Child/Teen Inquirer Information Form
Information is held in confidence and is not shared without your permission.
I. Parent/Guardian Information
List Below the name(s) of parent(s)/guardian(s) and present religious affiliation, if any:
II. RELIGIOUS HISTORY
If you answered “Yes” to Question 1, please provide the following information:
IV. FAMILY INFORMATION
List the name(s) of any siblings (e.g., John — Brother; Jean — Stepsister)
V. LEARNING STYLE
Not all people learn in the same way. You can help your child/teen get as much out of this process as possible by sharing about
your child’s learning abilities.
For example: “Mary is very outgoing and gets excited when she is having fun. She becomes quiet when she doesn’t understand
something. She works well with other children. Mary also has a 30% hearing loss in her left ear. She may not hear you if you
are standing behind her and speaking normally.”
VI. GENERAL QUESTIONS