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Child and Adolescent Assessment Checklist

Directions: In order to better assess your child, please complete this assessment checklist. Please choose all of the items that apply to your child. Rate them using the following scale:
1= Never,2 = Rarely,3 = Sometimes,4 = Often,5 = Always
  1. Complains of aches and pains
  2. Spends more time alone lately
  3. Tires easily and/or has little energy
  4. Fidgety, unable to sit still
  5. Has trouble with teacher(s)
  6. Less interested in school
  7. Acts as if driven by a motor
  8. Daydreams too much
  9. Is afraid of (reluctant to go into) new situations
10. Distracted easily
11. Expresses feelings of sadness, unhappiness
12. Has trouble concentrating
13. Expresses feelings of hopelessness, despair
14. Is irritable, angry
15. Less interested in friends
16. Fights with others
17. Absent from school
18. School grades dropping
19. Expresses feelings of self doubt and low self worth
20. Visits doctors who find nothing wrong
21. Has trouble sleeping
22. New friends of a different character/values than in the past
23. Wants to be with you more
24. Expresses thoughts/feelings that s/he is bad
25. Takes unnecessary risks
26. More slovenly/messy appearance and habits
27. Sleeps more than before
28. Worries a lot
29. Gets hurt frequently
30. Wears clothes that cover up most of the body
31. Seems to be having less fun
32. Acts less mature than children of the same age
33. Does not listen to rules
34. Is uncooperative at home and/or school (circle)
35. Does not show feelings
36. Does not understand and/or empathize with other's feelings
37. Teases, picks on others
38. Blames others for his/her troubles
39. Seems to be too emotional
40. Takes things that are not his/hers without asking
41. Refuses to share
42. Doesn't want to be with you or the family
43. Is sarcastic and/or belittling others' values
44. Comes late and/or procrastinates about tasks and respon-
sibilities more than before
45. Exudes an attitude of nonchalance and "I don't care"
Assessment Score:

0 - 60 Normal range
61 - 90 Mildly problematic
91 -135 Moderately problematic
136 - 180 Seriously problematic
Above 180 Extremely problematic

For more information or to make an appointment, please call 305-251-8609 or email me by Clicking Here

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Dita Teitelbaum, MSW LCSW
14440 SW 80th Avenue
Miami, FL 33158
Phone: 305-251-8609
Fax: 305-251-8609

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