? □ Yes □ No

If yes, what did she drink?

Approximately how much alcohol was consumed each day?

When was the alcohol consumed? □ 1st trimester □ 2nd trimester □ 3rd trimester

Were there times when five or more drinks were consumed at one time during pregnancy? □ Yes □ No

If yes, during which trimester? □ 1st trimester □ 2nd trimester □ 3rd trimester

During pregnancy, did the mother use drugs (including prescription, over-the-counter, and recreational)?
□ Yes □ No
If yes, what kind?

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During pregnancy, was the mother exposed to any x-rays or chemicals? □ Yes □ No
If yes, what kind?

Were there any complications associated with the delivery? □ Yes □ No

If yes, what kind?

Was the child premature? □ Yes □ No If yes, by how many weeks?

What was the child's birth weight?

Were there any birth defects or complications? □ Yes □ No

If yes, please describe:

Were there any other problems? □ Yes □ No

If yes, please describe:

CHECKLIST FOR SOCIAL & EMOTIONAL CONCERNS

Place a check next to any behaviour or difficulty that your child currently exhibits.
□ Has difficulty making friends Shows sexually provocative or inappropriate behaviour
Has difficulty keeping friends Is slow to learn
Does not get along with other children Fights Has difficulty accepting criticism
with other children Has difficulty with coordination Has
Is more interested in things (objects) than in unusual motor tics
people Has unusual vocal tics Bites
Prefers to be alone nails
Does not get along well with siblings Refuses Sucks thumb
to share Is jealous
Does not understand other people’s feelings Is shy and/or timid Is
Constantly seeks attention aggressive
Requires constant supervision Lies Is argumentative
Steals Has too many accidents
Is disobedient Injures self intentionally
Eats poorly Shows anger easily
Is clumsy Is Engaged in dangerous behaviour
nervous Is If yes, describe:
immature Has unusual fears, habits, or mannerisms
Is easily frustrated If yes, describe:
Worries excessively Rocks back and forth
Feels that he or she is bad Has trouble sleeping Has
Does not show feelings Gets frequent nightmares Wets
hurt frequently the bed
Does not learn from experience Tires easily and has little energy
Complains of aches and pains

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 CHILD’S MEDICAL HISTORY

Place a check next to any illness or condition that your child has had. When you check an item, please note the
approximate age of the child when he or she had the illness or condition and any other pertinent information.

□ Illness or Condition Age Explain

□ Encephalitis
□ Meningitis
□ Diabetes
□ Fainting Spells
Memory Problems
□
Eye Problems
□
Ear Problems
□
Suicide Attempt(s)
□
Sleeping Problems
□
Extreme Tiredness
□ Frequent Headaches
□ Convulsions
□ Epilepsy
□ Asthma

Has your child had any other serious illnesses? □ Yes □ No

If yes, what illness?

Has your child been hospitalized? □ Yes □ No

If yes, please describe:

Has your child had any operations? □ Yes □ No

If yes, please describe:

Has your child had any accidents? □ Yes □ No

If yes, please describe:

Has your child had a head injury? □ Yes □ No

If yes, please describe:

Has your child ever lost consciousness? □ Yes □ No

If yes, please describe:

Has your child experienced any emotional trauma? □ Yes □ No

If yes, please describe:

Additional Comments:

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