Child Behavioral Health Evaluation Form
Use this form to assess key behavioral, emotional, social, and developmental concerns for a child. Please answer each section to help guide the evaluation.
Child's First Name
*
Child's Age
*
Primary Behavioral Concerns
*
Difficulty focusing
Impulsivity
Anxiety or worry
Mood changes
Aggression or anger
Social withdrawal
Other
How often do these concerns occur?
*
Rarely
Sometimes
Often
Almost always
Please rate the child's current emotional state
*
1
2
3
4
5
Social and Developmental Context
*
Rows
Never
Sometimes
Often
Always
Plays/interacts with peers
1
2
3
4
Communicates needs effectively
5
6
7
8
Shows age-appropriate skills
9
10
11
12
Known triggers for behavioral or emotional difficulties
Transitions or changes
Academic stress
Peer conflicts
Family stress
Sensory overload
Other
Current supports or helpful strategies in place
Counseling/therapy
School support plan
Family routines
Peer support
Other
How urgent is the need for evaluation or support?
*
Routine (not urgent)
Soon (within weeks)
Urgent (within days)
Please provide any additional relevant information
Submit Evaluation
Should be Empty: