Early Childhood Mental Health Survey
Share information about a young child’s emotions, behavior, development, and recent home or childcare concerns.
Child Overview
Child First Name or Nickname
*
Child Age
*
Primary Caregiver Relationship
*
Parent
Guardian
Foster Parent
Grandparent
Other
Current Concerns and Observations
Main reason for this survey today
*
How long have these concerns been present?
*
Less than 2 weeks
2–4 weeks
1–3 months
More than 3 months
Overall severity of concern
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Child Functioning and Environment
Sleep
Significant concern
1
2
3
4
5
6
7
8
9
No concern
10
1 is Significant concern, 10 is No concern
Appetite / Eating
Significant concern
1
2
3
4
5
6
7
8
9
No concern
10
1 is Significant concern, 10 is No concern
Functioning and Environment Ratings
*
Rows
Concern level
Mood / Emotional Regulation
1
Behavior at Home
2
Behavior in Childcare / Preschool
3
Social Interaction with Other Children
4
Recent Family or Routine Changes
5
Additional Notes for the Provider
Submit
Should be Empty: