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CHILD MENTAL HEALTH SCREENING

 
 
 
 
DOB :: xx/xx/xxxx
 
 
 
 
 
 
 
 
0= none – never evidenced
 
1- Evidenced in past
 
2- Child evidences this behavior once a week
 
3- Child exhibits this behavior at least three times a week
 
4- Child exhibits this behavior almost daily
 

Section 1

 
1. Child has difficulty separating from parent or caregiver
 
 
2. Child worries about harm coming to parents or about losing parents
 
 
3. Child resists going to school or elsewhere without parents
 
 
4. Child resists being alone or without parents
 
 
5. Child wants to sleep in parents room or bed
 
 
6. Child worries about getting kidnapped or lost
 
 
7. Child complains of headache, stomach ache, nausea when anticipating separation from parent
 
 

Section II

 
1. Child worries excessively about many things that peers do not – family, school, health
 
 
2. Child experiences discrete incidents of intense fear that peak within 10-15 minutes
 
 
3. Child has recurring distressful thoughts – i.e worry about germs or monsters
 
 
4. Child appears driven to do things repeatedly i.e. wash hands, count things
 
 
5. Child has excessive, unreasonable fears of specific objects or situations
 
 
6. Child has repeated distressing memories of past painful or difficult events
 
 

Section III

 
1. Child makes inappropriate noises and often seems unaware of doing so
 
 
2. Child makes sudden, repetitive, nonrhythmic movements
 
 
3. Child evidences twitches
 
 
3. Child evidences twitches
 
 

Section IV

 
1. Child makes careless mistakes and appears not to pay close attention
 
 
2. Child does not seem to listen when spoken to directly
 
 
3. Child forgets parts of directions when given multiple steps directions
 
 
4. Child fails to finish school work or chores
 
 
5. Child has difficulty organizing age appropriate tasks or activities – ie. messy desk or room or backpack
 
 
6. Child has difficulty focusing attention during school
 
 
6. Child has difficulty focusing attention during school
 
 
7. Child can focus on fast paced video or computer games, but not on reading
 
 
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8. Child is easily distracted by irrelevant sights or sounds
 
 
9. Child is forgetful in day to day activities
 
 
10. Child fidgets or squirms in seat
 
 
11. Child has problems remaining in seat
 
 
12. Child climbs or runs or jumps excessively; is generally restless
 
 
13. Child talks non-stop
 
 
14. Child blurt out answers before you have even finished asking the question
 
 
15. Child interrupts others
 
 
16. Child has difficulty waiting turn
 
 
17. Child has difficulty thinking about the consequences of actions before taking them
 
 

Section V

 
1. Child evidences period of unusual irritability or elevated mood
 
 
2. During this period, child evidences inflated self esteem
 
 
3. During this period, child is more talkative than normal
 
 
4. During this period, child seems to jump from one topic to another
 
 
5. During this period, child is more distractible than normal
 
 
6. During this period, child becomes excessively involved in things
 
 
7. During this period, child engages in dangerous pleasurable activities
 
 

Section VI

 
1. Child appears irritable or depressed most of the day, most days during a period of at least one week
 
 
2. Child has had noticeable changes in appetite
 
 
3. Child has lost interest in activities or clubs that child previously enjoyed
 
 
4. Child has difficulty falling asleep or staying asleep
 
 
5. Child is excessively tired throughout the day
 
 
6. Child is lethargic or agitated much of the time
 
 
7. Child expresses feelings of helplessness or worthlessness
 
 
8. Child reports a lack of energy almost every day
 
 
9. Child says that s/he wishes s/he wasn’t born or wouldn’t care if s/he died
 
 

Section VII

 
1. Child intentional defies or refuses to comply with adult rules
 
 
2. Child deliberately annoys others
 
 
3. Child loses temper easily
 
 
4. Child is lacks patience with others
 
 
5. Child is spiteful or vindictive
 
 
6. Child blames others for his/her misbehavior or mistakes
 
 

Section VIII

 
1. Child smokes cigarettes, pot, drinks alcohol or uses other substances
 
 
2. Child has had a failed attempt at rehab
 
 
3. Child has done bad things when under the influence of substances
 
 

