Has your child’s performance at school been declining?

Yes No

Does your child seem to isolate him/herself more frequently?

Yes No

Does your child seem more irritable than “normal”?

Yes No

Do simple requests of your child turn into arguments?

Yes No

Do you ever feel like you just don’t know your child anymore?

Yes No

Has your child displayed any aggressive behaviors, physically or verbally?

Yes No

Has your child seemed to have lost interest in hobbies or interests that used to be enjoyable?

Yes No

Do you know or suspect that your child has experimented with drugs (including alcohol & marijuana)?

Yes No

Are you nervous or even fearful of the pathway your child seems to be on?

Yes No

Do you feel like you and your child just don’t communicate effectively anymore?

Yes No

Has your child displayed any behaviors that cause you concern?

Yes No

Does your child seem to lack respect for you or other adults in his/her life?

Yes No

Is your child sleeping much more or much less than you believe is normal?

Yes No

Have you noticed any significant change in eating patterns in your child?

Yes No

Do you notice any significant changes in your child’s mood (either up or down)?

Yes No