Child Emotional Safety Quiz Form
A calm, polished quiz for checking a child's emotional safety and identifying areas where support may help. Use the same title consistently throughout the form.
Child Profile
Child's First Name
*
Child's Age
*
Please Select
0-3 years
4-6 years
7-9 years
10-12 years
13-15 years
16-17 years
18+ years
Prefer not to say
Your Relationship to the Child
*
Please Select
Parent
Guardian
Teacher
Counselor
Relative
Foster Parent
Other
Emotional Safety Check
How often does the child feel the following at home or school?
*
Rows
Never
Rarely
Sometimes
Often
Always
Safe
1
2
3
4
5
Supported
6
7
8
9
10
Heard
11
12
13
14
15
Calm
16
17
18
19
20
Comfortable expressing feelings
21
22
23
24
25
How often does the child feel safe around trusted adults?
*
Never
Rarely
Sometimes
Often
Always
How often does the child feel supported when upset?
*
Never
Rarely
Sometimes
Often
Always
How comfortable is the child sharing feelings with others?
*
Never
Rarely
Sometimes
Often
Always
Recent Concerns and Follow-up
Main Concern or Observation
*
Observed Signs or Situations
Withdrawal or isolation
Frequent tearfulness
Sudden behavior changes
Difficulty sleeping
Conflict at home or school
Loss of interest in usual activities
Needs extra reassurance
Other
What Would Help Most Now?
*
General resources
Follow-up guidance
Submit
Should be Empty: