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Q.1
You made your child’s favorite after-school snack, but she said she wasn’t hungry, and then only picked at her dinner.
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Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.2
When the movie you wanted to see was sold out, your child burst into tears.
*
Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.3
Even though you have gone out of your way to cheer him up, your child still seems down in the dumps.
*
Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.4
Homework is always a struggle, but sometimes it seems like your child is incapable of even sitting down and getting started.
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Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.5
She’s regularly a chatty Kathy at home after school, but can be eerily quiet for days or weeks on end.
*
Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.6
Even after a bedtime story, your child can’t seem to fall asleep, and wakes up in the middle of the night more often than not.
*
Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.7
He’s always been full of confidence, but lately has been saying things like, “All the other kids in class are smarter than me.”
*
Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.8
Your child is easily distracted, even when doing things she likes, such as making cookies with Mom.
*
Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.9
When you ask how recess was, your child says, “No one wanted to play with me.”
*
Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.10
Usually, he’s racing around the house after dinner asking everyone to come outside and play catch. Lately, he’s been a bump on a log even when you try to get him moving.
*
Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.11
Your child said she doesn’t want to have a birthday party this year because she doesn’t have any friends she would want to invite.
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Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.12
Simple decisions, like what to wear in the morning, are lately extremely difficult to make.
*
Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.13
The teacher called, and lately his grades have been on a downward spiral.
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Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.14
Your child is suddenly scared of monsters under the bed, and very jumpy at the slightest sounds.
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Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.15
One or both of the child’s biological parents has a history of depression.
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Yes
No
I don't know
Q.16
His favorite video game has sat untouched for weeks, even when you offered to have friends over to play with.
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Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.17
She usually loves to ride her bike up and down the block, but when the neighbor stops by for a ride, she says she is too tired.
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Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.18
He doesn’t want to join the soccer team this year because he says, “I was never any good at it anyways. Why bother?”
*
Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.19
Your usually agreeable child is now a constant grump.
*
Yes – has happened or is likely to happen
No – has not happened and is not likely to happen
Q.20
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