Hope & Faith Wellness Clinic - Child Behavior Checklist
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Email *
Child Name: *
Completed by: *
Please check Y= yes for behaviors that are a concern for your child S= sometimes for behaviors that are sometimes a concern for your child and N= no for behaviors that are not a concern for your child
ATTENTION: *
When symptoms began (date)
MM
/
DD
/
YYYY
Attention symptoms: *
Y
S
N
Careless mistakes
Poor attention span
Doesn't listen
Doesn't finish tasks
Problems organizing
Avoids tasks requiring concentration
Loses needed items
Easily distracted
Trouble remembering/forgetful
Fidgets, squirms
Leaves seat when required to sit
On the go, seems driven
Runs, climbs excessively/restless
Talks all the time
Problems waiting turn
Interrupts
MOOD: *
When symptoms began (date)
MM
/
DD
/
YYYY
Mood Symptoms: *
Y
S
N
Weight changes/appetite changes
Energy level changes
Sleep disturbances
Difficulty concentrating
Crying spells
Loss of interest/pleasure
Hopeless feelings
Guilty feelings
Isolates self
Low self-esteem/self-hate
Gives things away
Wishes to be dead
Injures self
Thinks about death/violence often
Rage outbursts
Bizarre behaviors, hallucinations
Rapid, hard to follow speech/thoughts
Thinks s/he is the smartest, best person in the world
OPPOSITIONAL BEHAVIORS: *
When symptoms began (date)
MM
/
DD
/
YYYY
Oppositional Behaviors symptoms: *
Y
S
N
Touchy, easily annoyed
Argues
Defiant
Angry
Tantrums
Bothers others deliberately
Spiteful/mean
Blames others for own mistakes
ANXIETY/WORRY: *
MM
/
DD
/
YYYY
Anxiety symptoms:
Y
S
N
Worries something terrible will happen to self or important adults
Frequently refuses or is reluctant to go somewhere for fear of separation
Avoids being alone
Nightmares about separation
Physical complaints about the time of separation transition
Worries about parent(s) leaving
Fearfulness of new situations, people or objects
Engages in repeated behaviors (counting, cleaning, organizing, hand washing etc.)
Excessive worry about everyday things
Fear/excessive worry about social situations
Clear selection
CONDUCT: *
When symptoms began (date)
MM
/
DD
/
YYYY
Conduct symptoms: *
Y
S
N
Bullies/threatens others
Starts fights
Used a weapon
Physically cruel to people/animals
Forcibly stolen from victim
Stolen without confronting victim
Forces sexual activity
Deliberately sets fires to cause damage
Further comments about any of the above
Child's strength in school setting:
Child's strength in social setting:
Child's strength in home setting:
Special Interests/Hobbies:
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