Child Symptom Checklist Child Symptom Checklist Please mark any symptoms your child is currently experiencing Name* First Last Email* PhonePlease mark any symptoms your child is currently experiencing* Abuse -physical, emotional, sexual, neglect, bullying (to self or others) Aggression/violence Anxiety, nervousness Attention, concentration, distractibility Career / life choices Communication difficulties Compulsions Depression, low mood, sadness, crying Divorce, separation (of parents) Drug use (prescription, over-the-counter, street drugs) Eating problems (over-eating, under-eating, appetite, vomiting) Failure Fatigue, tiredness, low energy Feeling controlled Fears, phobias Grief, mourning, loss, death, divorce Guilt Hallucinations (hearing voices, seeing things) Headaches, stomachaches, or other physical pain Health concerns, illness, medical, physical concerns Hopelessness Inferiority, low self-esteem Impulsiveness, poor impulse control, loss of control Judgment problems, risk taking Legal matters, involvement with juvenile justice system Loneliness PhoneThis field is for validation purposes and should be left unchanged.
