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Are they depressed or sad?

Do they withdraw from the family?

Have they stopped doing things they used to enjoy?

Do they talk about suicide?

Have they ever attempted suicide?

Do they harm themselves intentionally?

Have they ever harmed anyone else?

Have they ever been abused or neglected?

Are they anxious or nervous?

Anxious or nervous about school?

Anxious or nervous about leaving the house?

Anxious or nervous about being separated from you?

Have they ever had a panic or anxiety attack?

Does your child accept consequences and responsibility for their actions?

Is your child cooperative at home?

Have they ever runaway from school?

Do they get in trouble at school?

Have they ever been suspended?

Do they often call to come home early?

Are they often tardy?

9 + 9 =

Do not use this form to seek emergency help for your child. If this is a medical emergency, call 911. If your child is expressing suicidal and/or homicidal thinking or planning call your current outpatient therapist, 911, or transport your child to the closest emergency room for an evaluation.