Child and Youth Mental Health General Screening Questionnaire – Caregiver Submission

This information will assist us in providing the best possible care for you and your family. Your answers will be kept strictly confidential as part of your child’s, teen’s or your clinical record.

If information through the course of this questionnaire suggests there may be harm to yourself or to others, including abuse or neglect, I am required by law to report my concerns to the appropriate authorities.

Please know that answering these questions is completely voluntary and will not affect the services you may receive from Island Community Services. However, we invite you to be as open as you can be to help us determine how best to support you and your child.

- Step 1 of 6

Date *

Child's Name *

First

Last

Child's DOB *

Age

Your Name *

First

Last

Relationship to Youth

Who currently lives in the family home? List name(s) and relationship(s).

Address

Address Line 1

City

State / Province / Region

Postal Code

Parent / Caregiver Name(s)

Parent / Caregiver Phone

Parent / Caregiver Email

Preferred Form of Contact

• Phone Call
• Text Message
• Email

Child's Gender

Language at Home

Ethnicity

• North American
• South Asian (East Indian, Pakistani, Sri Lankan)
• Southeast Asian (Vietnamese, Cambodian, Malaysian, Laotion)
• West Asian (Iranian, Afghani)
• Chinese
• Black
• Filipino
• Latin American
• Arab
• Korean
• Japanese
• Indigenous
• European

Is the student currently attending school? *

• Yes
• No

School Name

Grade

Is there a School Designation IEP in place? If so, which one (R,H, etc.).?

Student's Doctor Name

Medications

Next

Is the child aware of this referral?

• Yes
• No

What is your concern? *

How long have you been aware of this problem? Please check one. *

• Less than 3 months
• 3 to 6 months
• 6 to 12 months
• More than 1 year

What steps have you taken to deal with the problem at home / school, if any?

Have there been recent visits to the hospital. If so, how many in the last year?

• None
• 1-3
• More than 3

Is there a formal diagnosis that would be important for us to know? If so, please identify.

Is the person working with, or slotted to work with a psychologist or Psychiatrist?

• Yes
• No

If you have a psychiatric assessment report, can you share it as part of your intake process?

• Does not apply
• Yes
• No

Is there medication the person in question is taking that would be important for us to know (for example: antidepressants / anti-anxiety, stimulants, antipsychotics or modd stabilizers)? If yes, please specify.

If yes, has the medication regime changed recently?

• Does not apply
• Yes
• No

Have you received help in the past or currently for this problem? (check all that apply)

• Doctor
• SSICS
• MCFD
• School Support
• Parenting Group
• Other

Specify Other if applicable

Did you find previous supports helplful?

Do you have extended health or health insurance that can pay for a private practitioner?

• Yes
• No

Do any of the following apply to your family (Check any that apply).

• Separation / Divorce
• Custody / Access dispute
• Major Physical Illness (Parent)
• Major Physical Illness {Child}
• Financial Stressors
• Death of a Loved One
• Family Violence
• History of abuse {child}
• Substance use {Parent}
• Substance use {Child / Teen}
• Substance Affected
• Moved Homes or School
• Traumatic Event {e.g. fire, accident etc}
• Other

Comments

Next

Please indicate whether each is NEVER (0) true, SOMETIMES (1) true, or OFTEN (2) true for this child.

Do you notice that this student....

Is distractible or has trouble sticking to any activity? *NeverSometimesOften

Fails to finish things they start? *NeverSometimesOften

Has difficulty following directions or instructions? *NeverSometimesOften

Is impulsive or acts without stopping to think? *NeverSometimesOften

Jumps from one activity to another? *NeverSometimesOften

Fidgets? *NeverSometimesOften

Comments:

Do you notice that this student...

Worries that bad things will happen to loved ones? *NeverSometimesOften

Worries about being separated from loved ones? *NeverSometimesOften

Is scared to sleep without parents nearby? *NeverSometimesOften

Is overly upset when leaving loved ones? *NeverSometimesOften

Is overly upset when away from loved ones? *NeverSometimesOften

Complains of feeling sick before separating? *NeverSometimesOften

Comments:

Do you notice that this student....

Is cranky? *NeverSometimesOften

Is defiant or talks back to adults? *NeverSometimesOften

Blames others for their own mistakes? *NeverSometimesOften

Is easily annoyed by others? *NeverSometimesOften

Argues a lot with adults? *NeverSometimesOften

Is angry and resentful? *NeverSometimesOften

Comments:

Does this student....

Steal things at home? *NeverSometimesOften

Destroy things belonging to others? *NeverSometimesOften

Engage in vandalism? *NeverSometimesOften

Break into houses, buildings or cars? *NeverSometimesOften

Physically attack people? *NeverSometimesOften

Use weapons when fighting? *NeverSometimesOften

Comments:

Do you notice that this student...

