Parent Questionnaire

Please answer the following Yes or No questions:

1. Recently, have you become worried about your child's behavior?
   Yes    No
2. Have you noticed your child isolating, staying away from peers and activities he/she used to enjoy?
   Yes    No
3. Has your child's performance in school changed? Has his/her grades, attendance or school behaviors changed?
   Yes    No
4. Has your child become involved with a different set of peers or have a peer group of which you do not approve?
   Yes    No
5. Have you noticed your child demonstrating self-harming behavior such as cutting, impulsive actions, or talk of suicide?
   Yes    No
6. Have you noticed your child become more anxious in recent weeks or months?
   Yes    No
7. Do you notice your child becomes easily overwhelmed?
   Yes    No
8. Has your child become more irritable or argumentative at what seem to be insignificant situations?
   Yes    No
9. Has your child become more aggressive at home or at school or with peers?
   Yes    No
10. Does your child routinely have a difficult time following rules at home or from authority figures?
    Yes    No
11. Has your child become less communicative with you, teachers, or therapists?
    Yes    No
12. Has your child been engaging in risky behavior, running away, staying out really late, drug/alcohol use, sexual promiscuity?
    Yes    No
13. Have the sleep patterns or eating habits of your child changed recently?
    Yes    No
14. Has your child experienced a trauma or significant event within the last 6 months?
    Yes    No

Short Answer Questions

1. How has your child changed over the last 3-6 months?
2. What skills or talents does your child have?
3. What brings your child joy?
4. How does your child make friends/keep friends?
5. What school or extracurricular activities does your child excel at?
6. What have you done in the past to help your child or family get through difficult times?
7. If you have been shocked by your child's behavior in the last 6 months, what shocked you?
8. How does your child communicate with family members, teachers, and other parental/authority figures?
9. How does your child deal with stress?
10. When was the last time you saw your child smile or appear as though he/she was truly enjoying life?
11. What does your child do for fun?
12. Who have been the role models in your child's life?

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