UPDOX - PATIENT PORTAL

Available Forms

Narrative description of child (parent)

Narrative description of child (Parent)

Child's name *

Form completed by *

Date completed

Please rate what you see as your child's primary problems, both at home and at school. Scale from 0-10 (0=not at all; 2-3= just a little; 5= often; 7=quite a bit; 10= very much)

How your child's problems affect his or her relationship with playmates *

Regardless of weather this child is popular or unpopular with peers, does he or she have a special, close "best friend" that he or she has kept for more than a few months? *

Yes

How your child's problems affect his or her relationship with siblings? (If no siblings please choose 0) *

How your child's problems affect his or her relationship with you ( and your spouse if present) *

How your child's problems affect his or her academic progress at school *

How your child's problems affect his or her self-esteem *

How your child's problems affect your family in general *

What do you feel the overall severity of your child's problem in functioning is? *

How would you rate the overall need for treatment for your child? *

electronic signature of legal parent/guardian *

* Required field