FAMILY LIFE CENTER
PROBLEM CHECKLIST – PARENT FORM
Parent / Guardian Name:
Date:
Child / Adolescent Name:
Age:
Parents: In an effort to best understand the concerns you have regarding your child, please indicate
which of the following behaviors you have observed in your child. The more complete the
information you provide for us, the better we will be able to work with you and your child.
Please check which of the following behaviors have occurred in the past 6 months.
Being fidgety with hands or feet .................................................................................................................
Having difficulty staying seated even when required .................................................................................
Being easily distracted by things ................................................................................................................
Having difficulty waiting for turn in games or groups ...............................................................................
Giving answers to questions before they have been completed ..................................................................
Having difficulty following instructions .....................................................................................................
Having difficulty paying attention ..............................................................................................................
Shifting from one uncompleted activity to another ....................................................................................
Having difficulty playing or working quietly .............................................................................................
Talking excessively when expected to be quiet ..........................................................................................
Often “butting in” or interrupting others.....................................................................................................
Often not listening to what is being said or appearing not to hear ..............................................................
Losing things (pencils, books, assignments, toys) ......................................................................................
Impulsively doing dangerous things without thinking first ........................................................................
BID:
8
Often losing temper.....................................................................................................................................
Often getting into arguments with parents and/or teachers .........................................................................
Often refusing requests of parents and/or teachers .....................................................................................
Sometimes deliberately doing things that annoy others ..............................................................................
Often blaming others for own mistakes ......................................................................................................
Feeling irritable or easily annoyed by others ..............................................................................................
Feeling angry or resentful ...........................................................................................................................
Sometimes feeling mean or wanting to get even ........................................................................................
Often swearing or using obscene language with others ..............................................................................
BID2:
5
Stealing or shoplifting .................................................................................................................................
Staying out all night at least twice without parent’s permission .................................................................
Lying to someone just to stay out of trouble ...............................................................................................
Deliberately starting fires ............................................................................................................................
Breaking and entering someone’s house or car without permission ...........................................................
Destroying property just for the fun of it ....................................................................................................
Being physically cruel to animals ...............................................................................................................
Forcing someone to have sex ......................................................................................................................
Using a weapon in more than one fight ......................................................................................................
Starting physical fights ...............................................................................................................................
Robbing someone (purse snatching, robbery).............................................................................................
Being physically cruel or violent to a person ..............................................................................................
BID3:
3
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Having worries, thoughts, images, feelings or urges which seem silly ......................................................
Checking things over and over again ..........................................................................................................
Repeatedly washing self or items due to worries about contamination/germs/dirt.....................................
Having one or more behaviors which the child “just has to” do .................................................................
Counting and ordering items .......................................................................................................................
Having difficulty parting with belongings or items, no matter how insignificant ......................................
Having to have things “just so”...................................................................................................................
OCD:
2
Please check which of the following are true or usually true.
Depressed or irritable mood more days than not ........................................................................................
Decreased appetite (not hungry) .................................................................................................................
Difficulty falling asleep or staying asleep...................................................................................................
Fatigue or low energy level .........................................................................................................................
Low self-esteem ..........................................................................................................................................
Difficulty concentrating or making decisions .............................................................................................
Feelings of helplessness or hopelessness (things won’t ever get better).....................................................
DYS:
3
Depressed or irritable mood nearly every day for 2 weeks .........................................................................
Loss of interest or pleasure nearly every day for 2 weeks ..........................................................................
Decreased appetite nearly every day for 2 weeks .......................................................................................
Difficulty sleeping nearly every day for 2 weeks .......................................................................................
Feeling slowed down nearly every day for 2 weeks ...................................................................................
Fatigue or a loss of energy nearly every day for 2 weeks ...........................................................................
Feeling guilty or worthless nearly every day for 2 weeks ..........................................................................
Difficulty concentrating nearly every day for 2 weeks ...............................................................................
Thoughts of death, dying, suicide ...............................................................................................................
MAJ:
5
Worrying that a parent might get hurt or might not return home ................................................................
Worrying about getting hurt or kidnapped ..................................................................................................
Staying home from school to be with a parent............................................................................................
Difficulty going to sleep without being near a parent .................................................................................
Always trying to avoid being alone ............................................................................................................
Nightmares about being separated from parents or family .........................................................................
Being sick (headaches/stomachaches) on lots of school days ....................................................................
Worrying about being left alone .................................................................................................................
Worrying about parents while they are away from home ...........................................................................
SEP:
3
Worrying too much about the future ...........................................................................................................
Worrying too much about past behavior .....................................................................................................
Worrying too much about school and friends .............................................................................................
Physical problems (headaches/stomachaches) even when healthy .............................................................
Feeling overly self-conscious much of the time .........................................................................................
Needing lots of reassurance about things ....................................................................................................
Feelings of tension or inability to relax ......................................................................................................
OVE:
4
Confusion about long term goals or career choices ....................................................................................
Confusion about friendships or getting close to others ...............................................................................
Confusion about sexual feelings and/or behavior .......................................................................................
Confusion about religion or moral values ...................................................................................................
Confusion about group loyalties or “fitting in” with others ........................................................................
Confusion about “who am I?”.....................................................................................................................
IDE:
3
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Seems aloof and socially withdrawn...........................................................................................................
Repeats what other say/seems to memorize dialogue .................................................................................
Unusual body movements/repetitive movements (rocking, hand flapping) ...............................................
Plays with toys in an unusual manner .........................................................................................................
Resists changes in environment, routine .....................................................................................................
Unusual fears ..............................................................................................................................................
Unusual responses to sensory stimulation ..................................................................................................
(panic reaction to loud sounds, smells objects, makes odd noises, objects to toothbrush or tags in clothing)
PDD:
Hears voices when no one else is around ....................................................................................................
Knows special secrets which no one else believes......................................................................................
Believes someone else can read his/her mind or tamper with their thoughts .............................................
Believes an outside force controls their brain or thoughts ..........................................................................
Believes they can use their thought waves to control the thoughts of others..............................................
PSY:
2
Seems clumsy, uncoordinated .....................................................................................................................
Bumps into things, falls often, gets hurt (more than other children) ..........................................................
Has sustained a head injury.........................................................................................................................
Seems to stare off into space, seems blank .................................................................................................
Starts to say something, blanks out and forgets what s/he was saying .......................................................
A muscle or group of muscles twitch in this child ......................................................................................
Sleepwalking ...............................................................................................................................................
NEU:
Recurrent episodes of binge eating .............................................................................................................
Feeling a lack of control during episodes of binge eating ..........................................................................
Self-induced vomiting, dieting or use of laxatives to prevent weight gain .................................................
An average of two eating binges a week for at least three months .............................................................
Persistent concern with body shape or weight ............................................................................................
BUL:
5
Significant weight loss during the past year ...............................................................................................
Intense fear of gaining weight or becoming fat ..........................................................................................
Feeling fat regardless of actual body weight or appearance .......................................................................
Missing at least three consecutive menstrual periods .................................................................................
ANO:
4
Concern about use of chemicals..................................................................................................................
Change in friends or groups of friends........................................................................................................
Skipping school...........................................................................................................................................
Money missing from home .........................................................................................................................
Often breaking curfew ................................................................................................................................
Caught in lies or secretive about activities..................................................................................................
Giving up social/recreational activities due to substance use .....................................................................
Getting a “minor consumption” or other legal issues .................................................................................
Declining grades .........................................................................................................................................
Labile moods...............................................................................................................................................
Violent or significant increase in irritability ...............................................................................................
SUB:
3
What are your goals for seeking treatment for the child / adolescent at this time?
Adapted from Innovations in Clinical Practice: A Source Book, Vol 10
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