Strengths and Difficulties Questionnaire (Child 11-17)


For each item, please mark the box for Not True, Somewhat True, or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain. Please give your answers on the basis of how things have been for you over the last six months.

Your name    

 

Date of Birth

 

  Not
True
Somewhat
True
Certainly
True
I try to be nice to other people. I care about their feelings
I am restless, I cannot stay still for long
I get a lot of headaches, stomach-aches or sickness
Shares readily with other youth, for example CD’s, games, food
I get very angry and often lose my temper
I would rather be alone than with people of my age
I usually do as I am told
I worry a lot
I am helpful if someone is hurt, upset or feeling ill
I am constantly fidgeting or squirming
I have one good friend or more
I fight a lot. I can make other people do what I want
I am often unhappy, depressed or tearful
Other people my age generally like me
I am easily distracted, I find it difficult to concentrate
I am nervous in new situations. I easily lose confidence
I am kind to younger children
I am often accused of lying or cheating
Other children or young people pick on me or bully me
I often offer to help others (parents, teachers, children)
I think before I do things
I take things that are not mine from home, school or elsewhere
I get along better with adults than with people my own age
I have many fears, I am easily scared
I finish the work I'm doing. My attention is good

 

Do you have any other comments or concerns?

Overall, do you think that you have difficulties in any of the following areas:

emotions, concentration, behavior or being able to get on with other people?

 

If you have answered "Yes", please answer the following questions about these difficulties:

  • How long have these difficulties been present?

 

  • Do the difficulties upset or distress you?

 

  • Do the difficulties interfere with your everyday life in the following areas?
  Not
at all
Only a
little
A medium
amount
A great
deal
HOME LIFE
FRIENDSHIPS
CLASSROOM LEARNING
LEISURE ACTIVITIES

 

  • Do the difficulties make it harder for those around you (family, friends, teachers, etc.)?

 

Signature:  Today's Date:

 

Thank you very much for your help

 

Leave this empty:

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Document name: Strengths and Difficulties Questionnaire (Child 11-17)
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Timestamp Audit
October 9, 2021 8:32 am CSTStrengths and Difficulties Questionnaire (Child 11-17) Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 206.84.188.12