Ages 11-17 SDQ – Parent Form

Thank you for choosing Northland Counseling Center! Please take a few minutes to fill out the below form. Once complete, please remember to fill out the Minor Registration Age 11-17, Ages 11 -17 Health Questionnaire, GAIN-SS, SDQ-Teen Form, Authorization to treat a minor, GAD 7 & PHQ-A .

SDQ Ages 11-17 – Parent Fills Out

Today's Date
MM slash DD slash YYYY
Email
Person filling out this form
First Last
Young Person 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
The above information is true to the best of my knowledge
By clicking this I am acknowleding this to be true to the best of my office

Footer

Monday – Thursday: 8:00am to 5:00pm
Friday: 8:00am to 12:00pm

Subscribe to NCC News

Blog

Staff Email

Complete Continuum of Care

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.