Spence Anxiety Scale: Parent

1

Today's Date* This field is required.

Date

2

Child's Name:* This field is required.

3

Child's Date of Birth* This field is required.

Date

4

Name of person filling the form:* This field is required.

6

TOTAL SCORE (Interpret the score using the table below):

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	T-Score 60 (84th percentile)	T-Score 65 (94th percentile)	T-Score 70 (98th percentile)
Boys ages 7-9	26 and over	35 and over	47 and over
Boys ages 10-17	24 and over	39 and over	53 and over
Girls ages 7-9	28 and over	38 and over	53 and over
Girls ages 10-17	27 and over	36 and over	46 and over

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DIRECTIONS: Next 38 items has statements that describe children. For each one, pick the response that best matches how your child typically behaves

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1.My child worries about things.* This field is required.

Never

Sometimes

Often

Very often

10

2. My child is scared of the dark.* This field is required.

Never

Sometimes

Often

Very often

11

3. When my child has a problem, she/he complains of having a funny feeling in stomach .* This field is required.

Never

Sometimes

Often

Very often

13

5. My child would feel afraid of being alone at home.* This field is required.

Never

Sometimes

Often

Very often

14

6. My child is scared when she/he has to take a test.* This field is required.

Never

Sometimes

Often

Very often

15

7. My child is afraid when she/he has to use public toilets or bathrooms.* This field is required.

Never

Sometimes

Often

Very often

16

8. My child worries about being away from us/me.* This field is required.

Never

Sometimes

Often

Very often

17

9. My child feels afraid of making fool of self in front of people.* This field is required.

Never

Sometimes

Often

Very often

18

10. My child worries that she/he will do badly at school.* This field is required.

Never

Sometimes

Often

Very often

19

11. My child worries that something awful will happen to someone in our family.* This field is required.

Never

Sometimes

Often

Very often

20

12. My child complains of suddenly feeling as if she/he can't breathe when there is no reason for this.* This field is required.

Never

Sometimes

Often

Very often

21

13. My child has to keep checking that she/he has done things right (like the switch is off, or the door is locked).* This field is required.

Never

Sometimes

Often

Very often

22

14. My child feels scared when sleeping alone.* This field is required.

Never

Sometimes

Often

Very often

23

15. My child has trouble going to school in the mornings because she/he feels nervous or afraid.* This field is required.

Never

Sometimes

Often

Very often

24

16. My child is scared of dogs.* This field is required.

Never

Sometimes

Often

Very often

25

17. My child can't seem to get bad or silly thoughts out of her/his head.* This field is required.

Never

Sometimes

Often

Very often

26

18. When my child has a problem, she/he complains of her/his heart beating really fast.* This field is required.

Never

Sometimes

Often

Very often

27

19. My child suddenly starts to tremble or shake when there is no reason for this.* This field is required.

Never

Sometimes

Often

Very often

28

20. My child worries that something bad will happen to her/him.* This field is required.

Never

Sometimes

Often

Very often

29

21. My child is scared of going to the doctor or dentist.* This field is required.

Never

Sometimes

Often

Very often

30

22. When my child has a problem, she/he feels shaky.* This field is required.

Never

Sometimes

Often

Very often

31

23. My child is scared of heights (eg. being at the top of a cliff).* This field is required.

Never

Sometimes

Often

Very often

32

24. My child has to think special thoughts (like numbers or words) to stop bad things from happening.* This field is required.

Never

Sometimes

Often

Very often

33

25. My child feels scared if she/he has to travel in the car, or on a bus or train.* This field is required.

Never

Sometimes

Often

Very often

34

26. My child worries what other people think of her/him.* This field is required.

Never

Sometimes

Often

Very often

35

27. My child is afraid of being in crowded places (like shopping centres, the movies, buses, busy playgrounds).* This field is required.

Never

Sometimes

Often

Very often

36

28. All of a sudden my child feels really scared for no reason at all.* This field is required.

Never

Sometimes

Often

Very often

37

29. My child is scared of insects or spiders.* This field is required.

Never

Sometimes

Often

Very often

38

30. My child complains of suddenly becoming dizzy or faint when there is no reason for this.* This field is required.

Never

Sometimes

Often

Very often

39

31. My child feels afraid when she/he has to talk in front of the class.* This field is required.

Never

Sometimes

Often

Very often

40

32. My child’s complains of his/her heart suddenly starting to beat too quickly for no reason.* This field is required.

Never

Sometimes

Often

Very often

41

33. My child worries that she/he will suddenly get a scared feeling when there is nothing to be afraid of.* This field is required.

Never

Sometimes

Often

Very often

42

34. My child is afraid of being in small closed places, like tunnels or small rooms.* This field is required.

Never

Sometimes

Often

Very often

43

35. My child has to do some things over and over again (like washing her/his hands, cleaning or putting things in a certain order).* This field is required.

Never

Sometimes

Often

Very often

44

36. My child gets bothered by bad or silly thoughts or pictures in her/his head.* This field is required.

Never

Sometimes

Often

Very often

45

37. My child has to do certain things in just the right way to stop bad things from happening.* This field is required.

Never

Sometimes

Often

Very often

46

38. My child would feel scared if she/he had to stay away from home overnight.* This field is required.

Never

Sometimes

Often

Very often