Marygrove Background Information Form

Child's Date of Birth(Required)

Child's Age(Required)

Child's Gender(Required)

Child's Race(Required)

Most Recent Placement(Required)

Placement Since(Required)

Reasons for seeking therapy services now (describe behavior from past 60 days):

Provide a brief family history (who has the child lived with, when were they removed, describe sibling situation):

Describe child’s personality, strengths, interests, hobbies, primary support person(s), etc.:

If yes, where, when, etc:

Describe the plan for the child (reunification, TLP, traditional foster home, etc.) and child’s understanding of the plan:

Cultural Preferences (i.e. ethnic/cultural background, place of birth for family members, rituals, family traditions):

If Yes to any of the above, please provide dates & ages of incidents if possible:

Emotional Concerns:

Aggressive Behaviours:

Suicidal Ideations/Suicidal Attempts/Self-Injurious Behavior/Homicidal ideations (please include severity):

Sexual Behaviors:

Elopement Behaviors (run away):

Substance Use (include child and family):

Any other concerns not listed above:

Background Information Form