Please complete the assessment according to the instructions and submit them to us. We are happy to give you the assessment results via e-mail, however, we have found that telephone interaction and discussion are far more insightful and helpful.

When you begin to complete this evaluation, you will see that you can easily make your child look as healthy or unhealthy as you wish. Please do not do that. If you are as accurate as possible, it is more likely that you will be able to receive the help that you are seeking for your child.

We have learned through sad experience that some parents are trying to use this assesment tool in divorce and custody cases. The purpose of this assesment tool is informational in nature and is not to be used or represented as a diagnostic instrument.

DIRECTIONS:

• The assessment is only to be completed for children that are 13-18 years old.
• Fill out the evaluation test for ONE child only.
• Read each statement carefully.
• Select the number that most accurately describes your child.

Child Information

First Name What is your favorite color?	Last Name	Sex of Child: Male Female
Date of Birth of Child: Select January February March April May June July August September October November December Select 12345678910111213141516171819202122232425262728293031 Select 201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982		Person Filling This Form: Mother Father Guardian

Parent/Guardian Information

First Name	Last Name
E-mail	Phone Number	Best time to call (optional)
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Assessment

	1. Wants to be alone more than 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.
	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.
	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 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.
	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.

Child Information

How urgent is your need to get help for your child? Please Select… I must get help immediately I am looking for treatment within the next week I am looking for treatment within the next month I am just evaluating the options for treatment if my child worsens

Are you aware of the financial commitment required for treatment? Yes    No

Do you have access to the resources needed to pay for treatment? Yes    No

If you chose to place your child in treatment, would you need to borrow funds? Yes    No

Are there any legal or court related issues that would need to be resolved prior to placement in treatment? Yes    No

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