Child & Adolescent Parent Questionnaire

Child & Adolescent Parent Questionnaire

CBCL
Today's Date*

MonthDayYear
Date
Name of Client*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Below is a list of items that describe children and youth. For each item please select the option that best describes your child within the past 6 months.

Please answer all items as well as you can, even if some do not seem to apply to your child. There will be space at the end of the questionnaire to add comments if needed.

Please select:
- 0 if the item is "Not True" (as far as you know)
- 1 if the item is "Somewhat True"
- 2 if the item is "Very True or Often True"

	0	1	2
1. Acts too young for his/her age
2. Drinks alcohol without parents’ approval:
3. Argues a lot
4. Fails to finish things he/she starts
5. There is very little he/she enjoys
6. Bowel movements outside toilet
7. Bragging, boasting
8. Can’t concentrate, can’t pay attention for long
9. Can’t get his/her mind off certain thoughts; obsessions (describe):
10. Can’t sit still, restless, or hyperactive
11. Clings to adults or too dependent
12. Complains of loneliness
13. Confused or seems to be in a fog
14. Cries a lot
15. Cruel to animals
16. Cruelty, bullying, or meanness to others
17. Daydreams or gets lost in his/her thoughts
18. Deliberately harms self or attempts suicide
19. Demands a lot of attention
20. Destroys his/her own things
21. Destroys things belonging to his/her family or others
23. Disobedient at school
24. Doesn’t eat well
25. Doesn’t get along with other kids
26. Doesn’t seem to feel guilty after misbehaving
27. Easily jealous
28. Breaks rules at home, school or elsewhere
29. Fears certain animals, situations, or places, other than school
31. Fears he/she might think or do something bad
32. Feels he/she has to be perfect
33. Feels or complains that no one loves him/her
34. Feels others are out to get him/her
35. Feels worthless or inferior
36. Gets hurt a lot, accident prone
37. Gets in many fights
38. Gets teased a lot
39. Hangs around with others who get in trouble
40. Hears sound or voices that aren’t there
41. Impulsive or acts without thinking
42. Would rather be alone than with others
43. Lying or cheating
44. Bites fingernails
45. Nervous, high-strung, or tense
46. Nervous movements or twitching
47. Nightmares
48. Not liked by other kids
49. Constipated, doesn’t move bowels
50. Too fearful or anxious
51. Feels dizzy or lightheaded
52. Feels too guilty
53. Overeating
54. Overtired without good reason
55. Overweight
56. Physical problems without know physical cause
a. Aches or pains (not stomach or headaches)
b. Headaches
c. Nausea, feels sick
d. Problems with eyes (not if corrected by glasses)
e. Rashes or other skin problems
f. Stomachaches
g. Vomiting, throwing up
57. Physically attacks people
58. Picks nose, skin, or other parts of body
59. Plays with own sex parts in public
60. Plays with own sex parts too much
61. Poor school work
62. Poorly coordinated or clumsy
63. Prefers being with older kids
64. Prefers being with younger kids
65. Refuses to talk
66. Repeats certain acts over and over; compulsions
67. Runs away from home
68. Screams a lot
69. Secretive, keeps things to self
70. Sees things that aren't there
71. Self-conscious or easily embarrassed
72. Sets fires
73. Sexual problems
74. Showing off or clowning
75. Too shy or timid
76. Sleeps less than most kids
77. Sleeps more than most kids during day and/or night
78. Inattentive or easily distracted
79. Speech problem
80. Stares blankly
81. Steals at home
82. Steals outside the home
83. Stores up too many things he/she doesn’t need
84. Strange behavior (describe)
85. Strange ideas (describe)
86.Stubborn, sullen or irritable
87. Sudden changes in mood or feelings
88. Sulks a lot
89. Suspicious
90. Swearing or obscene language
91. Talks about killing self
92. Talks or walks in sleep
93. Talks too much
94. Teases a lot
95. Temper tantrums or hot tempers
96. Thinks about sex too much
97. Threatens people
98. Thumb sucking
99. Smokes, chews or sniffs tobacco
100. Trouble sleeping
101. Truancy, skips school
102. Underactive, slow moving, lacks energy
103. Unhappy, sad or depressed
104. Unusually loud
105. Uses drugs for non medical purposes (don't include alcohol or tobacco)
106. Vandalism
107. Wets self during the day
108. Wets bed
109. Whining
110. Wishes to be of the opposite sex
111. Withdrawn, doesn't get involved with others
112. Worries

Please add other problems your child has that were not listed
Additional Comments/Concerns Regarding Any of the Questions
Name of parent who completed form*

First NameLast Name
Signature*

Clear
Please be sure you answered all items.
Should be Empty: