Mind & Mood Assessments

A brief and private tool to check in on your child's emotional well-being. It asks simple questions that screen for anxiety, depression, and how past experiences may be impacting your mood and daily life.
Parent's Full Name (if under the age of 18)

First NameLast Name
Parent's email*
example@example.com
Phone Number*
Youth's Full Name *

First NameLast Name
Youth's Date of Birth*

MonthDayYear
Date

Using the provided prompt, respond to the questions below.

Stressful of scary events happens to many people. Below is a list of stressful and scary events that sometimes happen. Mark Yes if it happened to you. Mark No it if didnt happen to you.
Serious natural disaster like a flood, tornado, hurricane, earthquake, or fire.*
Serious accident or injury like a car/bike crash, dog bite, or sports injury? *
Threatened, hit or badly within the family*
Threatened, hit or hurt badly in school or community*
Attacked, stabbed, shot at or robbed by threat. *
Seeing someone in the family threatened, hit or hurt badly*
Seeing someone in school or the community threatened, hit or hurt badly*
Someone doing sexual things to you or making you do sexual things to them when you couldn't say no. Or when you were forced or pressured*
Online or social media, someone asking or pressuring you to do something sexual. Like take or send a pictures*
Someone bullying you online. Saying very mean things that scare you. *
Someone close to you dying suddenly or violently.*
Stressful or scary medical procedure*
Being around war*
Other stressful or scary event*
Someone bullying you online. Saying very mean things that scare you. *
ACEs Score:

	0 Never	1 One in a while	2 Half the time	3 Almost Always
1. Upsetting thoughts or pictures about what happened that pop into your head
2. Bad dreams reminding you of what happened
3. Feeling as if what happened is happening all over again
4. Feeling very upset when you are reminded of what happened.
5. Strong feelings in your body when you are reminded of what happened (sweating, heart beating fast, upset stomach)
6. Trying not to think about or talk about what happened. Or to not have feelings about it.
7.Staying away from people, places, things, or situations that remind you of what happened.
8. Not being able to remember part of what happened.
9. Negative thoughts about yourself or others. Thoughts like I won't have a good life, no one can be trusted, the whole world is unsafe.
10. Blaming yourself for what happened, or blaming someone else when it isn't their fault
11. Bad feelings (afraid, angry, guilty, ashamed) a lot of the time.
12. Not wanting to do things you used to do.
13. Not feeling close to people
14. Not being able to have good or happy feelings.
15. Feeling mad. Having fits or anger and taking it out on others.
16. Doing unsafe things
17. Being overly careful or on guard (checking to see who is around you)
18. Being jumpy
19. Problems paying attention
20. Trouble falling or staying asleep

	Not True or Hardly Ever True	Somewhat True or Sometimes True	Very True or Often True
1. When I feel frightened, it's hard to breathe.
2. I get headaches when I am at school.
3. I don't like to be with people I don't know well.
4. I get scared if I sleep away from home.
5. I worry about other people liking me.
6. When I get frightened, I feel like passing out.
7. I am nervous.
8. I follow my mother or father wherever they go.
9. People tell me that I look nervous.
10. I feel nervous with people I don't know well.
11. I get stomachaches at school
12. When I get frightened, I feel like I am going crazy.
13. I worry about sleeping alone.
14. I worry about being as good as other kids.
15. When I get frightened I feel like things are not real.
16. I have nightmares about something bad happening to my parents.
17. I worry about going to school.
18. When I get frightened, my heart beats fast.
19. I get shaky.
20. I have nightmares about something bad happening to me.
21. I worry about things working out for me.
22. When I get frightened, I sweat a lot.
23. I am a worrier.
24. I get really frightened for no reason at all.
25. I am afraid to be alone in the house.
26. It is hard for me to talk with people I don't know well.
27. When I get frightened, I feel like I am choking.
28. People tell me that I worry too much.
29. I don't like to be away from my family.
30. I am afraid of having anxiety (or panic) attacks.
31. I worry that something bad might happen to my parents.
32. I feel shy with people I don't know well.
33. I worry about what is going to happen in the future.
34. When I get frightened, I feel like throwing up.
35. I worry about how well I do things.
36. I am scared to go to school.
37. I worry about things that have already happened.
38. When I get frightened, I get dizzy.
39. I feel nervous when I am with other children or adults and I have to do something while they watch me (for example: read aloud, speak, play a game, play a sport)
40. I feel nervous when I am going to parties, dances, or any place where there will be people that I don't know well.
41. I am shy.

	Not At All	A Little	Some	Alot
1. I was bothered by things that usually don't bother me.
2. I did not feel like eating, I wasn't very hungry.
3. I wasn't able to feel happy, even when my family or friends tried to help me feel better.
4. I felt like I was just as good as other kids.
5. I felt like I couldn't pay attention to what I was doing.
6. I felt down and unhappy
7. I felt like I was too tired to do anything.
8. I felt like something good was going to happen.
9. I felt like things I did before didn't work out right.
10. I felt scared.
11. I didn't sleep as well as I usually sleep.
12. I was happy.
13. I was more quiet than usual.
14. I felt lonely, like I didn't have friends.
15. I felt like kids I know were not friendly or that they didn't want to be with me.
16. I had a good time.
17. I felt like crying.
18. I felt sad.
19. I felt people didn't like me.
20. It was hard to get started doing things.

A brief and private tool to check in on your child's emotional well-being. It asks simple questions that screen for anxiety, depression, and how past experiences may be impacting your mood and daily life.