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List any hobbies, recreational interests, sports, games, or other leisure activities your child enjoys or would like to try.

What effects have your child’s substance use or mental health problems had on their leisure time?

Describe any behavioral issues your child had growing up:

Is your child currently receiving treatment services for an emotional/psychiatric diagnosis? If yes, for what are you being treated?

Does your child have a history of an eating disorder?

How does your child sleep?

Has your child had any significant weight loss/gain of 10lbs or more in the last year?

Has your child ever talked about hurting or killing someone?

Does your child suffer from chronic pain?

Do you have any physical limitations that would hinder your participation in physical activities, if yes, please elaborate:

Has your child experienced a death or loss that impacts them today?

Describe your child’s childhood family experience

Has your child witnessed physical/verbal/sexual abuse toward others?

.Has your child experienced physical/verbal/sexual abuse from others?

Are there other trauma experiences your child has been through?

How does your child pay for drugs or alcohol?

What is the highest level of education completed?

When your child was in elementary, middle or high school did they have an IEP (Individualized Education Plan), a 504 plan, or in any other special (remedial, gifted/talented, advanced) classes?

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