DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent/Guardian Name* First Last Parent/Guardian Email* Enter Email Confirm Email Relationship to ChildMotherFatherChild's Name* First Last Child's Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's GenderMaleFemaleStrengths and Difficulties QuestionnaireTo 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.I try to be nice to other people. I care about their feelings. Not True Somewhat True Certainly True I am restless, I cannot stay still for long Not True Somewhat True Certainly True I get a lot of headaches, stomach-aches or sickness Not True Somewhat True Certainly True I usually share with others, for example CD's, games, food Not True Somewhat True Certainly True I get very angry and often lose my temper Not True Somewhat True Certainly True I would rather be alone than with people of my age Not True Somewhat True Certainly True I usually do as I am told Not True Somewhat True Certainly True I worry a lot Not True Somewhat True Certainly True I am helpful if someone is hurt, upset, or feeling ill Not True Somewhat True Certainly True I am constantly fidgeting or squirming Not True Somewhat True Certainly True I have one good friend or more Not True Somewhat True Certainly True I fight a lot. I can make other people do what I want Not True Somewhat True Certainly True I am often unhappy, depressed, or tearful Not True Somewhat True Certainly True Other people my age generally like me Not True Somewhat True Certainly True I am easily distracted, I find it difficult to concentrate Not True Somewhat True Certainly True I am nervous in new situations. I easily lose confidence Not True Somewhat True Certainly True I am kind to younger children Not True Somewhat True Certainly True I am often accused of lying or cheating Not True Somewhat True Certainly True Other children or young people pick on me or bully me Not True Somewhat True Certainly True I often offer to help others (parents, teachers, children) Not True Somewhat True Certainly True I think before I do things Not True Somewhat True Certainly True I take things that are not mine from home, school, or elsewhere Not True Somewhat True Certainly True I get along better with adults than with people my own age Not True Somewhat True Certainly True I have many fears, I am easily scared Not True Somewhat True Certainly True I finish the work I'm doing. My attention is good Not True Somewhat True Certainly True Do you have any others comments or concerns?Overall, do you think that you have difficulties in any of the following areas: emotions, concentration, behavior, or being able to get on with other people? No Yes - minor difficulties Yes - definite difficulties Yes - severe difficulties How long have these difficulties been present? Less than a month 1-5 months 6-12 months Over a year Do the difficulties upset or distress you? Not at all Only a little A medium amount A great deal Do the difficulties make it harder for those around you (family, friends, teachers, etc)? Not at all Only a little A medium amount A great deal Do the difficulties interfere with your everyday life in the following areas?Home Life Not at all Only a little A medium amount A great deal Friendships Not at all Only a little A medium amount A great deal Classroom Learning Not at all Only a little A medium amount A great deal Leisure Activities Not at all Only a little A medium amount A great deal Columbia-Suicide Severity Rating ScaleTo be filled out by Child.In the past month, have you wished you were dead or wished you could go to sleep and not wake up?YesNoIn the past month, have you actually had any thoughts about killing yourself?YesNoIn the past month, have you thought about how you might do this?YesNoIn the past month, have you had any intention of acting on these thoughts of killing yourself, as opposed to you have the thoughts but you definitely would not act on them?YesNoIn the past month, have you started to work out or worked out the details of how to kill yourself?YesNoIf yes, do you intend to carry out this plan?YesNoHave you done any of the following in the past 3 months? Attempted to kill yourself even if ending your life was only part of your motivation Started to do something to end your life but someone or something stopped you before you actually did anything Taken any steps towards making a suicide attempt or preparing to kill yourself 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.In your entire lifetime, how many times have you done any of these things?Adverse Childhood Experience (ACE) QuestionnaireTo be filled out by Child. While you were growing up, during your first 18 years of life:Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you? Or act in a way that made you afraid that you might be physically hurt?YesNoDid a parent or other adult in the household often push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured?YesNoDid an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? Or try to or actually have oral, anal, or vaginal sex with you?YesNoDid you often feel that no one in your family loved you or thought you were important or special? Or that your family didn't look out for each other, feel close to each other, or support each other?YesNoDid you often feel that no one in your family loved you or thought you were important or special? Or that your family didn't look out for each other, feel close to each other, or support each other?YesNoDid you often feel that you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? Or that your parents were too drunk or high to take care of you or take you to the doctor if you needed it?YesNoWere your parents ever separated or divorced?YesNoWas your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her? Or sometimes or often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?YesNoDid you live with anyone who was a problem drinker or alcoholic or who used street drugs?YesNoWas a household member depressed or mentally ill or did a household member attempt suicide?YesNoDid a household member go to prison?YesNoNow add up your "Yes" answers in this section.This is your ACE Score.PHQ-Scoring Tally SheetOver the last 2 weeks, how often have you been bothered by any of the following problems? Read each item carefully and mark your response.Feeling down, depressed, or hopelessNot at allSeveral daysMore than half the daysNearly every dayLittle interest or pleasure in doing thingsNot at allSeveral daysMore than half the daysNearly every dayTrouble falling asleep, staying asleep, or sleeping too muchNot at allSeveral daysMore than half the daysNearly every dayPoor appetite or over eatingNot at allSeveral daysMore than half the daysNearly every dayFeeling tired or having little energyNot at allSeveral daysMore than half the daysNearly every dayFeeling bad about yourself - or that you are a failure or have let yourself or your family downNot at allSeveral daysMore than half the daysNearly every dayTrouble concentrating on things such as reading the newspaper or watching televisionNot at allSeveral daysMore than half the daysNearly every dayMoving or speaking slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you are moving around a lot more than usualNot at allSeveral daysMore than half the daysNearly every dayThinking that you would be better off dead or that you want to hurt yourself in some wayNot at allSeveral daysMore than half the daysNearly every dayIn the past year have you felt depressed or sad most days, even if you felt okay sometimes?YesNoIf you checked off any problems in this section so far, how difficult have these problems made it for you to work, take care of things at home, or get along with other people?Not at allSeveral daysMore than half the daysNearly every dayHas there been a time in the past month when you have had serious thoughts about ending your life?YesNoHave you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?YesNoGAIN-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. When was the last time that you had significant problems with feeling very trapped, lonely, sad, blue, depressed, or hopeless about the future? