Section 1: Contact and Demographic Information

Neurobehavior Services

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Background Questionnaire

Confidential: For Report Purposes Only

Thank you for filling out the following questionnaire. Please click "Submit" at the end of each section. (Note: You will not be able to save your progress, so please complete each section fully before submitting.)

Know that this information is very important to the assessment, so please be comprehensive and provide as much detail as possible.

* Indicates a required field.

Section 1: Contact and Demographic Information

* Indicates required field

Child's name *

First

Last

Today's Date *

Form completed by (include relationship to child) *

Child's birthdate *

Child's current age *

Child's current grade *

Child's sex *

Male Female

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Alternate Email *

Best Contact Number *

Alternate Contact Number *

Mother's name *

First

Last

Highest grade completed / Degree(s) *

Occupation *

Age *

Home Phone Number *

Cell Phone Number *

Work Phone Number *

Choose One *

Part time Full time Overtime Not working

Father's name *

First

Last

Highest grade completed / Degree(s) *

Occupation *

Age *

Home Phone Number *

Cell Phone Number *

Work Phone Number *

Choose One *

Part time Full time Overtime Not working

Stepparent's name *

First

Last

Highest grade completed / Degree(s) *

Occupation *

Age *

Home Phone Number *

Cell Phone Number *

Work Phone Number *

Choose One *

Part time Full time Overtime Not working

List all people living in household (including housekeepers / nannies) *

Please include NAME, RELATIONSHIP to child, and AGE for each person listed.

List all people working in household *

Please include NAME, RELATIONSHIP to child, and AGE for each person listed.

If any brothers or sisters are living outside the home, please list their names and ages *

Be sure to include NAME, RELATIONSHIP to child, and AGE for each person listed.

Primary language spoken in the home *

Ethnicity / Race *

Other languages spoken in the home *

Be sure to indicate BY WHOM for each additional language.

Religion *

If you would like to qualify any responses or add additional notes, please do so here. After you click "submit," you will be redirected to the For Clients page. *

Submit