Child's Name Male Female

Date of Birth

Person Completing Form and Relationship to Child

Contact Telephone Email

Best Time to Call Morning Afternoon Evening Anytime

Home Town

During the Past 6 Months

How would you describe your child's self esteem?

Above Average
Average
Below Average

Does your child's physical appearance negatively impact his or her self-esteem?

Yes
No

Is your child argumentative, easily offended, or does he/she quickly become defensive?

Yes
No

Is your child disrespectful towards authority figures, e.g., parents, teachers, coaches, etc.?

Yes
No

Does your child engage in "sneaky" behaviors, lying, or lying by omission, e.g., "white lies", "half truths", etc.?

Yes
No

Does your child externalize his or her negative behaviors by blaming others?

Yes
No

Does your child try to negotiate or manipulate in an effort to avoid consequences?

Yes
No

Is it a struggle to get your child to participate in family activities or social events?

Yes
No

Is your child's school performance a chronic problem or frequent source of conflict at home?

Yes
No

Has your child been given lunch detention or after school detention?

Never
Occasionally
Often

Is it difficult for your child to relate to peers or make friends?

Yes
No

Is your child forgetful or often viewed as "lazy"?

Yes
No

Do you feel as though you have to be careful when confronting your child for fear you might "set them off"?

Yes
No

Does your child attempt to rationalize or justify his or her negative behaviors?

Yes
No

Has your child been caught steeling?

Yes
No

Does your child feel as though everyone is against him/her?

Yes
No

During the past 12 months

Has your child been suspended from school or expelled?

Yes
No

Has your child experienced recurrent problems associated with a traumatic event, e.g., divorce, abuse, death, etc.?

Yes
No

Has your child exhibited violent or aggressive behaviors?

Yes
No

Has your child withdrawn socially, or suffer from frequent depression or discouragement?

Yes
No

Are you concerned your child might be using drugs or alcohol?

Yes
No

Has your child attended therapy or been evaluated by a mental health professional?

Yes
No

Lifestyle assessment

Does your child participate in organized recreational activities, e.g., youth sports, piano lessons, church group, etc.?

Yes
No

Does your child participate in overlapping activities, e.g., soccer and baseball during the same season?

Yes
No

Has your child expressed a desire to skip organized activities because they are "too tired" or "need a break"?

Yes
No

Does your child spend an excessive amount of time on the computer, watching TV, or playing video games?

Yes
No

Does your child participate in unstructured activities or "free play" on a regular basis?

Yes
No

Does your child sleep restfully for 8 or more hours each night?

Yes
No

Does your child often sleep or nap during the day?

Yes
No

In the space provided below please describe a recent event which you feel is significant or indicative of your child's current behavior pattern: