| 1. Does your child argue with you frequently? |
Yes Sometimes No |
| 2. Does your child refuse to follow your rules? |
Yes Sometimes No |
| 3. Does your child engage in behavior that is contrary to your values? |
Yes Sometimes No |
| 4. Does your child avoid talking with you by isolating him/herself? |
Yes Sometimes No |
| 5. Is your child verbally aggressive (cussing, name calling, threatening) with you or others? |
Yes Sometimes No |
| 5. Does your child abuse drugs or alcohol? |
Yes Sometimes No |
| 6. Do you suspect that your child's friends are using drugs or alcohol? |
Yes Sometimes No |
| 7. Has your child's behavior or emotional state changed significantly over the past year? |
Yes Sometimes No |
| 8. Does it seem that your child is negatively influenced by peers? |
Yes Sometimes No |
| 7. Is your child experiencing academic difficulties? |
Yes Sometimes No |
| 9. Is your child having difficulty with hyperactivity and/or distractibility? |
Yes Sometimes No |
| 10. Does your child have behavior problems in school? |
Yes Sometimes No |
| 11. Is your child skipping school? |
Yes Sometimes No |
| 12. Does your child engage in behavior that you believe may lead him or her into legal trouble? |
Yes Sometimes No |
| 13. Is your child manipulative? |
Yes Sometimes No |
| 14. Does your child act is if he/she feels entitled to whatever he or she wants without working for it? |
Yes Sometimes No |
| 15. Does your child appear to be struggling with emotional difficulties such as depression or anxiety? |
Yes Sometimes No |
| 16. Has your child talked about hurting him/herself or wanting to die? |
Yes Sometimes No |
| 17. Has your child attempted suicide? |
Yes Sometimes No |
| 18. Has your child engaged in self-injurious behavior such as cutting or burning him/herself? |
Yes Sometimes No |
| 19. Does your child become easily overwhelmed with stress? |
Yes Sometimes No |
| 20. Does your child have an eating problem (anorexia, binging, bulimia)? |
Yes Sometimes No |
| 21. Does your child engage in risky behavior that could lead to serious injury or death? |
Yes Sometimes No |
| 22. Is your child promiscuous? |
Yes Sometimes No |
| 23. Does your child appear to lack motivation? |
Yes Sometimes No |
| 24. Do you believe your child may be struggling with adoption or attachment issues? |
Yes Sometimes No |
| 25. Does your child have a problem expressing anger appropriately? |
Yes Sometimes No |