FAMILY QUESTIONNAIRE
To be filled out by the parent(s):
Student`s name _________________________
(please print)
Should your child be enrolled at CISP, as instructors and care-givers, we need to be aware of any unusual difficulties your
child may have. Please consider the following list of potential issues, check any or all that apply to your child and where
appropriate please give your comments.

Has your child experienced any of these?
 parental separation or divorce,
 parental remarriage,
 care in a foster home,
 adoption,
 a death in the family,
 raised by a single parent,
 extended time living away from parent(s), including previous boarding school?
 None of the above.

Has your child been administered any formal assessments* –
 educational,
 cognitive (i.e. IQ test),
 emotional,
 behavioral,
 other__________________?
 None of the above.
*CISP requires copies of any formal assessment(s), and any subsequent diagnosis and or treatment.

Has your child experienced professional counseling of any kind  spiritual,
 behavioral,
 academic,
 emotional?
 None of the above.

Has your child any current or past issues relating to things like  eating disorders,
 cutting or self-disfigurement,
 anxiety disorders,
 mood disorders (depression, bi-polar disorder, etc.),
 abuse – physical, emotional, or sexual,
 substance abuse?
 None of the above.

Has your child had any traumatic experiences such as
 a dangerous evacuation?
 close proximity to terrorist activity?
 life in a war-torn area or a country in unrest?
 Other __________________?
 None of the above.
T/Admin. files/Admissions/ family questionnaire 2014-2015
If any of these examples, or others like them, relate to your child, we must know an appropriate amount of detail about the
issues involved so that we can determine if CISP can provide the required care for your child.
To help facilitate the transfer of information we have provided space below. You may use more than one sheet of paper if
needed. When completed, if you wish, you may place your documentation in an envelope marked “Confidential”.
Confidential information will be shared only on a “need to know basis” to be determined by the Principal or School
Counselor. If you require a phone conversation or interview, please indicate so and this will be arranged.
___________________________________
_________________________________________
Signature: Father/Guardian
Signature: Mother/Guardian
Date
____________________________________
Name (please print)
Date
____________________________________________
Name (please print)
Rev. June 2014
Sídlo: Dělnická 24/1155, 170 00, Praha 7, Czech Republic
Pošta: Legerova 5, 120 00 Praha 2, Czech Republic
Phone/Fax: +420-272-730-091
www.cisprague.org, info@cisprague.org