Child and Youth Mental Health Screening – Youth Submission

This information helps us in providing the best possible care for you and your family. Your answers will be kept strictly confidential as part of your clinical record. If information given during this questionnaire suggests there may be harm to yourself or to others, including abuse or neglect, we are required by law to report 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. We invite you, however, to be as open as you can be to help us decide how to best support you.

- Step 1 of 6

Date *

Student's Name *

First

Last

Student DOB *

Age

Preferred Pronouns

Ethnicity

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

Your Family Doctor Name

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

Student's Phone

Student's Email *

Preferred Form of Contact

• Phone call
• Text Message
• Email

Student's Address

Address Line 1

City

State / Province / Region

Postal Code

Are you currently attending school? *

• Yes
• No

School Name

Grade

Teacher

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

Next

What are the reasons for wanting to talk with a counsellor? (Check all that apply)

• Bullying / Harassment
• Feeling down / Sad
• Feeling worried / Stressed
• Anger / Temper
• Alcohol / Drugs
• School Problems
• Friendship Problems
• Family Problems
• Sleeping Difficulties
• Eating / Body Image
• Traumatic Event
• Relationship Problems
• Grief / Loss
• Physical health Concerns
• Other

How long has this been a problem? Please check one. *

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

Are your parents / caregivers aware of this problem?

• Yes
• No

Is your parent / caregiver aware that you are seeking counselling support?

• Yes
• No

Have you received counselling services in the last year?

• Yes
• No

If yes, was this support provided by SSICS? Private Practition? Please specify.

If yes, did you find it helpful?

Are you working with, or slotted to work with a psychologist or psychiatrist?

• Yes
• No

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

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

• None
• 1-3
• More than 3

Is there medication that you are taking that would be important for us to know? (for example: antidepressant or anti-anxiety medication, stimulants, antipsychotics or mood stabilizers). If yes, please specify.

If yes, has the medication regime changed recently?

• Does not apply
• Yes
• No

Please tell us any more about your concerns and any help that you would like.

Next

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

Do you notice that you....

Are easily distracted or have trouble sticking to any activity? *NeverSometimesOften

Fail to finish things they start? *NeverSometimesOften

Hve difficulty following directions or instructions? *NeverSometimesOften

Are impulsive or acts without stopping to think? *NeverSometimesOften

Jump from one activity to another? *NeverSometimesOften

Fidget? *NeverSometimesOften

Comments:

Do you notice that yout...

Worry that bad things will happen to people you are close to? *NeverSometimesOften

Worry about being separated from those closest to you? *NeverSometimesOften

Are scared to sleep without parents nearby? *NeverSometimesOften

Are overly upset when leaving those you are close to? *NeverSometimesOften

Are overly upset when away those you are close to? *NeverSometimesOften

Feel sick before being separated from those you are closest to? *NeverSometimesOften

Comments:

Do you notice that you....

Are cranky? *NeverSometimesOften

Are defiant or talk back to adults? *NeverSometimesOften

Blame others for their own mistakes? *NeverSometimesOften

Are easily annoyed by others? *NeverSometimesOften

Argue a lot with adults? *NeverSometimesOften

Are angry and resentful? *NeverSometimesOften

Comments:

Do you....

Steal things at home? *NeverSometimesOften

Destroy things belonging to others? *NeverSometimesOften

Break into someone else's house, building or car? *NeverSometimesOften

Physically attack people? *NeverSometimesOften

Use weapons when fighting? *NeverSometimesOften

Comments:

Do you notice that you...

Worry about doing better at things? *NeverSometimesOften

Worry about past behaviour? *NeverSometimesOften

Worry about doing the wrong thing? *NeverSometimesOften

Worry about things in the future? *NeverSometimesOften

Are afraid of making mistakes? *NeverSometimesOften

Are overly anxious to please people? *NeverSometimesOften

Comments

Do you notice that you....

Have no interest in yourusual activities? *NeverSometimesOften

Get no pleasure from usual activities? *NeverSometimesOften

Have trouble enjoying yourself? *NeverSometimesOften

Are not as happy as others? *NeverSometimesOften

Feels hopeless? *NeverSometimesOften

Feel unhappy, sad or depressed? *NeverSometimesOften

Comments:

Total Score

0

Next

The next section asks a few questions about how these problems have affected you. Please indicate if it is NONE, A LITTLE, or A LOT. If unsure, please skip.

How much have you withdrawn or isolated yourself as a result of these problems?

• None
• A Little
• A Lot

How much less have you been doing things with others as a result of the problems?

• None
• A Little
• A Lot

How much has your life become less enjoyable as a result of these problems?:

• None
• A Little
• A Lot

Any Comments:

How much trouble have you had getting along with teachers as a result of these problems?

• None
• A Little
• A Lot

How much trouble have you had getting along with your parents as a a result of these problems?

• None
• A Little
• A Lot

How much school have you missed as a result of these problems?

• None
• A Little
• A Lot

How much have your grades gone down as a result of these problems?

• None
• A Little
• A Lot

Comments:

Next

Other Concerns Checklist

The following items may help us to understand your situation better. Please indicate if the following issues affect you NONE, A LITTLE, or A LOT.

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., irritability, intrusive thoughts).

• 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

These next 4 items check in about some disturbing things some young people have experienced.

Have you been physically abused?

• Yes
• No
• Unsure

Have you been sexually abused?

• Yes
• No
• Unsure

Have you experienced physical or emotional discomfort due to neglect?

• Yes
• No
• Unsure

Have you witnessed verbal or physical violence amongst the adults who have been involved in parenting you?

• Yes
• No
• Unsure

Have you smoked cigarettes or vaped daily for a month or longer/

• Yes
• No

Have you ever had 3 or more drinks of beer, wine or any other alcoholic beverage at one time?

• Yes
• No

How many times in the last 6 months did you use non-prescription drugs such as cannabis / marijuana, amphetamines, barbiturates, cocaine, opiates or psychedelics?

How many times in the last 6 months did you use prescription drugs that were not your own?

Comments:

Have we missed anything important that we need to know about you or your family?

Please let us know any questions you might have at this point.

Thank you for taking the time to complete this form. We currently have a waitlist and we cannot kknow exactly when you will be placed with a counsellor.

Submit