SDQ Parent Form Ages 4-10

Parents please fill this form out for children age 4-10-years old!

When you have finished filling out this form please make sure you have also filled out the Health Questionnaire for ages 0-10, Minor Registration Form & Authorization to treat a minor. Once complete an intake staff will be contacting you!

SDQ Ages 4-10 – Parent Fills Out

Today's Date
MM slash DD slash YYYY
Parent/Guardian Email
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 knowledge

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Northland Counseling Center, Inc.
Grand Rapids
Hibbing
International Falls
Kiesler Wellness Center
Aitkin

Northland Recovery Center, Inc.
Grand Rapids, MN
International Falls, MN

Northland Counseling Center Inc. does not discriminate in the provision of services to individuals based on their inability to pay, race, color, sex, national origin, disability, religion, or sexual orientation. It is the policy of Northland Counseling Center to provide essential medical services regardless of the patient’s ability to pay. Discounts are offered based upon household income and size. A sliding fee schedule is used to calculate the basic discount and is updated each year using the federal poverty guidelines. Northland Counseling Center Inc. accepts Medicare, Medicaid, private and CHIP. We will work with you to determine insurance eligibility.

SDQ Parent Form Ages 4-10

SDQ Ages 4-10 – Parent Fills Out

If you answered 'YES', please answer the following questions about these difficulties:

Do the difficulties interfere with your Childs everyday life in the following areas?

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