Child Intake Documents I And Ii Page 3

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CURRENT SYMPTOM CHECKLIST
Please check any of the following symptoms experienced by your child.
BEHAVIOR
CURRENT
PAST
BEHAVIOR
CURRENT
PAST
Crying, sadness, depression
Temper Outbursts
No longer enjoys activities
Irritability; Anger
Expressed a wish to die
Argues
Bedtime fears/sleep issues
Disobedience
Is anxious/worries
Annoys Others
Repeats unnecessary acts
Unusual fears/phobias
Has rituals
Twitches or unusual movements
Eats very little to lose weight
Binge eats or gorges
Sleepwalks
Blames others for own mistakes
Withdrawn
Easily annoyed by others
Nightmares/night terrors
Uses swear words/obscene language
Low self-esteem
Wants to run away
Tiredness/fatigue
Sneaks out
Sleeps too much
Injures self
Over active
Steals
Impulsive
Lies
Has trouble finishing things
Hurts animals
Disruptive
Destroys property
Short attention span
Drug/alcohol use
Daydreams
Cigarette use
Easily distracted
Problems with authority
Hallucinates
Problems with the law
Bedwetting or Daytime wetting
Low motivation
Unusual behavior
Learning difficulties
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