Functional Emotional Assessment Form
Assess functional and emotional status using the same form title throughout. Provide accurate ratings, context, and observations to support the assessment.
Assessment Overview
Respondent Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Role or Relationship to Person Being Assessed
*
Please Select
Self
Parent/Caregiver
Teacher
Supervisor
Therapist
Other
Functional Emotional Ratings
Emotional Awareness
*
Very Low
1
2
3
4
Very High
5
1 is Very Low, 5 is Very High
Emotional Regulation
*
Very Low
1
2
3
4
Very High
5
1 is Very Low, 5 is Very High
Stress Tolerance
*
Very Low
1
2
3
4
Very High
5
1 is Very Low, 5 is Very High
Motivation / Engagement
*
Very Low
1
2
3
4
Very High
5
1 is Very Low, 5 is Very High
Social Interaction
*
Very Low
1
2
3
4
Very High
5
1 is Very Low, 5 is Very High
Context and Notes
Current Main Concern / Reason for Assessment
*
Additional Observations or Context
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