Biopsychosocial Assessment Page 7
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10RELIGION / SPIRITUALITY:
Religion:
Protestant Catholic Buddhist Hindu Jewish Muslim Atheist Agnostic Other:
_____________________________
LEGAL INFORMATION:
Has the child ever:
Had difficulty or contact with police? Yes No
Appeared in juvenile conference? Yes No
Been on probation?
Yes No
Please explain: ________________________________________________________________________
_____________________________________________________________________________________
OTHER INFORMATION:
What are your child’s favorite activities?
1. _____________________________________
2. ____________________________________
3. _____________________________________
4. ____________________________________
5. _____________________________________
6. ____________________________________
What activities would your child like to engage in more often than he/she does at present?
1. _____________________________________
2. ____________________________________
What activities does your child like least?
1. ____________________________________
2. ____________________________________
What disciplinary techniques do you usually use when your child behaves inappropriately? Place a check next to each
technique that you usually use. There also is space for writing in any other disciplinary techniques that you use.
Check Disciplinary technique
Check Disciplinary technique
_____ Ignore problem behavior
_____ Tell child to sit on chair
_____ Scold child
_____ Send child to his or her room
_____ Spank child
_____ Take away some activity or food
_____ Threaten child
_____ Other technique (describe) _________________
_____ Reason with child
_____ Redirect child’s interest
_____ Don’t use any technique
Which disciplinary techniques are usually effective? ___________________________________________
_____________________________________________________________________________________
With what type of problem(s)? ____________________________________________________________
_____________________________________________________________________________________
Which disciplinary techniques are usually ineffective? __________________________________________
_____________________________________________________________________________________
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