Assessment Form

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Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Child First Name

Child Last Name

Child Age in Years

Child Gender at birth

Male
Female

1: Wants to be alone more than with other children of the same age.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

2: Complains of dizziness or headaches.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

3: Doesn't participate in activities that were previously enjoyable.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

4: Argues or is verbally disrespectful.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

5: Is more fearful than other children of the same age.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

6: Cuts school or is truant.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

7: Cooperates with rules and expectations.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

8: Has difficulty completing assignments or completes them carelessly.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

9: Complains or whines that things are unfair.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

10: Experiences trouble with her/his bowels, such as constipation or diarrhea.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

11: Gets into physical fights with peers or family members.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

12: Worries and/or can't get certain ideas out of his/her mind.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

13: Steals or lies.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

14: Is fidgety, restless, or hyperactive.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

15: Seems anxious or nervous.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

16: Communicates in a pleasant and appropriate manner.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

17: Seems tense, is easily startled.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

18: Soils or wets self.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

19: Is aggressive toward adults.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

20: Sees, hears, or believes things that are not real.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

21: Has participated in self-harm (e.g. cutting or scratching self, attempted suicide)

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

22: Uses alcohol or drugs.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

23: Seems unable to get organized.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

24: Enjoys relationships with family and friends.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

25: Appears sad or unhappy.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

26: Experiences pain or weakness in muscles or joints.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

27: Has a negative or distrustful attitude toward friends, family members, or adults.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

28: Believes that others are trying to hurt him/her even when they are not.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

29: Threatens to or has run away from home.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

30: Experiences rapidly changing and strong emotions.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

31: Deliberately breaks rules, laws, or expectations.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

32: Appears happy with her/himself.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

33: Sulks, pouts, or cries more than other children of the same age.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

34: Pulls away from family or friends.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

35: Complains of stomach pains or feeling sick more than other children of the same age.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

36: Doesn't have or keep friends.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

37: Has friends of whom I don't approve.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

38: Believes that others can hear his/her thoughts or that s/he can hear the thoughts of others.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

39: Engages in inappropriate sexual behavior (e.g. sexually active, exhibits self, sexual abuse toward family members or others).

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

40: Has difficulty waiting his/her turn in activities or conversations.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

41: Thinks about suicide, says s/he would be better if s/he were dead.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

42: Complains of nightmares, difficulty getting to sleep, oversleeping, or waking up from sleep too early.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

43: Complains about or challenges rules, expectations, or responsibilities.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

44: Has times of unusual happiness or excessive energy.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

45: Handles frustration or boredom appropriately.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

46: Has fears of going crazy.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

47: Feels appropriate guilt for wrongdoing.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

48: Is unusually demanding.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

49: Is irritable.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

50: Vomits or is nauseous more than other children of the same age.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

51: Becomes angry enough to be threatening to others.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

52: Seems to stir up trouble when bored.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

53: Is appropriately hopeful and optimistic.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

54: Experiences twitching muscles or jerking movements in face, arms, or body.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

55: Has deliberately destroyed property.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

56: Has difficulty concentrating, thinking clearly, or attending to tasks.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

57: Talks negatively, as though bad things are all his/her fault.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

58: Has lost significant amounts of weight without medical reason.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

59: Acts impulsively without thinking of the consequences.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

60: Is usually calm.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

61: Will not forgive him/herself for past mistakes.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

62: Lacks energy.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

63: Feels that s/he doesn't have any friends or that no one likes him/her.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True

64: Gets frustrated and gives up or gets upset easily.

Never or Almost Never True
Rarely True
Sometimes True
Frequently True
Almost Always or Always True