Preschool Child Psychiatric Assessment Questionnaire Form
Please complete this brief questionnaire to help us better understand the child's behavioral and emotional patterns. All responses are confidential and used solely for assessment purposes.
Child's First and Last Name
*
First Name
Last Name
Child's Age
*
Relationship to Child
*
Parent/Guardian
Teacher
Other
How often does the child have difficulty paying attention to activities?
*
1
2
3
4
5
How frequently does the child display signs of anxiety (e.g., excessive worry, clinginess)?
*
1
2
3
4
5
How often does the child have trouble interacting with other children?
*
1
2
3
4
5
Select any behaviors you have observed in the child (check all that apply):
Frequent temper tantrums
Difficulty following instructions
Unusual repetitive movements
Withdrawal from group play
Other
Please rate the following behaviors observed in the past month:
*
Rows
Never
Rarely
Sometimes
Often
Always
Restless or fidgety
1
2
3
4
5
Difficulty calming down
6
7
8
9
10
Easily frustrated
11
12
13
14
15
Avoids eye contact
16
17
18
19
20
Are there any specific concerns or additional comments about the child's behavior?
Submit Assessment
Should be Empty: