Child/Teen Client Screening Questionnaire

Child/Teen Client Screening Questionnaire · Carla E. Marin, PhD

What this form is for

Please complete this form so we can determine whether this practice is a good fit for your child’s needs before scheduling an initial appointment. It is a screening form, not an intake.

How to complete this form

Complete everything below on your phone or computer. When you are done, tap “Save as PDF” at the bottom and then email the file to Dr. Marin at carlamarinphd@gmail.com.

Nothing you type here is sent or saved anywhere until you send the file yourself. If you close or reload this page before saving, your answers will be deleted. It takes about five minutes. Blanks are fine.

Person completing this form

Your name

Relationship to child

Best contact phone

Child information

Initials only at this stage. Full details are collected later, on the intake form.

Child’s initials

Date of birth

Mental health treatment history

Has your child previously received therapy or counseling?

Yes No

Has your child previously seen a psychiatrist or prescriber?

Yes No

Has your child previously been hospitalized or received a higher level of psychiatric care (for example, partial hospitalization or intensive outpatient)?

Yes No

Is your child currently taking any psychiatric medication(s)?

Yes No

If currently or previously on psychiatric medication, please list it here (name, dose if known, prescriber)

Past diagnoses, treatment providers, and how treatment went

Most pressing concerns right now

What is bringing you to seek services at this time? Please describe your top concern(s) for your child.

Current symptoms and functioning

For each area below, mark the number that best reflects your child’s functioning over the past two to four weeks.

0 Not a problem · 1 Mild or occasional · 2 Moderate or frequent · 3 Severe or almost constant

Area	0	1	2	3
Anxiety, fears, or worry
Intrusive or unwanted thoughts
Low mood or sadness
Impulsivity, hyperactivity, or inattentiveness
Irritability or anger
Repetitive or compulsive behaviors
Sleep difficulties
School difficulties (academic or behavioral)
Friendship or peer difficulties

Your child’s strengths and supports

Every child has strengths. Please share what you are noticing that is going well for your child right now: skills, interests, supports, recent progress, anything else.

Your answers are used only to help us decide whether this practice can meet your child's needs. This is not a diagnostic tool and nothing here is a diagnosis. If your child is in crisis or having thoughts of self-harm, please call or text 988 (Suicide and Crisis Lifeline) or call 911.