Early Identification Checklist - School Refusal

Early Identification Checklist for School Refusal

A Checklist for Teachers and Parents

Research shows that early identification of warning signs is key to successful school refusal interventions.

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* 1. Which of the following School Refusal symptoms have you observed in the past week?

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* 2. On a scale from 0 to 10 thumbs, how manageable is the current situation for you?

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* 3. I would like the School Refusal Clinic to contact me to discuss an appointment:

Yes please

No thanks, just having a look

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* 4. If you selected 'Yes please' (above), please enter your contact information below:

First Name

Last Name

Age of child

Grade or Year level of child

Email Address

Phone Number

	✓	✘
Complaints about attending school	Complaints about attending school ✓	Complaints about attending school ✘
Reluctance to talk with parents about school	Reluctance to talk with parents about school ✓	Reluctance to talk with parents about school ✘
Sleeping difficulties (under or over sleeping, frequently tired at home and school)	Sleeping difficulties (under or over sleeping, frequently tired at home and school) ✓	Sleeping difficulties (under or over sleeping, frequently tired at home and school) ✘
Social withdrawal, isolating behaviour at home	Social withdrawal, isolating behaviour at home ✓	Social withdrawal, isolating behaviour at home ✘
Excessive internet use (gaming, youtube and social media)	Excessive internet use (gaming, youtube and social media) ✓	Excessive internet use (gaming, youtube and social media) ✘
Feeling sick before school (waking up with a headache, stomach ache or sore throat)	Feeling sick before school (waking up with a headache, stomach ache or sore throat) ✓	Feeling sick before school (waking up with a headache, stomach ache or sore throat) ✘
Frequent crying spells or temper tantrums / aggressive behaviour	Frequent crying spells or temper tantrums / aggressive behaviour ✓	Frequent crying spells or temper tantrums / aggressive behaviour ✘
Separation anxiety (difficulty leaving the house, getting out of the car or in the school gate)	Separation anxiety (difficulty leaving the house, getting out of the car or in the school gate) ✓	Separation anxiety (difficulty leaving the house, getting out of the car or in the school gate) ✘
Unexplained absences (or often running late to school)	Unexplained absences (or often running late to school) ✓	Unexplained absences (or often running late to school) ✘
Frequent crying with requests to go home	Frequent crying with requests to go home ✓	Frequent crying with requests to go home ✘
Absences on significant days (tests, oral presentations, physical education classes)	Absences on significant days (tests, oral presentations, physical education classes) ✓	Absences on significant days (tests, oral presentations, physical education classes) ✘
Conflict with teacher/s and parents	Conflict with teacher/s and parents ✓	Conflict with teacher/s and parents ✘
Peer relational problems (being bullied)	Peer relational problems (being bullied) ✓	Peer relational problems (being bullied) ✘
Academic difficulties	Academic difficulties ✓	Academic difficulties ✘
Excessive worry about a parent when at school	Excessive worry about a parent when at school ✓	Excessive worry about a parent when at school ✘
Panic symptoms	Panic symptoms ✓	Panic symptoms ✘
Threats of self-harm	Threats of self-harm ✓	Threats of self-harm ✘

Question Title

* 1. Which of the following School Refusal symptoms have you observed in the past week?

Question Title

* 2. On a scale from 0 to 10 thumbs, how manageable is the current situation for you?

Question Title

* 3. I would like the School Refusal Clinic to contact me to discuss an appointment:

Question Title

* 4. If you selected 'Yes please' (above), please enter your contact information below:

Question Title

* 5. Are there any other concerns or questions you have?