Child Bipolar Disorder Screening Questionnaire
Please complete this questionnaire to help screen for possible symptoms of bipolar disorder in children. This form is for screening purposes only and does not provide a diagnosis.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Gender
*
Male
Female
Other
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Screening
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate how often the following behaviors have been observed in your child over the past 6 months.
*
Rows
Never
Rarely
Sometimes
Often
Very Often
Has periods of unusually elevated or irritable mood
1
2
3
4
5
Shows rapid changes in mood (mood swings)
6
7
8
9
10
Has bursts of energy or activity beyond normal
11
12
13
14
15
Displays risky or impulsive behavior
16
17
18
19
20
Has trouble sleeping or sleeps very little
21
22
23
24
25
Talks excessively or more rapidly than usual
26
27
28
29
30
Is easily distracted or has trouble focusing
31
32
33
34
35
Experiences periods of sadness or withdrawal
36
37
38
39
40
Has your child been previously diagnosed with any mental health condition?
*
Yes
No
If yes, please specify the diagnosis (optional)
Please provide any additional comments or concerns you may have about your child's mood or behavior.
Submit Screening
Should be Empty: