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Parent/Caregiver Rating of Child's Adjustment - B

1.

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* Parent/Guardian First and Last Name

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* Child's First Name

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* Child's Last name

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* Child's Group at Ele's Place

Preschool/Kindergarten

Early Elementary

Upper Elementary

Middle School

High School

Young Adult

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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 several areas in which children may display problems, whether or not a death has occured. We are interested in each child's functioning in each area NOW, since coming to Ele's Place. Please use the following scale to rate the extent to which these statements apply to your child.

	1 - Does not apply	2	3 - Sometimes	4	5 - Most of the time
My child is moody, irritable or easily upset.	My child is moody, irritable or easily upset. 1 - Does not apply	My child is moody, irritable or easily upset. 2	My child is moody, irritable or easily upset. 3 - Sometimes	My child is moody, irritable or easily upset. 4	My child is moody, irritable or easily upset. 5 - Most of the time
My child has nightmares or bad dreams.	My child has nightmares or bad dreams. 1 - Does not apply	My child has nightmares or bad dreams. 2	My child has nightmares or bad dreams. 3 - Sometimes	My child has nightmares or bad dreams. 4	My child has nightmares or bad dreams. 5 - Most of the time
My child does not sleep well, or sleeps too much.	My child does not sleep well, or sleeps too much. 1 - Does not apply	My child does not sleep well, or sleeps too much. 2	My child does not sleep well, or sleeps too much. 3 - Sometimes	My child does not sleep well, or sleeps too much. 4	My child does not sleep well, or sleeps too much. 5 - Most of the time
My child gets angry or has tantrums.	My child gets angry or has tantrums. 1 - Does not apply	My child gets angry or has tantrums. 2	My child gets angry or has tantrums. 3 - Sometimes	My child gets angry or has tantrums. 4	My child gets angry or has tantrums. 5 - Most of the time
My child has trouble paying attention.	My child has trouble paying attention. 1 - Does not apply	My child has trouble paying attention. 2	My child has trouble paying attention. 3 - Sometimes	My child has trouble paying attention. 4	My child has trouble paying attention. 5 - Most of the time
My child has difficulty with schoolwork.	My child has difficulty with schoolwork. 1 - Does not apply	My child has difficulty with schoolwork. 2	My child has difficulty with schoolwork. 3 - Sometimes	My child has difficulty with schoolwork. 4	My child has difficulty with schoolwork. 5 - Most of the time
My child has aches and pains.	My child has aches and pains. 1 - Does not apply	My child has aches and pains. 2	My child has aches and pains. 3 - Sometimes	My child has aches and pains. 4	My child has aches and pains. 5 - Most of the time
My child is frequently sick.	My child is frequently sick. 1 - Does not apply	My child is frequently sick. 2	My child is frequently sick. 3 - Sometimes	My child is frequently sick. 4	My child is frequently sick. 5 - Most of the time
My child is anxious and worried.	My child is anxious and worried. 1 - Does not apply	My child is anxious and worried. 2	My child is anxious and worried. 3 - Sometimes	My child is anxious and worried. 4	My child is anxious and worried. 5 - Most of the time
My child does not want to be apart from me.	My child does not want to be apart from me. 1 - Does not apply	My child does not want to be apart from me. 2	My child does not want to be apart from me. 3 - Sometimes	My child does not want to be apart from me. 4	My child does not want to be apart from me. 5 - Most of the time
My child is quiet and withdrawn.	My child is quiet and withdrawn. 1 - Does not apply	My child is quiet and withdrawn. 2	My child is quiet and withdrawn. 3 - Sometimes	My child is quiet and withdrawn. 4	My child is quiet and withdrawn. 5 - Most of the time
My child is overly active or impulsive.	My child is overly active or impulsive. 1 - Does not apply	My child is overly active or impulsive. 2	My child is overly active or impulsive. 3 - Sometimes	My child is overly active or impulsive. 4	My child is overly active or impulsive. 5 - Most of the time
It's hard for my child to express his/her feelings.	It's hard for my child to express his/her feelings. 1 - Does not apply	It's hard for my child to express his/her feelings. 2	It's hard for my child to express his/her feelings. 3 - Sometimes	It's hard for my child to express his/her feelings. 4	It's hard for my child to express his/her feelings. 5 - Most of the time
My child gets into trouble.	My child gets into trouble. 1 - Does not apply	My child gets into trouble. 2	My child gets into trouble. 3 - Sometimes	My child gets into trouble. 4	My child gets into trouble. 5 - Most of the time
My child has talked about wanting to die.	My child has talked about wanting to die. 1 - Does not apply	My child has talked about wanting to die. 2	My child has talked about wanting to die. 3 - Sometimes	My child has talked about wanting to die. 4	My child has talked about wanting to die. 5 - Most of the time

Other (please specify)

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* What was the relationship of the person who died to this child?

Parent

Sibling

Friend

Relative

If relative or other please specify

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* What was the cause of death?

Accident

Suicide

Homicide

Other sudden death

Illnss

Other (please specify)