Ages 11-17 SDQ – Teen

Thank you for choosing Northland Counseling Center. This form needs to be filled out by the teen. Once complete please be sure to fill out the other forms needed for intake Minor Registration, Ages 11-17 Health Questionnaire (HQ), GAIN-SS , SDQ-Parent Form, Authorization to treat a minor, GAD 7 & PHQ-A.

SDQ Ages 11 -17 – Child/Teen Fills Out

Today's Date
MM slash DD slash YYYY
Email
Person filling out this form
First Last
Client name
First Middle Last
Considerate of other people's feelings
- Not true
- Somewhat true
- Certainly true
I am restless, I cannot stay still for long
- Not true
- Somewhat true
- Certainly true
I get a lot of headaches, stomach-aches or sickness
- Not true
- Somewhat true
- Certainly true
I usually share with others, for example CD's games, food
- Not true
- Somewhat true
- Certainly true
I get very angry and often lose my temper
- Not true
- Somewhat true
- Certainly true
I would rather be alone than with people my age
- Not true
- Somewhat true
- Certainly true
I usually do as I am told
- Not true
- Somewhat true
- Certainly true
I worry a lot
- Not true
- Somewhat true
- Certainly true
I am helpful if someone is hurt, upset or feeling ill
- Not true
- Somewhat true
- Certainly true
I am constantly fidgeting or squirming
- Not true
- Somewhat true
- Certainly true
I have one good friend or more
- Not true
- Somewhat true
- Certainly true
I fight a lot. I can make other people do what I want.
- Not true
- Somewhat true
- Certainly true
I am often unhappy, depressed or tearful
- Not true
- Somewhat true
- Certainly true
Other people my age generally like me
- Not true
- Somewhat true
- Certainly true
I am easily distracted, I find it difficult to concentrate
- Not true
- Somewhat true
- Certainly true
I am nervous in new situation. I easily lose confidence
- Not true
- Somewhat true
- Certainly true
I am kind to younger children
- Not true
- Somewhat true
- Certainly true
I am often accused of lying or cheating
- Not true
- Somewhat true
- Certainly true
Other children or young people pick on me or bully me
- Not true
- Somewhat true
- Certainly true
I often offer to help others (parents, teachers, children)
- Not true
- Somewhat true
- Certainly true
I think before I do things
- Not true
- Somewhat true
- Certainly true
I take things that are not mine from home, school or elsewhere
- Not true
- Somewhat true
- Certainly true
I get along better with adults than with people my own age
- Not true
- Somewhat true
- Certainly true
I have many fears, I am easily scared
- Not true
- Somewhat true
- Certainly true
I finish the work I am doing. My attention is good
- 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 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.