Dream Pathways Foundation
LIKE US ON FACEBOOK!
Child Intake Form
Children's Book Tour
Human Development Across Lifespan
African American Psychopathology
Psychopathology in Children
Psychopathology in Adults
Article Submission Form
Mental Health Matters
Community Health & Awarness
Family & Relationships
Saving & Investing in Our Youth
Dream Pathways Magazine Writers
Writer of the Month
Writers' Free Book Bank
Christmas Giveway for Kids RSVP
About the Founder
Projects in Development
Dream Pathways Behavioral Health Institute
DP Behavioral Health Survey
Foster HOPE Today
Share My Story Form
Community Resources LA
The Small Business Corner
Donate Kids Books
Join Our Online Community
Child Intake Form
Indicates required field
Select Grade Level
What is the reason for the referral?
Has your child been evaluated before?
What are the presenting problems?
When did the problems begin?
Where do they occur?
Does anything relieve or reduce the reported problems or symptoms?
Please list all of your child's prescription medications
Have there been any significant events or stressors in the child's home or family? Please describe.
How do you think your child's problems affect their daily performance at school? at home? in other settings?
When was your child's most recent medical exam?
Please list all medical conditions if applicable
How would you describe your child's overall health?
Does your child have visual or hearing difficulties?
Describe your family composition. Who lives in the household?
What is the family's ethnic and cultural background?
Please indicate family's income status
My child has problems with... (check all that apply)
staying on task
respect for authority
aggression towards others
getting dressed in the morning
falling asleep at night
How does the family handle the child's problems?
How does your child spend their free time?
What responsibilties/chores does your child have at home?
What are your child's strengths?
What type of interventions, including services would you like to receive for your child?
Feedjit Live Blog Stats
Copyright 2009-2017 Dream Pathways Foundation All Rights Reserved
'Dreams are merely visions waiting to happen.'
-Danielle Leach, author of American Dreamer/founder of Dream Pathways