Child Information

Parent/Guardian Information

Additional Information

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Assessment - 2 of 5
1. Wants to be alone more than with other children of the same age.
2. Complains of dizziness or headaches.
3. Doesn't participate in activities that were previously enjoyable.
4. Argues or is verbally disrespectful.
5. Is more fearful than other children of the same age.
6. Cuts school or is truant.
7. Cooperates with rules and expectations.
8. Has difficulty completing assignments or completes them carelessly.
9. Complains or whines that things are unfair.
10. Experiences trouble with her/his bowels, such as constipation or diarrhea.
11. Gets into physical fights with peers or family members.
12. Worries and/or can't get certain ideas out of his/her mind.
13. Steals or lies.
14. Is fidgety, restless, or hyperactive.
15. Seems anxious or nervous.
16. Communicates in a pleasant and appropriate manner.
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2/5
Assessment - 3 of 5
17. Seems tense, is easily startled.
18. Soils or wets self.
19. Is aggressive toward adults.
20. Sees, hears, or believes things that are not real.
21. Has participated in self-harm (e.g. cutting or scratching self, attempted suicide)
22. Uses alcohol or drugs.
23. Seems unable to get organized.
24. Enjoys relationships with family and friends.
25. Appears sad or unhappy.
26. Experiences pain or weakness in muscles or joints.
27. Has a negative or distrustful attitude toward friends, family members, or adults.
28. Believes that others are trying to hurt him/her even when they are not.
29. Threatens to or has run away from home.
30. Experiences rapidly changing and strong emotions.
31. Deliberately breaks rules, laws, or expectations.
32. Appears happy with her/himself.
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3/5
Assessment - 4 of 5
33. Sulks, pouts, or cries more than other children of the same age.
34. Pulls away from family or friends.
35. Complains of stomach pains or feeling sick more than other children of the same age.
36. Doesn't have or keep friends.
37. Has friends of whom I don't approve.
38. Believes that others can hear his/her thoughts or that s/he can hear the thoughts of others.
39. Engages in inappropriate sexual behavior (e.g. sexually active, exhibits self, sexual abuse toward family members or others).
40. Has difficulty waiting his/her turn in activities or conversations.
41. Thinks about suicide, says s/he would be better if s/he were dead.
42. Complains of nightmares, difficulty getting to sleep, oversleeping, or waking up from sleep too early.
43. Complains about or challenges rules, expectations, or responsibilities.
44. Has times of unusual happiness or excessive energy.
45. Handles frustration or boredom appropriately.
46. Has fears of going crazy.
47. Feels appropriate guilt for wrongdoing.
48. Is unusually demanding.
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4/5
Assessment - 5 of 5
49. Is irritable.
50. Vomits or is nauseous more than other children of the same age.
51. Becomes angry enough to be threatening to others.
52. Seems to stir up trouble when bored.
53. Is appropriately hopeful and optimistic.
54. Experiences twitching muscles or jerking movements in face, arms, or body.
55. Has deliberately destroyed property.
56. Has difficulty concentrating, thinking clearly, or attending to tasks.
57. Talks negatively, as though bad things are all his/her fault.
58. Has lost significant amounts of weight without medical reason.
59. Acts impulsively without thinking of the consequences.
60. Is usually calm.
61. Will not forgive him/herself for past mistakes.
62. Lacks energy.
63. Feels that s/he doesn't have any friends or that no one likes him/her.
64. Gets frustrated and gives up or gets upset easily.
5/5