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Adolescent/Child Self Evaluation - B

1.

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* Your First Name

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* Your Last name

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* Your Group at Ele's Place

Middle School

High School

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* After a death, it is common for people to experience some changes in feelings and behavior. This is a normal part of grief. The following list includes areas in which children or teens may have problems, whether or not a death has occured. We would like you to rate the extent to which each statement applies to you NOW, since coming ot Ele's Place. Please us the following scale:

	1 - Does not apply	2	3 - Sometimes	4	5 - Most of the time
I am moody and easily upset.	I am moody and easily upset. 1 - Does not apply	I am moody and easily upset. 2	I am moody and easily upset. 3 - Sometimes	I am moody and easily upset. 4	I am moody and easily upset. 5 - Most of the time
I have nightmares or bad dreams.	I have nightmares or bad dreams. 1 - Does not apply	I have nightmares or bad dreams. 2	I have nightmares or bad dreams. 3 - Sometimes	I have nightmares or bad dreams. 4	I have nightmares or bad dreams. 5 - Most of the time
I do not sleep well, or I sleep too much.	I do not sleep well, or I sleep too much. 1 - Does not apply	I do not sleep well, or I sleep too much. 2	I do not sleep well, or I sleep too much. 3 - Sometimes	I do not sleep well, or I sleep too much. 4	I do not sleep well, or I sleep too much. 5 - Most of the time
I get very angry.	I get very angry. 1 - Does not apply	I get very angry. 2	I get very angry. 3 - Sometimes	I get very angry. 4	I get very angry. 5 - Most of the time
I have trouble paying attention.	I have trouble paying attention. 1 - Does not apply	I have trouble paying attention. 2	I have trouble paying attention. 3 - Sometimes	I have trouble paying attention. 4	I have trouble paying attention. 5 - Most of the time
I have difficulty with schoolwork.	I have difficulty with schoolwork. 1 - Does not apply	I have difficulty with schoolwork. 2	I have difficulty with schoolwork. 3 - Sometimes	I have difficulty with schoolwork. 4	I have difficulty with schoolwork. 5 - Most of the time
I have aches and pains.	I have aches and pains. 1 - Does not apply	I have aches and pains. 2	I have aches and pains. 3 - Sometimes	I have aches and pains. 4	I have aches and pains. 5 - Most of the time
I am often sick.	I am often sick. 1 - Does not apply	I am often sick. 2	I am often sick. 3 - Sometimes	I am often sick. 4	I am often sick. 5 - Most of the time
I worry alot.	I worry alot. 1 - Does not apply	I worry alot. 2	I worry alot. 3 - Sometimes	I worry alot. 4	I worry alot. 5 - Most of the time
I don't like to be away from my parent.	I don't like to be away from my parent. 1 - Does not apply	I don't like to be away from my parent. 2	I don't like to be away from my parent. 3 - Sometimes	I don't like to be away from my parent. 4	I don't like to be away from my parent. 5 - Most of the time
I keep to myself.	I keep to myself. 1 - Does not apply	I keep to myself. 2	I keep to myself. 3 - Sometimes	I keep to myself. 4	I keep to myself. 5 - Most of the time
I have trouble settling down.	I have trouble settling down. 1 - Does not apply	I have trouble settling down. 2	I have trouble settling down. 3 - Sometimes	I have trouble settling down. 4	I have trouble settling down. 5 - Most of the time
It's hard for me to express my feelings.	It's hard for me to express my feelings. 1 - Does not apply	It's hard for me to express my feelings. 2	It's hard for me to express my feelings. 3 - Sometimes	It's hard for me to express my feelings. 4	It's hard for me to express my feelings. 5 - Most of the time
I get into trouble.	I get into trouble. 1 - Does not apply	I get into trouble. 2	I get into trouble. 3 - Sometimes	I get into trouble. 4	I get into trouble. 5 - Most of the time
I think about wanting to die.	I think about wanting to die. 1 - Does not apply	I think about wanting to die. 2	I think about wanting to die. 3 - Sometimes	I think about wanting to die. 4	I think about wanting to die. 5 - Most of the time

Other (please specify)