Parent fills out SDQ Ages 2-4 – Parent Fills Out Today's Date MM slash DD slash YYYY Person filling out this form First Last Child's Name First Middle Last Considerate of other people's feelings Not true Somewhat true Certainly true Restless, overactive, cannot stay still for long Not true Somewhat true Certainly true Often complains of headaches, stomach-aches or sickness Not true Somewhat true Certainly true Shares readily with other youth, for example books, games, food Not true Somewhat true Certainly true Often loses temper Not true Somewhat true Certainly true Would rather be alone than with other youth Not true Somewhat true Certainly true Generally well behaved, usually does what adults request Not true Somewhat true Certainly true Many worries or often seems worried Not true Somewhat true Certainly true Helpful if someone is hurt, upset or feeling ill Not true Somewhat true Certainly true Constantly fidgeting or squirming Not true Somewhat true Certainly true Has at least one good friend Not true Somewhat true Certainly true Often fights with other youth or bullies them Not true Somewhat true Certainly true Often unhappy, depressed or tearful Not true Somewhat true Certainly true Generally liked by other youth Not true Somewhat true Certainly true Easily distracted, concentration wanders Not true Somewhat true Certainly true Nervous in new situations. easily loses confidence Not true Somewhat true Certainly true Kind to younger children Not true Somewhat true Certainly true Often lies or cheats Not true Somewhat true Certainly true Picked on or bullied by other youth Not true Somewhat true Certainly true Often offers to help others (parents, teachers, children) Not true Somewhat true Certainly true Thinks things out before acting Not true Somewhat true Certainly true Steals from home, school or elsewhere Not true Somewhat true Certainly true Gets along better with adults than with other youth Not true Somewhat true Certainly true Many fears, easily scared Not true Somewhat true Certainly true Good attention span, sees work through to the end Not true Somewhat true Certainly true Overall, do you think that your child has difficulties in one or more of the following areas: Emotions, Concentration, Behavior or Being able to get along with other people? No Yes, Minor Difficulties Yes, Definite Difficulties Yes, Severe Difficulites If you answered 'YES', please answer the following questions about these difficulties:How long have these difficulties been present? Less than a month 1-5 Months 6-12 Months Over a Year Do the difficulties upset or distress your child? Not at all Only a little A medium amount A great deal Do the difficulties interfere with your Childs everyday life in the following areas?Home Life Not at all Only a little A medium amount A great deal Friendships Not at all Only a little A medium amount A great deal Classroom settings Not at all Only a little A medium amount A great deal Leisure activities Not at all Only a little A medium amount A great deal Do the difficulties put a burden on you or the family as a whole? Not at all Only a little A medium amount A great deal The above information is true to the best of my knowledge By clicking this I am acknowledging this to be true to the best of my knowledgeIf you do not receive a call from a staff within 2 days of submitting your paperwork please contact your local Northland Counseling Center location to ensure they have received your paperwork. Please ensure you click submit.Parent / Guardian Email
