(P) Ohio Mental Health Consumer Outcomes System Ohio Youth Problem

Ohio Mental Health Consumer Outcomes System Ohio Youth Problem, Functioning, and Satisfaction Scales

Parent Rating – Short Form
Clinician:
Please select the clinician from the card given to you by the front Desk:
P
*Please turn device hoizontal to view form correctly
Childs Name

First NameLast Name
Date

MonthDayYear
Date
Child's Grade:
Child's Grade:
Child's Date of Birth:

MonthDayYear
Date
Child's Sex:
Child's Race
Form Completed By:

Other

Instructions: Please rate the degree to which your child has experienced the following problems in the past 30 days.

Rows	Not at All	Once Or Twice	Several Times	Often	Most of the Time	All of the time
1. Arguing with others
2. Getting into fights
3. Yelling, swearing, or screaming at others
4. Fits of anger
5. Refusing to do things teachers or parents ask
6. Causing trouble for no reason
7. Using drugs or alcohol
8. Breaking rules or breaking the law (out past curfew, stealing)
9. Skipping school or classes
10. Lying
11. Can’t seem to sit still, having too much energy
12. Hurting self (cutting or scratching self, taking pills)
13. Talking or thinking about death
14. Feeling worthless or useless
15. Feeling lonely and having no friends
16. Feeling anxious or fearful
17. Worrying that something bad is going to happen
18. Feeling sad or depressed
19. Nightmares
20. Eating problems

Rows	Extreme Troubles	Quite a Few Troubles	Some Troubles	OK	Doing Very Well
1. Getting along with friends
2. Getting along with family
3. Dating or developing relationships with boyfriends or girlfriends
4. Getting along with adults outside the family (teachers, principal)
5. Keeping neat and clean, looking good
6. Caring for health needs and keeping good health habits (taking medicines or brushing teeth)
7. Controlling emotions and staying out of trouble
8. Being motivated and finishing projects
9. Participating in hobbies (baseball cards, coins, stamps, art)
10. Participating in recreational activities (sports, swimming, bike riding)
11. Completing household chores (cleaning room, other chores)
12. Attending school and getting passing grades in school
13. Learning skills that will be useful for future jobs
14. Feeling good about self
15. Thinking clearly and making good decisions
16. Concentrating, paying attention, and completing tasks
17. Earning money and learning how to use money wisely
18. Doing things without supervision or restrictions
19. Accepting responsibility for actions
20. Ability to express feelings