Problem Checklist of a Child

Name:_______________________________

Date: _______________________________

CHILD PROBLEM CHECKLIST

Directions: Put a number next to any item as 1, somewhat true; 2, mostly true; or 0, not true of the child in your class.

EMOTIONAL CONCERN

___ Lost of interest in many things ___Crying often

___Jealous of siblings ___Overly shy

___Nervous habits ___Feels inferior

___Acts first, thinks later ___Acts to get their attention

___Has thought of killing self ___Moody

___Irritable ___Sad and unhappy

___Fears things(e.g., bugs, animals). What?____________________________________

___Worries a lot. What about? ______________________________________________

BEHAVIORAL AND PHYSICAL CONCERN

___Disobedient at home ___Disobedient at school

___Denies problimatic behavior ___Does't like rules

___Trouble learning ___Lost in thoughts

___Can't finish things ___Lies a lot

___Steals ___Destroy possessions

___Cruel to animals ___Lacks energy

___Hyperactive ___Clumsy

___Temper outburst ___Impulsive reaction

___Needs everything in its place ___Has aches and pains

___Problems with speech ___Uses baby talk

___Eats too much ___Eats too little

SOCIAL RELATIONSHIP CONCERN

___Clowns around a lot ___Argues a lot

___Cheats in games ___Uses bad language

___Bosses or bullies others ___Aggressive with peers

___Few friends ___Accident prone

___Too dependent on adults ___Lack of respect to adult

___Not trusting adult

BACKGROUND OF A CHILD

___Having emotional problems

___Having learning problems – what? _______________________________________

___Felt neglected or unloved – by whom?____________________________________

___Close family member dying – who? ______________________________________

___Having parents separated

___Having a parent with emotional problems

___Having a depressed parent – who?________________________________________

___Having a drug abusing parent

___Having an alcoholic parent

___Being sexually abused – by whom?_______________________________________

___Being emotionally abused – by whom? ____________________________________

___Being physically abused – by whom? _____________________________________

OTHER PROBLEMS:

COMMENTS:

www.coloradofamilycenter.net/index.php?option=com_docman&task=doc_view&gid=15&itemid=8

www.counselingforcontenment.com/forms/Interactive System Checklist.pdf