Preventing Sexual Violence
An Educational Toolkit for Health Care Professionals

What Is Sexual Violence?
How Do I Prevent It?
Overview of Web version



Bright Futures Pediatric Intake Form

Pediatricians need to periodically assess the families they serve to gather further insight into specific areas of family functioning. The pediatrician may wish to ask parents questions on topics such as:

  • parental depression
  • substance use
  • domestic violence
  • parental history of abuse
  • social supports

The Bright Futures, 2nd edition, Pediatric Intake Form, developed by Kathi Kemper, MD, MPH, FAAP and Kelly Kelleher, MD, MPH, FAAP, is available in Bright Futures in Practice: Mental Health, Volume II. It is a comprehensive form that covers all of these topics and more. It can be given to the parents to fill out, or practice staff can ask parents a subset of these questions during the visit.

NOTE: Because of the nature of some of these questions, it may be beneficial to let parents know that these questions are asked of everyone and are being asked for your practice to be able to provide the best possible care for their child. In addition, it is important that you follow up and refer any families to appropriate resources, if a member of the family indicates difficulties in any of these areas.