Worries about doing better at things? *NeverSometimesOften

Worries about past behaviour? *NeverSometimesOften

Worries about doing the wrong thing? *NeverSometimesOften

Worries about things in the future? *NeverSometimesOften

Is afraid of making mistakes? *NeverSometimesOften

Is overly anxious to please people? *NeverSometimesOften

Comments

Do you notice that this student....

Has no interest in their usual activities? *NeverSometimesOften

Gets no pleasure from usual activities? *NeverSometimesOften

Has trouble enjoying themselves? *NeverSometimesOften

Is not as happy as other children? *NeverSometimesOften

Feels hopeless? *NeverSometimesOften

Seems unhappy, sad or depressed? *NeverSometimesOften

Comments:

Is there any concern re: possible depression or self-harm? Please answer the next 3 questions NEVER, SOMETIMES or OFTEN.

Would you say that this young person has lost a lot of weight without trying *NeverSometimesOften

Talks about killing themself? *NeverSometimesOften

Has deliberately harmed themself or has attempted suicide? *NeverSometimesOften

Total Score

0

Next

The next section asks a few questions about day-to-day functioning and how all of this may have affected him or her. Please indicate if it is NEVER, SOMETIMES, OFTEN or ALWAYS.

Impact on Family

Family Activities

How frequently has the child's behaviour prevented you from taking them out shopping or visiting?

• Never
• Sometimes
• Often
• Always

How frequently has the child's behaviour made you decide not to leave them with a babysitter?

• Never
• Sometimes
• Often
• Always

How frequently has the child's behaviour prevented you from having friends, relatives or neighbours come to the home?

• Never
• Sometimes
• Often
• Always

How frequently has the child's behaviour prevented siblings from having friends, relatives or neighbours come to the home?

• Never
• Sometimes
• Often
• Always

Comments:

Family Comfort

How frequently have you quarreled with your spouse regarding the child's behaviour?

• Never
• Sometimes
• Often
• Always

How frequently has the child's behaviour caused you to be anxious / worried about their chances for doing well in the future?

• Never
• Sometimes
• Often
• Always

How frequently have neighbours, relatives or friends expressed conderns about the child's behaviour?

• Never
• Sometimes
• Often
• Always

Comments:

Please indicate if it is NONE, A LITTLE, or A LOT. Only select items which seem to be a concern.

How much has the child withdrawn or isolated themselves as a result of these problems?

• None
• A Little
• A Lot

How much less has the child been doing things with other kids as a result of the problems?

• None
• A Little
• A Lot

How much has the child's life become less enjoyable as a result of these problems?:

• None
• A Little
• A Lot

Comments:

How much trouble has the student had getting along with teachers as a result of these problems?

• None
• A Little
• A Lot

How much trouble has the child had getting along with your or your partner as a result of these problems?

• None
• A Little
• A Lot

How much has the child been irritable or fighting with friends as a result of these problems?

• None
• A Little
• A Lot

Comments:

How much school has the child missed as a result of these problems?

• None
• A Little
• A Lot

How much have the child's grades gone down as a result of these problems?

• None
• A Little
• A Lot

Comments:

Next

Other Concerns Checklist

Other types of concerns that help us to understand the overall situation better. Only select items which seem to be a concern to the school or others.

Bullying: Repeatedly bullies, teases, harasses or excludes other children from social activities.

• None
• A Little
• A Lot

Cruelty to Animals: Cruel to animals, hurts and/or teases animals repeatedly

• None
• A Little
• A Lot

Fire: Inappropriate involvement with fire, matches etc.

• None
• A Little
• A Lot

Substance use: Recurrent use of alcohol or drugs leading to impaired functioning (e.g. substance related absences, suspension, or expulsions from school).

• None
• A Little
• A Lot

Specific Fear: Unusually strong and persistent fear of something specific (e.g. travel, animals, needles, heights).

• None
• A Little
• A Lot

Social Phobia: Persistent fear & avoidance of social situations with peers or social performance demands due to a fear of embarassment or scrutiny.

• None
• A Little
• A Lot

Obsessions: Recurrent thoughts or impulses that cause distress or impair functioning.

• None
• A Little
• A Lot

Compulsions: Repetitive behaviours (e.g. hand-washing, ordering, checking) that causes distress or impair functioning.

• None
• A Little
• A Lot

Movement Problems: Recurrent move ents (tics) or vocalizations that cause stress or impairment.

• None
• A Little
• A Lot

Thought Probems: Delusions, hallucinations, paranoia, disorganized speaking or behaviour resulting in significant impairment.

• None
• A Little
• A Lot

School Refusal: Persistent unwillingness or refusal to regularly attend school due to anxiety or a fear of separation.

• None
• A Little
• A Lot

Selective Mutism: Consistent failure to speak in some situations (e.g. school) but speaks commfortably in other situations (e.g. home).

• None
• A Little
• A Lot

Victimized / Bullied: Is repeatedly bullied, teased, harassed or excluded from social activities.

