ALERT Child Questionnaire
Jane Rekas, LCSW / Western Psychological & Counseling Services
Over the past week, how often had the child?
destroyed property
Clear selection
been unhappy
Clear selection
behavior caused school problems
Clear selection
had temper tantrums
Clear selection
worrying prevented doing things
Clear selection
felt worthless or inferior
Clear selection
had trouble sleeping
Clear selection
changed moods quickly
Clear selection
used alcohol
Clear selection
was restless, trouble staying seated
Clear selection
engaged in repetitious behavior
Clear selection
used drugs
Clear selection
worried about almost anything
Clear selection
needed constant attention
Clear selection
Child's first name
Your email
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