Certificates in: Play Therapy, Sexual Abuse and Trauma Recovery,

Marriage and Family Therapy, and

Canine Assisted Therapy
Licensed Mental Health Counselor MH 9099
924 N. Magnolia Ave, Suite 210 p 407. 312.8295
Orlando, FL 32803 f 407.704.7999
ehollingsworthlmhc@gmail.com

Parent Questionnaire: (Please answer each question based on your childs information
when appropriate)

Childs Information:

1. Who has legal custody of your child?

________________________________________________________________________
________________________________________________________________________

2. Which parent is the legal decision maker regarding medical treatment for your
child?___________________________________________________________________

3. Who is providing financial support for the family?

________________________________________________________________________
________________________________________________________________________

4. How did you arrive today?

________________________________________________________________________
________________________________________________________________________

5. Are there any current or past legal issues facing your family?
________________________________________________________________________
________________________________________________________________________

6. What is your marital status? Married Single Divorced

Widow/Widower Cohabitating
Please provide date of marriage, separation, and/or divorce:
________________________________________________________________________
________________________________________________________________________

7. Do you as a parent and/or guardian take any prescribed medications? Yes or No

If yes, please list:
________________________________________________________________________
________________________________________________________________________

8. Have there been any recent deaths, losses, and/or any major changes in the family
recently? Yes or No
If yes, please describe:
________________________________________________________________________
________________________________________________________________________

9. Is anyone is the family diagnosed with a terminal illness or mental health illness?
Yes or No If yes, please explain:
________________________________________________________________________
________________________________________________________________________

10. What are the families Religious and /or Spiritual Preference?
________________________________________________________________________
________________________________________________________________________

11. What are the families Cultural/Ethnic Background?

________________________________________________________________________
________________________________________________________________________

Developmental Information Regarding Your Child

1. How long was the pregnancy of the child? ___________________________________

2. What did your child weigh at birth? ________________________________________
3. Medications taken during pregnancy? _______________________________________
4. Use of tobacco/ alcohol/ drugs during pregnancy? If yes, please describe:
________________________________________________________________________
5. Were their any complications before, during, or immediately after the childs delivery
for you or your child? If yes, please explain: ____________________________________
________________________________________________________________________
6. What type of delivery? Vaginal or Cesarean
7. What age did the child start: Walking ________ Talking _________Toilet Training
_________?
8. At what age did the child begin school?______________________________________
9. Was pregnancy planned? _________________________________________________

Social Development of the Child

1. Does the individual exhibit social difficulties and/or struggles making friends? If yes,
please explain: ________________________________________________________
_____________________________________________________________________
2. Does the individual struggle with eye contact and/or social cues? If yes, please
explain: ______________________________________________________________
 Does the individual exhibit anger outbursts and/or tantrums? If yes, please explain:
_____________________________________________________________________
3. Please describe your childs use of the internet:
a. Amount of time spent daily ________________________________________
b. Does the individual play fantasy role play games? ______________________
c. Does the individual use of social media, length of time?
_____________________
d. Please describe any problems associated with the individuals use of the
internet and/or computer: __________________________________________
_______________________________________________________________
4. Does your child engage in self harming behaviors, e.g., cutting? If yes, please explain
________________________________________________________________________

Sexual Development of the Child

Female
What age did individual start her period? ______________________________________
Has the individual ever had a baby, if yes, how many? ____________________________

Males
At what age did the individual begin puberty? __________________________________
Has the individual ever had a baby, if yes, how many? ____________________________

Males/Females
Has your child complained about the way their body looks?________________________
________________________________________________________________________
Has your child taken steps to loose/gain weight, e.g., increase/decrease exercise,
restricting food, vomiting after eating, and/or surgery?
________________________________________________________________________
________________________________________________________________________
Has your child been diagnosed with an eating disorder?___________________________
Do you as the parent struggle with body image issues? Please explain
__________________________________________________________________

School Information of the Child

1. Where does the individual go to school? ____________________________________

2. What grade are they currently in? _________________________________________
Have they ever been held back or advance a grade? ___________________________
If yes, please explain: ___________________________________________________
_____________________________________________________________________
3. What type of school program are they currently in? SED Regular EH LD
Other: _______________________________________________________________
5. Has your child had any problems reading or writing? __________________________
If yes, please explain: ______________________________________________________
6. Are there any physical/Developmental/ Academic Problems that have been diagnosed
that might be affecting the individuals learning?
________________________________________________________________________
________________________________________________________________________
7. In your own words, what are the individuals academic and personal strengths?
________________________________________________________________________
________________________________________________________________________
8. What are their areas for growth academically?
________________________________________________________________________
________________________________________________________________________

Abuse/Neglect Information
(Due to legal obligation, any child or elder abuse or neglect disclosed that has not
been reported in the past will be reported today)

To your knowledge, has your child or the child you are the guardian of ever been abused
Physically: Yes or No
Sexually: Yes or No
Emotionally: Yes or No
Neglected: Yes or No

1. If yes to any of these questions, has the abuse registry been notified? Yes or No
If yes, when?
________________________________________________________________________
________________________________________________________________________

2. Has the individual ever witness family violence? Yes or No

If yes, please explain
________________________________________________________________________
________________________________________________________________________

3. Has the individual ever been an abuser towards someone else? Yes or No
If yes, please explain
________________________________________________________________________
________________________________________________________________________

4. Has the individual ever lived with anyone besides you? Foster Care,
Family Member, Shelter, Other
________________________________________________________________________
________________________________________________________________________

Goal

What do you hope to accomplish through this counseling experience?

________________________________________________________________________
________________________________________________________________________
What are the individuals strengths?
________________________________________________________________________
________________________________________________________________________
What are their growth areas?
________________________________________________________________________
________________________________________________________________________

________________________________________________________________________
Parent/Guardian Signature Date