Forms to fill out to help the doctor with your care before your first visit and during your treatment.
Filling out questionnaires that apply to your child's situation before your visit, and during care, allows for greater depth and time to go into detail in the office. We highly recommend utilizing this resource. (please disregard instructions for clinicians and do not attempt to score at home, just answer the numbered questions and bring them to your office visit).
Anxiety
Child Anxiety Questionnaire for Child Ages 8 and Above
Child Anxiety Questionnaire for Parent Ages 8 and Above
Child Anxiety Questionnaire Self Report Ages 2.5 to 6.5
Child Anxiety Questionnaire for Parent Ages 2.5 to 6.5
Autism or Intellectual Disability
Behaviors Commonly Associated with Autism or Intellectual Disability Questionnaire
Autism Screening / Infants with Social Difficulties
Autism Screening Questionnaire for Parents with Children Aged 16 to 30 Months
Depression
Child Depression Questionnaire Parent Report Ages 13-18 - Long Version
Child Depression Questionnaire Parent Report Ages 13-18 - Short Version
Child Depression Questionnaire Self Report Ages 13-18 - Long Version
Child Depression Questionnaire Self Report Ages 13-18 - Short Version
Child Depression Questionnaire Self Report Ages 6–17
Development
*You may choose one or both developmental websites to help assess your child's developmental level
http://www.cdc.gov/ncbddd/actearly/milestones
*Developmental milestones for your child. Print out and bring to your visit to help assess your child's developmental stage.
https://www.healthychildren.org/English/ages-stages/Pages/default.aspx
*This website from the American Academy of Pediatrics provides useful developmental milestone information along with a variety of age relevant health topics for parents. Useful to review development milestones for your child and bring the paper to your first visit.
Level of Disability, Caregiver Report
Level of Disability, Caregiver Report - Long Version (whodas 2.0)
Level of Disability, Caregiver Report - Short Version (whodas 2.0)
*This questionnaire helps determine the effect of the disorder on the Child or adolescent's functioning.
© World health organization, 2012. Measuring health and disability: Manual for WHO disability assessment schedule (WHODAS 2.0), World health organization, 2010, Geneva.
Menstrual Cycle Related Mental Health Concerns (Females)
Daily Record of Symptoms in Relation to the Menstrual Cycle
Physical or Verbal Aggression
Problems with Aggression Questionnaire
Poor Focus and Hyperactivity
ADHD Screening Questionnaire for Parents and Teachers Long Version for Children Ages 6–18
*For First Assessment (teacher fills out one, parent fills out one)
ADHD Screening Questionnaire for Parents and Teachers Short Version for Children Ages 6–18
*For Following Symptoms During Treatment (teacher fills out one, parent fills out one)
Psychiatric Medication Response and Side Effect Monitoring Forms
Antidepressant Monitoring Form Child and Adolescent
Antipsychotic Monitoring Form Child and Adolescent
Repetitive Obsessive Thoughts and Compulsive Routine Behaviors
Repetitive Obsessive Thoughts and Compulsive Routine Behaviors Questionnaire
*Parent/Child to Fill Out Ages 6-14
Sleep Problems
Two-week sleep diary
*This sleep diary will help identify issues related to sleep and track improvements over time.
Trauma Exposure
Trauma History Questionnaire Self Report for Adolescents Ages 12 and Above
*All forms listed above are provided as a courtesy for our patients. Mental Fitness Clinic is not responsible for any material provided by websites other than www.mentalfitnesclinic.com.
