Child and Adolescent Addendum Form

(to complete with parent/guardian)

*If any items are unknown, please mark with N/A.

Developmental Milestones?(Required)
Any problems with fine motor skills?(Required)
Any problems with gross motor skills?(Required)
Any problems with speech/language?(Required)
Is the child adopted?(Required)
Describe early relationship of each significant caretaker with child (bonding & attachment)
Have client or siblings ever been removed from the home?(Required)
Has client ever run away from home or been gone more than 12 hours without permission?(Required)
Are child's parents separated or divorced?(Required)
Is either parent incarcerated?(Required)
Have there ever been foster children/step-siblings/other children in the home for extended periods of time?(Required)
Is peer group(Required)
Do parents know peer group?(Required)
Do parents approve of peer group?(Required)
Has child repeated a grade?(Required)
Has child's academic achievement level changed greatly?(Required)
Has child ever been suspended?(Required)
Has child ever been suspended from bus?(Required)
Has child ever been expelled?(Required)
Is truancy an issue?(Required)
Has child ever been identified as requiring special education services?(Required)
Learning Disabled?(Required)

Any sexual abuse?(Required)
Any physical abuse?(Required)
Any dating violence/rape?(Required)
Has child ever tried drugs or alcohol?(Required)
Has child ever engaged in sexual activity?(Required)
Does your child watch TV?(Required)
Does your child play video games?(Required)
Does your child surf the internet?(Required)
Supervision Status(Required)
Does your child prefer to play(Required)
How well does your child play with others?(Required)
Does your child prefer(Required)