.

Parent Report Form CBCL Survey

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

Secured
Survio
Create a survey
Parent Report Form (adapted from CBCL)
1

This form is filled out by:

Print your full name and relation to client
2

Client Information

Please provide the client's full name, birthdate, and gender
3

Today's Date

Select a date
4

How would you describe the client's behavior in the past 6 months?

5

Rate the overall level of stress in your family currently on a scale of 1 to 10.

Please rate from 1 (low stress) to 10 (high stress).
6

What are your main concerns regarding your child's participation in the play therapy program?

Please provide your main concerns in detail.
7

Has your child been diagnosed with any mental health condition?

Please select yes or no.
8

How do you feel about your child starting the play therapy program?

Please select the option that best represents your feelings.
9

How likely are you to recommend play therapy to other parents?

Please rate from 1 (not likely) to 10 (highly likely).
10

In what ways do you hope to see improvement in your child after the therapy program?

Please describe the improvements you hope for.
11

Do you have any specific goals or expectations from the play therapy program?

Please share your specific goals or expectations.
12

Are you currently receiving any support or counseling for yourself or your family?

Please select yes or no.
13

How would you rate your current communication with your child?

Please rate the communication level from 1 (poor) to 10 (excellent).
Create a survey