Brief Assessment Checklist for Children (ages 4 to 11)

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Brief Assessment Checklist for Children (ages 4 to 11)

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Here are some statements that describe children’s behavior and feelings. For each statement, please circle the number that best describes your child in the last 4 to 6 months.  circle 0 if the statement is not true for your child in the last 4 to 6 months.  circle 1 if the statement is partly true for your child in the last 4 to 6 months.  circle 2 if the statement is mostly true for your child in the last 4 to 6 months

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Q1. Child's name (Text)

Q2. Child's age

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Q3. Child's gender (Text)

Q4. Your relationship with the child (Text)

Q5. Craves affection (single choice)

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The Ask(s): how this will appear in the survey

0	1	2

Dropdown List used: Craves affection

Q6. Eats too much (single choice)

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The Ask(s): how this will appear in the survey

0	1	2

Dropdown List used: Eats too much

Q7. Fears you will reject her/him (single choice)

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The Ask(s): how this will appear in the survey

0	1	2

Dropdown List used: Fears you will reject her/him

Q8. Hides feelings (single choice)

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The Ask(s): how this will appear in the survey

0	1	2

Dropdown List used: Hides feelings

Q9. Is convinced that friends will reject her/him (single choice)

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The Ask(s): how this will appear in the survey

0	1	2

Dropdown List used: Is convinced that friends will reject her/him

Q10. Lacks guilt or empathy (single choice)

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The Ask(s): how this will appear in the survey

0	1	2

Dropdown List used: Lacks guilt or empathy

Q11. Prefers to be with adults, rather than children (single choice)

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The Ask(s): how this will appear in the survey

0	1	2

Dropdown List used: Prefers to be with adults, rather than children

Q12. Relates to strangers ‘as if they were family’ (single choice)

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The Ask(s): how this will appear in the survey

0	1	2

Dropdown List used: Relates to strangers ‘as if they were family’

Q13. Seems insecure (single choice)

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The Ask(s): how this will appear in the survey

0	1	2

Dropdown List used: Seems insecure

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