• None
• A Little
• A Lot

Trauma: Experienced or witnessed event(s) threatening death or serious injury to self or others. Re-experienced it, tries to avoid similar setting; has increased arousal, sleep difficulties.

• None
• A Little
• A Lot

Speech Problems: Significant difficulty speaking or undertanding speech.

• None
• A Little
• A Lot

Developmental Problems: General development significantly below age.

• None
• A Little
• A Lot

Learning Problems: Academic progress significantly below ability (comments section).

• None
• A Little
• A Lot

Sleep Difficulties: Persistent difficulty falling asleep, staying asleep, awakening from anxiety-provoking nightmares or prolonged sleep during the day which causes stress or impairment.

• None
• A Little
• A Lot

Eating Problems: Not maintaining weight, significant loss of weight, fear of being overweight, disturbed thinking about body shape or weight.

• None
• A Little
• A Lot

Urination Problems: Urinates in bed or clothing several times per week.

• None
• A Little
• A Lot

Bowel Movement Problems: Bowel movements in inappropriate places (e.g. clothes, floor) several times over a 3 month period.

• None
• A Little
• A Lot

Sexual Problems: Problems with sexual behaviour or identity which cause distress or impairment.

• None
• A Little
• A Lot

Comments:

Next

Parent's moods are very important. The following statements describe some of the ways people feel at different times. Please describe how often you have felt or behaved this way over the past week.

Mood - Caregiver

You did not feel like eating; your appetite was poor

• Less than 1 day
• 1-2 days
• 3-4 days
• 5+ days

You had trouble keeping your mind on what you were doing

• Less than 1 day
• 1-2 days
• 3-4 days
• 5+ days

You felt depressed

• Less than 1 day
• 1-2 days
• 3-4 days
• 5+ days

Your sleep was restless

• Less than 1 day
• 1-2 days
• 3-4 days
• 5+ days

You felt sad

• Less than 1 day
• 1-2 days
• 3-4 days
• 5+ days

You could not "get going"

• Less than 1 day
• 1-2 days
• 3-4 days
• 5+ days

Family Functioning

In times of crisis, we can turn to each other for support

• Strongly Agree
• Agree
• Disagree
• Stronglyl Disagree

Individuals in the family are accepted for who they are

• Strongly Agree
• Agree
• Disagree
• Stronglyl Disagree

We express feelings to each other

• Strongly Agree
• Agree
• Disagree
• Stronglyl Disagree

We are able to make decisions about how to solve problems

• Strongly Agree
• Agree
• Disagree
• Stronglyl Disagree

We do not get along well together

• Strongly Agree
• Agree
• Disagree
• Stronglyl Disagree

We confide in each other

• Strongly Agree
• Agree
• Disagree
• Stronglyl Disagree

Comments:

The next statements are about families and family relationships. How much do you agree or disagree with the following statements about your family?

To your knowledge has the child ever been physically abused?

• Yes
• No
• Don't know

To your knowledge has the child ever been sexually abused?

• Yes
• No
• Don't know

To your knowledge has the child ever been neglected to the extent that seemed to impair their emotional or physical well being?

• Yes
• No
• Don't know

To your knowledge has the child ever witnessed verbal or physical violence amongst the adults who have been involved in parenting them?

• Yes
• No
• Don't know

Comments:

Readiness and Barriers

The next questions ask about other services and information you may be interested in.

Readiness

Would you be interested in reading about the issues you described?

• Yes
• No
• Maybe

If there was a group of parents meeting together to discuss similar issues would you be interested in attending?

• Yes
• No
• Maybe

If workshops were available to learn about things you could do as a parent to help your child, would you be interested in attending?

• Yes
• No
• Maybe

Is your child interested in getting help with the difficulties they are having?

• Yes
• No
• Maybe

Would your child be interested in participating in a group for the difficulties they are having?

• Yes
• No
• Maybe

Comments:

Barriers

How much of a problem would it be for you to get to the service? Would that stop you from attending?

• None
• A little
• A lot but can participate
• Will prevent participation
• N/A

Would it be a problem if services were only during the day? Would that stop you from attending?

• None
• A little
• A lot but can participate
• Will prevent participation
• N/A

How much of a problem would babysitting be? Would that stop you from attending?

• None
• A little
• A lot but can participate
• Will prevent participation
• N/A

Would it be difficult for you to read and fill in a questionnaire? Would that stop you from attending?

• None
• A little
• A lot but can participate
• Will prevent participation
• N/A

How concerned are you or your family members about meeting in-person with COVID-19 protocols?

• None
• A little
• A lot but can participate
• Will prevent participation
• N/A

Would it be a problem for you if services were being delivered online using a secure counselling platform?

• None
• A little
• A lot but can participate
• Will prevent participation
• N/A

Comments:

Have we missed anything important that we need to know about this child, their home, or family?

Thank you for taking the time to support this young person.

Submit