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Submissive / Withdrawn / Vulnerable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Bashful, fearful, withdrawn and quiet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
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: