|
Please answer the following questions so we can help assess the problem your child is
experiencing and provide you with the most complete advice for your specific situation. There
will be room at the bottom of the form for additional comments.
When you are finished, please press the Send button.
Your Name:
Your E-mail:
Your Child's Age:
How long has this problem been going on?:
Setting(s) in which the problem occurs: (check all that apply)
Alone
At Home
At School
When Playing
Around Adults
Around Friends/Peers
What (if anything) do you recall was going on at home, work, or school with your family around
the time that the problem began?
My child is:
My child
been diagnosed with a learning disorder.
Please rate the following statements as occuring "Often", "Occasionally", or "Never" for your
child.
Is able to make and/or keep friends.
Often
Occasionally
Never
Interacts socially with others.
Often
Occasionally
Never
Shares with others on a social or emotional level.
Often
Occasionally
Never
Has developed adequate speech for age.
Often
Occasionally
Never
Can carry on an age appropriate conversation.
Often
Occasionally
Never
Repeats words, phrases, or movements over and over.
Often
Occasionally
Never
Plays alone at different activities in an age appropriate manner.
Often
Occasionally
Never
So preoccupied with activities, interests, or objects that it appears extreme.
Often
Occasionally
Never
Accepts changes readily.
Often
Occasionally
Never
Has begun to lose previously attained skills.
Often
Occasionally
Never
Doesn't pay attention to tasks and/or makes careless mistakes.
Often
Occasionally
Never
Can not maintain attention when working or playing.
Often
Occasionally
Never
Doesn't seem to listen and/or is easily distracted.
Often
Occasionally
Never
Finishes tasks and follows instructions well.
Often
Occasionally
Never
Is able to organize activities well.
Often
Occasionally
Never
Does not want to do (or fails to do) homework or schoolwork.
Often
Occasionally
Never
Appears absentminded, forgetful, and/or loses things.
Often
Occasionally
Never
Has trouble sitting still.
Often
Occasionally
Never
Gets in trouble at school for leaving seat.
Often
Occasionally
Never
Runs around or climbs on things when should be sitting or standing still.
Often
Occasionally
Never
Is able to enjoy quiet activities.
Often
Occasionally
Never
Appears overly active as if "driven".
Often
Occasionally
Never
Gets in trouble at school or home for talking excessively.
Often
Occasionally
Never
Isn't able to wait until a question is finished before blurting the answer.
Often
Occasionally
Never
Is able to take turns appropriately.
Often
Occasionally
Never
Has trouble staying out of others' conversations and/or games.
Often
Occasionally
Never
Wets the bed at night.
Often
Occasionally
Never
Wets self during the day.
Often
Occasionally
Never
Soils self at night.
Often
Occasionally
Never
Soils self during the day.
Often
Occasionally
Never
Bullies, threatens, intimidates, or starts fights.
Often
Occasionally
Never
Lies, steals, or cheats.
Often
Occasionally
Never
Has been physically cruel to either animals or people.
Often
Occasionally
Never
Sets fires and/or destroys property.
Often
Occasionally
Never
Stays out at night regardless of your rules.
Often
Occasionally
Never
Runs away from home.
Often
Occasionally
Never
Skips school or classes.
Often
Occasionally
Never
Loses temper easily.
Often
Occasionally
Never
Argues with and/or disregards rules and requests from adults.
Often
Occasionally
Never
Annoys other people on purpose.
Often
Occasionally
Never
Blames other people for own mistakes or behaviors.
Often
Occasionally
Never
Appears irritable or easily annoyed.
Often
Occasionally
Never
Appears angry, resentful, spiteful, or vindictive.
Often
Occasionally
Never
Appears sad, tearful, or depressed.
Often
Occasionally
Never
Lacks interest in activities that previously brought pleasure.
Often
Occasionally
Never
Eats adequate portions without overeating.
Often
Occasionally
Never
Has trouble sleeping or sleeps too much.
Often
Occasionally
Never
Appears tired or lacking energy.
Often
Occasionally
Never
Has poor self-esteem or feelings of guilt.
Often
Occasionally
Never
Threatens to hurt or kill self or talks about death and dying.
Often
Occasionally
Never
Is able to separate from you to go to school, sleep, or other activities.
Often
Occasionally
Never
Has nightmares with a recurring theme or is unable to recall nightmares.
Often
Occasionally
Never
Appears worried or anxious without an obvious cause.
Often
Occasionally
Never
Expresses fear that a loved one will be hurt or killed.
Often
Occasionally
Never
Avoids specific people, places, or discussions of specific events.
Often
Occasionally
Never
If there is anything else you would like to add to help our expert understand your child's
problem more clearly, please feel free to do so here:
By pressing "Send", you are signifying that you accept the following Terms
and Conditions: HouseTreePerson is providing you with expert advice and education only.
HouseTreePerson acknowledges that actual therapy and diagnosis should be performed in-person.
HouseTreePerson and the licensed professionals it employs are not responsible for the actions
of those who utilize advice and information given to consumers. The information provided for a
fee is in no way intended to replace the need for treatment in cases severe enough to warrant
this type of intervention.
|
