Children’s Mood Assessment Questionnaire
Please complete this questionnaire to help us understand the child’s current mood and emotional well-being.
Child’s Full Name
*
First Name
Last Name
Child’s Age
*
Your Relationship to the Child
*
Please Select
Parent/Guardian
Teacher
Counselor
Other
In the past two weeks, how often has the child experienced the following moods or feelings?
*
Rows
Never
Rarely
Sometimes
Often
Always
Appeared happy or content
1
2
3
4
5
Seemed sad or withdrawn
6
7
8
9
10
Showed signs of anxiety or worry
11
12
13
14
15
Became easily frustrated or angry
16
17
18
19
20
Had trouble focusing or paying attention
21
22
23
24
25
How would you rate the child’s overall mood in the past week?
*
1
2
3
4
5
Has the child shown any sudden changes in mood or behavior recently?
*
Yes
No
If yes, please describe the changes observed.
Does the child have difficulty sleeping or changes in appetite?
*
Difficulty sleeping
Changes in appetite
Both
Neither
Please indicate if the child has recently experienced any of the following (select all that apply):
*
Family changes (e.g., divorce, move)
Loss of a loved one
Bullying or social difficulties
Academic stress
No significant events
Other
Additional comments or concerns about the child’s mood or behavior
Submit Assessment
Should be Empty: