Describe your child's general personality traits: (examples: shy, quiet, busy, aggressive, violent, non-aggressive, struggles to sit still, depressed, anxious, doesn't like conflict, emotional, introverted, easily angered, curious)
Has your child's behavior changed recently?
Are there any indications something is upsetting your child or affecting his/her behavior lately? Add helpful add any notations in the comment section.
Describe any traits or behaviors that concern you:
Has there been any MAJOR changes in your life lately? (examples: moving, divorce, new school or grade, death, arguments, new stage). If you choose yes, make a brief note of the change.
Could there be any minor or hidden changes/stressors in your child's life lately? (examples: struggles with a friend, a teacher or class). If you choose yes, make a brief note of possible issues.
Could there be something your child isn't sharing with you or able to communicate? Use the comment box to include helpful notes on how you can support your child without this information.
Sometimes even minor issues to us, remain stressors in our child's life. These stressors don't have to be present today to affect our kids. Related triggers, such as music, certain peers, locations or comments can trigger our child's anxiety. Anniversary dates of past incidences (such as moving, a death or divorce) can also trigger the child. Could there an issue in the past that may still be affecting your child today?
Sometimes even minor issues to us, remain stressors in our child's life. These stressors don't have to be present today to affect our kids. Related triggers, such as music, certain peers, locations are comments can trigger our child's anxiety. Anniversary dates of past incidences (such as moving, a death or divorce) can also trigger the child.
Could there an issue in the past that may still be affecting your child today?
Has your child been diagnosed with an emotional, mental, physical or learning disability that may affect his/her behavior, actions or anxiety levels? Use the comment box for any notes.
If you answered "no" to the above question, feel free to skip this step.
How does this tend to effect your child's behavior?
What helpful steps can you take to support you, your family and your child? (Examples: listing specific triggers to avoid, reaching out to a specialist or support group, sticking to a schedule, etc.)
Have you had a "gut" feeling about your child's health, safety or well-being that you have not been able to determine yet?
If yes, to the previous question, have you been able to find any support to get more information (example: asking a pediatrician, teacher, counselor, specialist, support group, etc.) Use the comment box to add helpful notes.
Note any common triggers that effect your child's normal behavior. (Mark all that apply) My child tends to struggle when:
What are some reasonable actions you would like to take to target specific behavioral issues. (Check all that apply.)
Is your child entering a new phase/stage in life and practicing his/her independence?
(Examples: toddler exploration, starting school, hormones or teenage independence). Use the comment field to make any helpful notes.
It's not uncommon for children to misbehave to gain attention. This includes attention from peers (acting like the tough guy or class clown) as well as attention from us-the parents. Acting out may be your child's way of saying: "I feel scared, alone; I need more boundaries or discipline; I am angry or feel a lack of control; I am overwhelmed or struggling; My sibling gets more attention than I do; I am no good," etc.) Again, use the comment box for notes.
Is it possible your child may be acting out for attention?
Are you concerned your child may be struggling with anxiety, stress, depression, drugs, alcohol, bullying, peer pressure or other major concerns? Please note: This relates to children of almost every age-even elementary. This generation is facing one of the highest stress, depression and suicide rates seen in decades. If you have ANY potential concerns at all, please reach out to a professional (physician, pediatrician, counselor, school social worker, your child's peer group, etc.). Use the comment box, to make a definitive list of the steps you'll take to ensure your child's safety as best as you can. Some children hide depression/dangerous behavior very well, others act out when struggling.)