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The birthdate of your child is needed for us to identify your data while keeping it anonymous to others. Your data will be transmitted securely as scrambled numbers without any text labels.
Birthday of child
MM
/
DD
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YYYY
Name
Please rate your child's behavior over the last six months. Select 2 if the item is very true or often true of your child. Select 1 if the item is somewhat or sometimes true. Select 0 if the item is not true of your child. Answer all items as best as you can, even if you are not absolutely certain. *
0- Not true (as far as you know)
1- Somewhat or sometimes true
2- Very true or often true
Feels unloved
Feels misunderstood
Disobedient at home
Disobedient at school
Drinks alchohol
Argues excessively
Physically damages or destroys things
Fights with other kids
Hangs around other kids who get in trouble
Acts impulsively or without thinking
Lying
Nightmares
Rejected by other kids
Feels excessively guilty
Physically attacks other people
Threatens to physically attack other people
Repeats certain acts over and over again (compulsions)
Away from home without permission after curfew
Screams or yells a lot
Sets fires
Sexual problems
Steals at home
Steals outside the home
Uses unacceptable language (e.g., swearing or obscene language)
Talks about harming or killing self
Temper tantrums or rage
Vandalism
Poor grades at school
In the last 6 months how many times have the following occured? *
0
1
2
3
4
5
6
7
8+
Child's behavior led to police intervention
Went to a hospital for a psychiatric emergency
Physically harmed self with minimal risk of death
Attempted suicide by taking pills
Attempted suicide in other ways
Physically attacked another person or an animal
Physically damaged or destroyed something
Away from home without permission after curfew
In the last 6 months have the difficulties burdened either parent or the family as a whole? *
During the last 4 weeks of school homework completion was: *
During the last 4 weeks of school average grades on homework assignments were *
During the last 4 weeks of school (20 days) how many full days of school were missed? *
During the last 4 weeks of school (20 days) how many times has your child left school without permission? *
On the last 5 school days, on how many days did the following occur
0
1
2
3
4
5
How many days late for school (for any reason)?
How many hours of school were missed (for any reason)
Clear selection
In the last 7 days, on how many days did the following occur? *
0
1
2
3
4
5
6
7
Talked about harming or killing self
Threatened to physically attack another person or animal
Screamed or yelled at other people
Used unacceptable language (e.g., swearing or obscene language)
Less than 8 hours of sleep
Less than 7 hours of sleep
Less than 6 hours of sleep
Asleep until 12 noon
Filled out by:
Clear selection
Submit
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