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8040 NW 155 St
Miami Lakes, FL 33016, US
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Menu
Home
About
Services
Applied Behavior Analysis
Evaluations
Online Therapy
Resources
E-Learning
Blog
Insurances
SCREEN YOUR CHILD
REFER A CLIENT
CONTACT US
Get Help
305 827 2822
ADOLESCENTS SCREENING
Home
About
Services
Applied Behavior Analysis
Evaluations
Online Therapy
Resources
E-Learning
Blog
Insurances
SCREEN YOUR CHILD
REFER A CLIENT
CONTACT US
ADOLESCENTS SCREENING
Please enable JavaScript in your browser to complete this form.
Parent Name
*
First
Last
Child Name
*
First
Last
Phone
Child's age
*
Email
*
Complain of aches or pains
*
Never
Sometime
Often
Spend more time alone
*
Never
Sometime
Often
Tire easily, little energy
*
Never
Sometime
Often
Fidgety, unable to sit still
*
Never
Sometime
Often
Have trouble with teacher
*
Never
Sometime
Often
Less interested in school
*
Never
Sometime
Often
Act as if driven by motor
*
Never
Sometime
Often
Daydream too much
*
Never
Sometime
Often
Distract easily
*
Never
Sometime
Often
Are afraid of new situations
*
Never
Sometime
Often
Feel sad, unhappy
*
Never
Sometime
Often
Are irritable, angry
*
Never
Sometime
Often
Feel hopeless
*
Never
Sometime
Often
Have trouble concentrating
*
Never
Sometime
Often
Less interested in friends
*
Never
Sometime
Often
Absent from school
*
Never
Sometime
Often
School grades dropping
*
Never
Sometime
Often
Visit doctor with doctor finding nothing wrong
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Have trouble sleeping
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Feel that you are bad
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Worry a lot
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Feel that you are bad
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Take unnecessary risks
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Get hurt frequently
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Do not listen to rules
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Seem to be having less fun
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Do not show feelings
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Do not understand other people's feelings
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Tease others
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Blame others for your troubles
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Take things that do not belong to you
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Refuse to share
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Do you have any emotional or behavioral problems for which you need help?
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
Down on yourself
*
Never
Sometime
Often
Please note: Online screening tools are not diagnostic instruments. You are encouraged to share your results with your child’s physician or healthcare provider.
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