Section IX

 
• Child is excessively worried about figure or weight gain
 
 
• If female, child has stopped having regular menstrual cycles
 
 
• Child thinks s/he is fat even though is not truly overweight
 
 
• Binges or purges
 
 

Section X

 
1. Child threatens or intimidates others, bullies
 
 
2. Child starts physical fights
 
 
3. Child has been physically cruel to animals
 
 
4. Child uses weapons (sticks, rocks, knives, guns) to harm others
 
 
5. Child deliberately destroys other people’s property
 
 
6. Child has stolen items from family members or shoplifted
 
 
7. Child has deliberately set fires
 
 
8. Child plays hooky from school
 
 
9. Child lies to avoid responsibilities and consequences
 
 
10. Child lies to obtain goods or attention
 
 
11. Child has run away from home overnight at least twice
 
 

Section XI

 
1. Child loses temper easily
 
 
2. Child intentionally defies adults or refuses to comply with adult rules
 
 
3. Child annoys others on purposes
 
 
4. Child blames others for his mistakes or misbehavior
 
 
5. Child has run away from home overnight at least twice
 
 
6. Child stays out all night despite parental rules
 
 
7. Child plays hooky from school
 
 
8. Child lacks patients with others
 
 
9. Child is spiteful and/or vindictive
 
 

Section XII

 
1. Child has unusual thoughts that others cannot understand
 
 
2. Child reports hearing voices that others don’t hear
 
 
3. Child reports seeing things that others do not
 
 
4. Child reports feeling things (like ants crawling on them) when the stimulus is not present
 
 
5. Child believes things occurred or are occurring that others do not believe
 
 

Section XIII

 
1. Child does poorly at sports or games that require physical coordination
 
 
2. Child has problems with balance
 
 
3. Child displays impaired fine motor skills
 
 
4. Child has problems with writing or writes extremely slowly
 
 
5. Child seems clumsy
 
 
6. Child does not get the humor in a joke because s/he interprets it literally
 
 
7. Child has difficulty reading the other person’s non-verbal cues such as body stance or tone of voice.
 
 
8. Child does not understand metaphors or analogies, but takes things literally
 
 
9. Child has difficulty transferring what is learned in one social situation to another similar one.
 
 
10. Child has difficulty remembering and organizing visual or spatial information
 
 
11. Child is slow to become familiar with new physical locations
 
 
12. Child has difficulty remembering the faces of people s/he met
 
 
13. Child loses his or her way easily and needs help finding his or her way around
 
 
14. Child has relatively strong verbal skills
 
 
15. Child has an auditory memory like a tape recorder
 
 
16. Child has difficulty at school with reading, writing, math or spelling
 
 
17. Child has delayed speech
 
 

Section XIV

 
1. Child avoids eye contact during conversations
 
 
2. Child ignores other people
 
 
3. Child is uncooperative and resistant
 
 
4. Child pays little or no attention when addressed
 
 
5. Child prefer to be left alone
 
 
6. Child shows little or no affection
 
 
7. Child fails to greet parents
 
 
8. Child doews not imitate
 
 
9. Child dislikes being held or cuddled
 
 
10. Child does not share
 
 
11. Child is disagreeable or non compliant
 
 
12. Child evidences temper tantrums
 
 
13. Child lacks friends or companions
 
 
14. Child is insensitive to other’s feelings
 
 
15. Child is indifferent to being liked
 
 
16. Child is indifferent if parent’s leave
 
 
17. Child has difficulty starting or stopping conversation
 
 
18. Childs uses unusual phrases, possibly over and over
 
 
19. Child does not engage in make-believe play
 
 
20. Child pays alone more than with others
 
 
21. Child shows unusual physical mannerisms (hand-flapping, shrieks, objects in mouth)
 
 
22. Child has unusual preoccupations (schedules, own alphabet, weather reports)
 
 
I would like to schedule an intake interview with Dr Crum to discuss my child’s needs in more detail:
 
 
 
 
 
 
I give permission for Dr. Crum to share these results with my child’s pediatrician:
 
 
 
 
 
Date :: xx/xx/xxxx
 
 
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