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Zumbro Valley Health Center
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  • Mental Health
    • Adult Counseling
      • ARMHS
      • Substance Use & Recovery Services
    • Integrative Healthcare & Wellbeing
    • Depression & Anxiety Treatment
    • Youth and Family Counseling
      • ADD/ADHD
      • Mood or Behavior Disorders
      • Trauma Treatment
      • Psychiatric Evaluation
      • Substance Use & Recovery Services
    • Community Support
    • Crisis & Residential Services
    • Telehealth
  • Substance Use
    • Detoxification
    • DUI Education
    • Counseling
    • Drug Testing Services
    • Support Groups
  • Medication Management
    • ADD/ADHD
    • Anxiety & Depression
    • Bipolar Disorder
    • Obsessive Compulsive Disorder
    • Post Traumatic Stress Disorder
    • Schizophrenia
  • Your Visit
    • What To Expect
    • About Us
    • Locations
    • Insurance Accepted
    • Client Forms
    • Make A Referral
  • Providers
    • Meet The Team
    • Leadership and Staff
    • Licensing and Certifications
    • Make A Donation
    • Annual Report
  • Resources
    • Classes & Groups
    • Types of Therapy
    • Teachers & Parents
    • Video Resources
    • FAQs
    • News

Child Evaluation Form (ages 11-17)

  • Strengths and Difficulties Questionnaire

    To be filled out by Child: For each item, please mark the box for Not True, Somewhat True, or Certainly True. It would help us if you answered all the items as best as your can even if you are not absolutely certain. Please give your answers on the basis of how things have been for you over the last six months.
  • Do the difficulties interfere with your everyday life in the following areas?

  • Columbia-Suicide Severity Rating Scale

    To be filled out by Child.
    Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn't jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.
  • Adverse Childhood Experience (ACE) Questionnaire

    To be filled out by Child. While you were growing up, during your first 18 years of life:
  • This is your ACE Score.
  • PHQ-Scoring Tally Sheet

    Over the last 2 weeks, how often have you been bothered by any of the following problems? Read each item carefully and mark your response.
  • GAIN-Short Screener (GAIN-SS)

    The following questions are about common psychological, behavioral, and personal problems. These problems are considered significant when you have them for two or more weeks, when they keep coming back, when they keep you from meeting your responsibilities, or when they make you feel like you can't go on.
  • Lied or conned to get things you wanted or to avoid having to do something
  • Had a hard time paying attention at school, work, or home
  • Had a hard time listening to instructions at school, work, or home
  • Were a bully or threatened other people
  • Started physical fights with other people
  • Strengths and Difficulties Questionnaire

    To be filled out by Parent/Guardian: For each item, please mark the box for Not True, Somewhat True, or Certainly True. It would help us if you answered all the items as best as your can even if you are not absolutely certain. Please give your answers on the basis of your child's behavior over the last six months.
  • Do the difficulties interfere with your child's everyday life in the following areas?

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Zumbro Valley Health Center

507.289.2089

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  • Monday - Thursday - 7:30am - 7:00pm
  • Friday - 7:30am - 12:00pm
  • Emergency/Crisis Hotline 844.274.7472

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