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you had significant problems with sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you had significant problems with feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you had significant problems with becoming very distressed and upset when something reminded you of the past? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you had significant problems with thinking about ending your life or committing suicide? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you did the following thing two or more times?Lied or conned to get things you wanted or to avoid having to do something Past month 2 to 12 months ago 1+ years ago Never When was the last time that you did the following thing two or more times?Had a hard time paying attention at school, work, or home Past month 2 to 12 months ago 1+ years ago Never When was the last time that you did the following thing two or more times?Had a hard time listening to instructions at school, work, or home Past month 2 to 12 months ago 1+ years ago Never When was the last time that you did the following thing two or more times?Were a bully or threatened other people Past month 2 to 12 months ago 1+ years ago Never When was the last time that you did the following thing two or more times?Started physical fights with other people Past month 2 to 12 months ago 1+ years ago Never When was the last time that you used alcohol or other drugs weekly or more often? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or feeling the effects of alcohol or other drugs? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people? Past month 2 to 12 months ago 1+ years ago Never When was the last time that your use of alcohol or other drugs caused you to give up, reduce or have problems at important activities at work, school, home, or social events? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or that you used any alcohol or other drugs to stop being sick or avoid withdrawal problems? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you had a disagreement in which you pushed, grabbed, or shoved someone? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you took something from a store without paying for it? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you sold, distributed, or helped someone make illegal drugs? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you drove a vehicle while under the influence of alcohol or illegal drugs? Past month 2 to 12 months ago 1+ years ago Never When was the last time that you purposely damaged or destroyed property that did not belong to you? Past month 2 to 12 months ago 1+ years ago Never Do you have other significant psychological, behavioral, or personal problems that you want treatment for or help with? Yes No If yes, please describe belowWhat is your gender?MaleFemaleHow old are you today?Please check the symptoms you are having now Child symptoms only Aches/pains Anxious/nervous Ashamed Body image concerns Can't enjoy myself Choking feeling Cries easily/often Decreased appetite/weight loss Depressed/sad Difficulty breathing Distressing memories Disturbing thoughts Dizziness Elevated mood Excessive worry Feels inferior Feels unworthy Feeling paranoid/suspicious Frequent mood swings Guilt feelings Headaches Hears voices Heart racing Heavy feeling Hopelessness Increased appetite/weight gain Irritable/angry Lack of motivation Loneliness Loses temper Low energy/tired Low self-esteem Nightmares Numbness/tingling Poor concentration Poor memory Racing thoughts Repetitive actions Restless/fidgety Sees images or objects Self harming behaviors/urges Sexual issues/concerns Shaking Sleep problems Social discomfort Tense feelings Thoughts of wanting to die Thoughts of wanting to hurt others Violent behavior Wound up Please describe any other symptomsStrengths and Difficulties QuestionnaireTo 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.Considerate of other people's feelings Not True Somewhat True Certainly True Restless, overactive, cannot stay still for long Not True Somewhat True Certainly True Often complains of headaches, stomach-aches, or sickness Not True Somewhat True Certainly True Shares readily with other youth, for example CD's, games, food Not True Somewhat True Certainly True Often loses temper Not True Somewhat True Certainly True Would rather be alone than with other youth Not True Somewhat True Certainly True Generally well behaved, usually does what adults request Not True Somewhat True Certainly True Many worries or often seems worried Not True Somewhat True Certainly True Helpful if someone is hurt, upset, or feeling ill Not True Somewhat True Certainly True Constantly fidgeting or squirming Not True Somewhat True Certainly True Has at least one good friend Not True Somewhat True Certainly True Often fights with other youth or bullies them Not True Somewhat True Certainly True Often unhappy, depressed, or tearful Not True Somewhat True Certainly True Generally liked by other youth Not True Somewhat True Certainly True Easily distracted, concentration wanders Not True Somewhat True Certainly True Nervous in new situations, easily loses confidence Not True Somewhat True Certainly True Kind to younger children Not True Somewhat True Certainly True Often lies or cheats Not True Somewhat True Certainly True Picked on or bullied by other youth Not True Somewhat True Certainly True Often offers to help others (parents, teachers, children) Not True Somewhat True Certainly True Thinks things out before acting Not True Somewhat True Certainly True Steals from home, school, or elsewhere Not True Somewhat True Certainly True Gets along better with children than with other youth Not True Somewhat True Certainly True Many fears, easily scared Not True Somewhat True Certainly True Good attention span, sees chores or homework through to the end Not True Somewhat True Certainly True Do you have any other comments or concerns?Overall, do you think that your child has difficulties in one or more of the following areas: emotions, concentration, behavior, or being able to get on with other people? No Yes - minor difficulties Yes - definite difficulties Yes - severe difficulties How long have these difficulties been present? Less than a month 1-5 months 6-12 months Over a year Do the difficulties upset or distress your child? Not at all Only a little A medium amount A great deal Do the difficulties put a burden on you or the family as a whole? Not at all Only a little A medium amount A great deal Do the difficulties interfere with your child's everyday life in the following areas?Home Life Not at all Only a little A medium amount A great deal Friendships Not at all Only a little A medium amount A great deal Classroom Learning Not at all Only a little A medium amount A great deal Leisure Activities Not at all Only a little A medium amount A great deal
