Programa de prevencion de conductas agresivas

DESTRUCTIVA

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NO DESTRUCTIVA

Comorbilidad con TDAH, ansiedad y depresión.

General Parent Questionnaire

Note: Please complete all information on this questionnaire. All information istreated in confi-
dence and will not be released without your permission.
Date ______________________ Form completed by ____________________________________________
Child’s full name_____________________________ [ ] Male [ ] Female Birthdate ________________
Address ____________________________________________________________

________________________
Street City County State Zip
Homephone ____________ Work phone ____________ (Mother) __________ (Father) ___________
Who referred the child? ____________________________________________________________

_________
Name AddressChild’s primary physician ____________________________________________________________

_______
Insurance company ___________________________ Child’s Social Security # ______-______-______

FAMILYFather’s name ____________________________________________________ Birthdate _______________
Address (if different from above) ___________________________________________________________
Occupation____________________ Education level _________________ # of dependents ________
Mother’s name _____________________________________________ Birthdate _________________
Address (if different fromabove) ________________________________________________________
Occupation ____________________ Education level _________________ # of dependents ________
Date of marriage __________ Present maritalstatus ________________________________________
With whom does the child live? [ ] Birth parents [ ] Adoptive parents [ ] Foster parents
[ ] Other (specify) _________________________________________If parents are separated or divorced: Date of separation/divorce _______________________________
Who has physical custody? __________________ Who has legal custody? _______________________
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