Child'S Evaluation Form - Age 6-12 Years Old - Nv Mental Health Page 2
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3Conduct Symptoms:
Sometimes
Never
Often
27. Plays hooky from school.
28. Stays out at night when not supposed to.
29. Lies to get things or to avoid responsibilities (cons others)
30. Bullies, threatens or intimidates others
31. Starts physical fights.
32. Has runaway from home overnight.
33. Has stolen things when others were not looking.
34. Has deliberately destroyed others’ property.
35. Has deliberately started fires.
36. Has stolen things from others using physical force.
37. Has broken into someone else’s house, building, or car.
38. Has used a weapon when fighting (bat, brick, bottle, etc.)
39. Has been physically cruel to animals.
40. Has been physically cruel to people.
41. Has been preoccupied with or involved in sexual activity.
Anxiety Symptoms:
Sometimes
Never
Often
42. Is overly concerned about abilities in academic, athletic,
or social activities.
43. Has difficulty controlling worries.
44. Acts restless or edgy.
45. Is irritable for most of the day.
46. Is extremely tense or unable to relax.
47. Has difficulty falling asleep or staying asleep.
48. Complains about physical problems (headaches, upset
stomach, etc.) for which there is no apparent cause.
Depressive Symptoms:
Sometimes
Never
Often
49. Depressed most of the day
50. Little interest
51. Recurrent thoughts of death or suicide.
52. Feels worthless or guilty.
53. Low energy or tired for no apparent reason.
54. Poor self image/lack confidence
55. Feels things will never work right for him/her.
56. Significant decline in school grades.
Autistic Symptoms:
Sometimes
Never
Often
57. Avoids Eye contact
58. Does not play or relate well with others.
59. Not interested in making friends.
60. Unaware or takes no interest in other peoples feelings.
61. Significant language delays.
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