| Is your child hyperactive?
|
| Indicate which of these describes
your child and his or her behavior: |
|
Must you force him or her to go to school? |
|
Is s/he despondent, does s/he not believe in him/herself?
|
|
Does s/he fear or avoid structured situations? |
|
Does s/he have an inordinate need for love and attention? |
|
Does s/he fail to learn from his or her mistakes? |
|
Is s/he temperamental or impatient? |
|
Does she wander from activity to activity, but fail to engage? |
|
Is s/he violent, angry, or vengeful? |
| Does your child wet his or her bed? |
| Indicate the supposed reason: |
|
Fearful |
|
Experienced trauma(s) |
|
Needs attention |
|
Insecure |
|
Angry / Envious / Hateful |
|
Doesn’t share his or her problems |
|
Mother obsessed with cleanliness |
|
Guilty or self-punishing |
|
Submissive / Withdrawn / Vulnerable |
| More childhood situations |
| Indicate which of these describes your child and his
or her behavior: |
|
Bashful, fearful, withdrawn and quiet |
|
Suffers from panic attacks or is phobic |
|
Lacks confidence |
|
Mood swings |
|
Depressed or ill |
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Sleeps an inordinate amount, yet complains of fatigue |
|
Irritable and demanding |
|
Wants it all, and now |
|
Fear of obesity |
|
Steals |
|
Holds breath / bangs head against wall |
|
Takes risks, is reckless |
|
Suffers frequent injuries |
|
Wants to die |
|
Loner |
|
Tries to hide distress and pretend everything’s OK |
|
Small and weak |
|
Prematurely born |
|
Demands constant attention |
|
Whines; is easily offended |
|
Restless |
|
Finds it difficult to deal with failure |
|
Panic attacks |
|
Is about to face or has just gone through a stressful or frightening
situation |
|
Feels guilty |
|
Is afraid of disappointing others, feels a need to please |
|
Blames others for his or her problems |
|
Whines; makes accusations of “It’s not fair” |
|
Gives up easily; feels it’s not worth trying |
|
Is not with family and is homesick |
|
Feels a sense of loss |
|
First sibling just born |
|
Motion sickness / Dislikes traveling |
| |
Name of child:
|
|
