Collateral Questionnaire

Please use the survey below to help us gather information about an applicant in our psychological services program. Please fill out the questions thoroughly and with as much detail as possible. This helps inform treatment planning.

Ideally, this form should be filled out by someone close to the applicant who has known them since before age 12 but preferably before age 3. Thank you for assisting with this service on behalf of the applicant!

If the applicant you are answering about has not yet reached the age for the teen or adult questions you can just leave them blank or put “Not Applicable” in the answers for those questions.

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Who are you completing this questionnaire for?

First

Last

Your Name

First

Last

my I Name

Relationship to Applicant

Your Email

Phone

If you are the parent of the applicant, what was the pregnancy like?

Were there any complications either during the pregnancy or birth? Were they born early, on-time, or late? Any medical issues? What was the delivery like?

What were they like as a baby? (Pre-12 months)

Was there any significant trauma? Were they a happy or fussy baby? Any medical issues? Did they meet their developmental milestones? If not, what happened? Give us a good overall picture of the applicant during their infant years.

What were they like as a toddler?

Was there any significant trauma? Were they a a difficult toddler? Any medical issues? Did they meet their developmental milestones? If not, what happened? Give us a good overall picture of the applicant during these years.

What were they like as a child?

Was there any significant trauma? Were they a a difficult child? Any medical issues?Did they get along well with others? Did they meet their developmental milestones? If not, what happened? Did they go to school on time? What was school like for them? Give us a good overall picture of the applicant during these years.

What were they like as a teen? (If applicable)

Was there any significant trauma? Were they a a difficult teen? Any medical issues? Did they meet their developmental milestones? If not, what happened? What was school like for them? Did they get in trouble at school? How were they in relationships both within and external to family? Give us a good overall picture of the applicant during these years.

What were they like as an adult? (If applicable)

Was there any significant trauma? Medical issues? Any behaviours of note? Give us a good overall picture of the applicant during these years.

By checking "Yes I confirm" below and submitting this survey I am confirming I am the person listed above and any information provided, to my knowledge, is accurate.

Yes I confirm

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Collateral Questionnaire

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