Please select the response option that best reflects the degree that the item represents your child.

Background Information: Columbia Public Schools has formed a school-based mental health committee to explore the mental health needs of our students. The goal of this work is to design a service model to efficiently address the growing mental health needs of Columbia Public Schools students and families through the use of evidence-based practices.

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* 1. Is your child ever NOT considerate of other people’s feelings?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 2. Do you have a child who is restless, overactive or cannot stay still for long?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 3. Do you have a child who often complains of headaches, stomach-aches or sickness?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 4. Do you have a child who readily shares with others, for example pencils, books, food?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 5. Do you have a child who often loses his/her temper?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 6. Do you have a child who would rather be alone than with other youth?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 7. Do you have a child who is generally well behaved and usually does what adults request?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 8. Do you have a child with many worries or who often seems worried?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 9. Do you have a child who is NOT helpful if someone is hurt, upset, or feeling ill?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 10. Do you have a child who is constantly fidgeting or squirming?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 11. Do you have a child who does NOT have at least one good friend?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 12. Do you have a child who fights with or bullies others?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 13. Do you have a child who is often unhappy, depressed, or tearful?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 14. Do you have a child who is NOT generally liked by other youth?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 15. Do you have a child who is easily distracted and whose concentration wanders?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 16. Do you have a child who is nervous in new situations and who easily loses confidence?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 17. Do you have a child who lies or cheats?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 18. Do you have a child who is picked on or bullied by others?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 19. Do you have a child who does NOT offer to help others (parents, teachers, students)?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 20. Do you have a child who does NOT think things out before acting?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 21. Do you have a child who steals from home, school, or elsewhere?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 22. Do you have a child who gets along better with adults than with other youth?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 23. Do you have a child who has many fears or is easily scared?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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* 24. Do you have a child who does NOT have good attention span and does not see work through to the end?

  Always Often Rarely Not Applicable
If yes, please select the degree that best represents your child. If no, please select Not Applicable.

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