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 you... More

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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0 1 2

Q6. Eats too much (single choice)

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0 1 2

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

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0 1 2

Q8. Hides feelings (single choice)

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0 1 2

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

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0 1 2

Q10. Lacks guilt or empathy (single choice)

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0 1 2

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

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0 1 2

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

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0 1 2

Q13. Seems insecure (single choice)

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0 1 2

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