Therapist Survey

First I would like to get to know you before we dive in, so please take a few minutes and fill out this survey. By filling out this survey, I can make sure I’m clear on your goals and overall needs in this program. This information is confidential and will NOT be shared.

Name:

Email:

Phone:

State/Country:

Treatment Training Received by:

Years of Experience:

Areas of Expertise:

If you have a specific client you are focusing on in this course please complete:

BioAdopted
Client's Name (First name only or pseudonym):
Age:

Number of client's older siblings:

Ages:

Number of younger siblings:

Ages:

Client History

State/Country of origin:

Came to this family at age:

Previous Trauma: PhysicalSexualEmotionalPrenatal AlcoholPrenatal DrugsMeth Exposure

Number of moves child has had:

Visits with perpetrator of trauma: NoneIn the PastCurrently

Current Concerns with this Client:

Health:
DietSleepDigestionConstipationAllergiesSensoryDevelopmentAilments (list)

IQ: LowAverageHighVery High

Home behavior concerns (list):

School behavior concerns (list):

Public behavior concerns (list):

Other info you want me to know (list):

Thank you for taking the time to fill this out. I know your time is valuable! This info will help me expedite the course to be the most beneficial to you. I want to be sure I leave no stone unturned in helping you with your quest for success with the children. I know your investment of time and energy during this course will pay off! I believe this program could be a turning point for your clients to have more love and laughter in their homes!

We can make a difference,
Nancy