Development (physical, cognitive, social)
Emotional Distress - (grief/loss, trauma, regression to former behaviors, significant changes in sleep/eating, high irritability, inactive or hyperactive, more afraid of things, clinging to adults, increased/frequent crying, angry outbursts)
Behavior Problems: (acting out behaviors, not following rules for safety, destroying things, hitting or threatening)
Yes
No
MILD - My child does not have prior treatment history and/or their symptoms have limited impact on daily life
MODERATE - My child has symptoms that negatively impact their daily functioning at home and/or school
SEVERE
MILD -My child does not have prior treatment history and/or their symptoms have limited impact on daily life
MODERATE -My child has symptoms that negatively impact their daily functioning at home and/or school
SEVERE -My child's emotional/behavioral difficulties are highly disruptive at home, in school and/or in the community; my child has a significant psychiatric diagnosis and/or is at risk of out-of-home placement/hospitalization or is being discharged from a hospital or out-of-home placement and we will need a high level of therapeutic support
