COLLATERAL SOURCE QUESTIONNAIRE Family/Parent Name: Child(ren)’s Name(s): Reported By: Collateral Source Name: Collateral Source Address: Please answer each question honestly and as fully as you feel is necessary. Both positive and negative information should be included. If additional space is needed, feel free to use the back of the questionnaire or additional sheets. 1. How long have you known this family and in what capacity? (friend, relative, neighbor or co-worker) 2. How much opportunity have you had to observe the parent or parents with their and in what child(ren) settings? How recently, and how often in the past year, have you had contact with this family? 3. How would you describe each parent in the following areas? Types of activities each parent participates in with the child(ren): What kinds of rules and guidelines each parent sets for the child(ren): How does each parent discipline the Give examples: child(ren)? Communication and emotion shared between parent and child(ren): 4. Do you believe these parents are capable of working together for the good of their Why or child(ren)? why not? 5. Do you feel either parent would interfere with or try to control the other parent’s relationship or time with the in a destructive way? If so, please give examples or reasons for your opinions. child(ren) 6. What changes, if any, have you noticed in the behavior and/or emotions since the action child(ren)’s started? Please give examples.
COLLATERAL SOURCE QUESTIONNAIRE Family/Parent Name: Child(ren)’s Name(s): Reported By: Collateral Source Name: Collateral Source Address: Please answer each question honestly and as fully as you feel is necessary. Both positive and negative information should be included. If additional space is needed, feel free to use the back of the questionnaire or additional sheets. 1. How long have you known this family and in what capacity? (friend, relative, neighbor or co-worker) 2. How much opportunity have you had to observe the parent or parents with their child(ren) and in what settings? How recently, and how often in the past year, have you had contact with this family? 3. How would you describe each parent in the following areas? Types of activities each parent participates in with the child(ren): What kinds of rules and guidelines each parent sets for the child(ren): How does each parent discipline the child(ren)? Give examples: Communication and emotion shared between parent and child(ren): 4. Do you believe these parents are capable of working together for the good of their child(ren)? Why or why not? 5. Do you feel either parent would interfere with or try to control the other parent’s relationship or time with the child(ren) in a destructive way? If so, please give examples or reasons for your opinions. 6. What changes, if any, have you noticed in the child(ren)’s behavior and/or emotions since the action started? Please give examples.
10.%20Collateral%20Source%20Questionnaire%202017.docx