Mobile Family Life Coach Assessment Questionnaire

PEOPLE

List below the 8 people with whom your child spends the most time each week. Put the person with whom he spends the most time after "1" . Put the person with whom he spends the second most time after "2", and so on. In completing the list, consider brothers, sisters, parents, relatives, playmates, etc.

1. 2. 3. 4.
5. 6. 7. 8.

There may be other people (children or adults) with whom you think your child would like to spend more time each week, but doesn't get to. List below any such persons with whom you feel your child would like to spend more time than he presently gets to.

1. 2. 3. 4.

II. Child's General Information

A. Name:

B. Age: Less than 1 yr 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18+

C. School Grade: 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th

D. School Setting: Public Private Home Religious Special Education

E. If not in school, daytime care? Parental Care Day Care Nanny

F. Child's activities (complete below)

ACTIVITIES

List below the 10 activities on which your child spends the most time. Put them in order according to their frequency. By activities, we mean such things as doing homework, working puzzles, going to movies, reading, watching sports, playing sports, watching TV, singing, dancing, playing a musical instrument, hiking or walking, fishing, swimming, camping, riding a bike, sleeping, taking a bath, talking to other people, going to church, going shopping, being alone by him/herself, etc.

1. 2. 3. 4.
5. 6. 7. 8.
9. 10.

List below any activities in which you think he/she would like to engage more frequently than he presently does.

1. 2. 3. 4.

G. Family activities (complete below)



PLACES

List below the 8 places where your child spends the most time each week. Put the place he/she spends the most time after "1", second most after "2", etc. In making the list consider such places as bedroom, family room, kitchen, backyard, playground, classroom, baseball field, etc.
1. 2. 3. 4.
5. 6. 7. 8.
There may be other places where he/she would like to spend more time, but doesn't get to. List such places below.

1. 2. 3. 4.


H. Diet (typical eating habits/foods):


I. What time does your child prepare for school? 12 AM 1 AM 2 AM 3 AM 4 AM 5 AM 6 AM 7 AM 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM 10 PM 11 PM

J. What time does your child get ready bed? 12 AM 1 AM 2 AM 3 AM 4 AM 5 AM 6 AM 7 AM 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM 10 PM 11 PM

III. Child's Behavioral Information

A. What types of behavior does your child exhibit? If any of the below apply, please explain.

1. Aggressive


2. Tantrum


3. Self-Injury



B. How many times in a week does your child show this type of behavior? 1-2 3-4 5-6 7-8 9-10 Over 10

C. What activities usually precede these types of behaviors? (Ctrl-click to select more than one)
During transition time (example ask your child to stop playing video games, so he can clean up his room). Homework Morning Routine (getting ready for school) Bedtime Others

If Others, please describe below:


D. When does your child begin to escalate? Immediately Within an Hour Over an Hour Later Never

E. Consequences

1. In response to the exhibited behavior, do you give your child attention? Yes No

2. Do you give your child something (such as a book or toy to play with to calm him down)? Yes No

3. Does your child lose a privilege? Yes No

4. Do you ignore your child's behavior? Yes No

6. Do you punish your child's behavior? Yes No

7. Others, please describe below:


THINGS

List below the things your child does not own or to which he does not have ready access which he would most like to have.

1. 2. 3. 4.

List below the 8 things with which your child spends the most time each week. Put them in order beginning with the thing which he spends the most time. In making the list consider such things as specific toys (identify each kind), pets, books, puzzles, mechanical objects, musical instruments, bicycle, etc.

1. 2. 3. 4.
5. 6. 7. 8.

List below your child's 10 best liked foods and drinks. Include candy, desserts, and other treats in the list. Record the items according to preference beginning with the most preferred first. Include items which you many not allow your child to have very often, but which fall high on his list of preference.


1. 2. 3. 4.
5. 6. 7. 8.
9. 10.

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End of Assessment. Please click below to submit.