Intake PARENT Report of Child (under 12 years) Header Image

Intake Parent Report of Child (under 12 years)



Your Name*
Your Child's Name*
Your Child's Date of Birth*

Please rate the degree to which your child’s problems affect his or her current ability in everyday activities. Consider your child’s current level of functioning.

1a. Getting along with friends*
2a. Getting along with family*
3a. Dating or developing relationships with boyfriends or girlfriends*
4a. Getting along with adults outside the family (teachers, principal)*
5a. Keeping neat and clean, looking good*
6a. Caring for health needs and keeping good health habits (taking medicines or brushing teeth)*
7a. Controlling emotions and staying out of trouble*
8a. Being motivated and finishing projects*
9a. Participating in hobbies (baseball cards, coins, stamps, art)*
10a. Participating in recreational activities (sports, swimming, bike riding)*
11a. Completing household chores (cleaning room, other chores)*
12a. Attending school and getting passing grades in school*
13a. Learning skills that will be useful for future jobs*
14a. Feeling good about self*
15a. Thinking clearly and making good decisions*
16a. Concentrating, paying attention, and completing tasks*
17a. Earning money and learning how to use money wisely*
18a. Doing things without supervision or restrictions*
19a. Accepting responsibility for actions*
20a. Ability to express feelings*

Please select your response to each question.

1b. Overall, how satisfied are you with your relationship with your child right now?*
2b. How capable of dealing with your child’s problems do you feel right now?*
3b. How much stress or pressure is in your life right now?*
4b. How optimistic are you about your child’s future right now?*

Pediatric ACEs and Related Life Events Screener (PEARLS)
For Parents of Children Under 12 years old

At any point in time since your child was born, has your child seen or been present when the following experiences happened? Please include past and present experiences.
Please note, some questions have more than one part separated by “OR.” If any part of the question is answered “Yes,” then the answer to the entire question is “Yes.”

1c. Has your child ever lived with a parent/caregiver who went to jail/prison?*
2c. Do you think your child ever felt unsupported, unloved and/or unprotected?*
3c. Has your child ever lived with a parent/caregiver who had mental health issues? (for example, depression, schizophrenia, bipolar disorder, PTSD, or an anxiety disorder)*
4c. Has a parent/caregiver ever insulted, humiliated, or put down your child?*
5c. Has the child’s biological parent or any caregiver ever had, or currently has a problem with too much alcohol, street drugs or prescription medications use?*
6c. Has your child ever lacked appropriate care by any caregiver? (for example, not being protected from unsafe situations, or not cared for when sick or injured even when the resources were available)*
7c. Has your child ever seen or heard a parent/caregiver being screamed at, sworn at, insulted, or humiliated by another adult? OR has your child ever seen or heard a parent/caregiver being slapped, kicked, punched, beaten up, or hurt with a weapon?*
8c. Has any adult in the household often or very often pushed, grabbed, slapped, or thrown something at your child? OR has any adult in the household ever hit your child so hard that your child had marks or was injured? OR has any adult in the household ever threatened your child or acted in a way that made your child afraid that they might be hurt?*
9c. Has your child ever experienced sexual abuse? (for example, anyone touched your child or asked your child to touch that person in a way that was unwanted, or made your child feel uncomfortable, or anyone ever attempted or actually had oral, anal, or vaginal sex with your child)*
10c. Have there ever been significant changes in the relationship status of the child’s caregiver(s)? (for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in or out)*
11c. Has your child ever seen, heard, or been a victim of violence in your neighborhood, community or school? (for example, targeted bullying, assault or other violent actions, war or terrorism)*
12c. Has your child experienced discrimination? (for example, being hassled or made to feel inferior or excluded because of their race, ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)*
13c. Has your child ever had problems with housing? (for example, being homeless, not having a stable place to live, moved more than two times in a six-month period, faced eviction or foreclosure, or had to live with multiple families or family members)*
14c. Have you ever worried that your child did not have enough food to eat or that the food for your child would run out before you could buy more?*
15c. Has your child ever lived with a parent/caregiver who had a serious physical illness or disability?*
16c. Has your child ever been separated from their parent or caregiver due to foster care, or immigration?*
17c. Has your child ever lived with a parent or caregiver who died?*
18c. Has your child ever experienced a severe natural disaster such as a flood, tornado, hurricane, earthquake, or fire? (This includes a serious house fire.)*
19c. Has your child ever experienced a serious accident or injury caused by a car or bike crash, being bitten by a dog, or caused by playing sports?*
20c. Has your child ever had a highly stressful or frightening medical procedure? OR Has you child been diagnosed with a life-changing chronic medical condition?*
21c. Any other life-threatening or highly stressful events that your child experienced that was not listed above?*

Please answer the following questions in relation to the traumatic event(s) experienced by your child for which you are seeking treatment.

These questions ask about how YOUR CHILD feels about the upsetting event(s) noted above. Read each question carefully. Then circle the number (0-4) that best describes how often that problem has bothered your child IN THE LAST MONTH.

1d. Having upsetting thoughts or pictures about it that came into their head when they didn’t want them to*
2d. Having bad dreams or nightmares*
3d. Acting or feeling as if it was happening again (seeing or hearing something and feeling as if you are there again)*
4d. Feeling upset when they remember what happened (for example, feeling scared, angry, sad, guilty, confused)*
5d. Having feelings in their body when they remember what happened (for example, sweating, heart beating fast, stomach or head hurting)*
6d. Trying not to think about it or have feelings about it*
7d. Trying to stay away from anything that reminds them of what happened (for example, people, places, or conversations about it)*
8d. Not being able to remember an important part of what happened*
9d. Having bad thoughts about themselves, other people, or the world (for example, your child saying “I can’t do anything right”, “All people are bad”, “The world is a scary place”)*
10d. Thinking that what happened is their fault (for example, “I should have known better”, “I shouldn’t have done that”, “I deserved it”)*
11d. Having strong bad feelings (like fear, anger, guilt, or shame)*
12d. Having much less interest in doing things they used to do*
13d. Not feeling close to their friends or family or not wanting to be around them*
14d. Trouble having good feelings (like happiness or love) or trouble having any feelings at all*
15d. Getting angry easily (for example, yelling, hitting others, throwing things)*
16d. Doing things that might hurt themselves (for example, taking drugs, drinking alcohol, running away, cutting themselves)*
17d. Being very careful or on the lookout for danger (for example, checking to see who is around them and what is around them)*
18d. Being jumpy or easily scared (for example, when someone walks up behind them, when they hear a loud noise)*
19d. Having trouble paying attention (for example, losing track of a story on TV, forgetting what they read, unable to pay attention in class)*
20d. Having trouble falling or staying asleep*
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