Self Strengths and Difficulties Questionnaire 11-17

FAMILY CONNECTIONS

Strengths and Difficulties Questionnaire for age 11-17 (Self Form)
5891 Cedar Lake Road South, St. Louis Park, MN 55416

ph. 952-544-0964

fax 952-544-6405

www.familyconnectionsmn.com

STRENGTHS AND DIFFICULTIES QUESTIONNAIRE

Self Form, ages 11-17
For each item, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain. Please give your answers on the basis of your child's behavior over the last six months.
Your Name *

First Name Last Name
Email *
example@example.com
Select your therapist *
Email of your therapist *
example@example.com
Date of birth *

Month Day Year
Date
Age
Gender *

Male Female

	Not True	Somewhat True	Certainly True
I try to be nice to other people. I care about their feelings.
I am restless, I cannot stay still for long
I get a lot of headaches, stomach-aches or sickness
I usually share with others, for example CDs, games, food
I get very angry and often lose my temper
I would rather be alone than with other people of my age
I usually do as I am told
I worry a lot
I am helpful if someone is hurt, upset or feeling ill
I am constantly fidgeting or squirming
I have one good friend or more
I fight a lot. I can make other people do what I want
I am often unhappy, depressed or tearful
Other people my age generally like me
I am easily distracted, I find it difficult to concentrate
I am nervous in new situations. I easily lose confidence
I am kind to younger children
I am often accused of lying or cheating
Other children or young people pick on me or bully me
I often offer to help others (parents, teachers, children)
I thinks before I do things
I take things that are not mine from home, school or elsewhere
I get along better with adults than with people my own age
I have many fears, I am easily scared
I finish the work I’m doing. My attention is good Good

Do you have any other comments or concerns?

Overall, do you think that your child has difficulties in one or more of the following areas: emotions, concentration, behavior or being able to get on with other people? *

	No	Yes, minor difficulties	Yes, definite difficulties	Yes, severe difficulties

If you answered “Yes”, please answer the following questions about these difficulties: *

	Less than a month	1 - 5 monts	6 - 12 months	Over a year
How long have these difficulties been present?

	Not at all	Only a little	A medium amount	A great deal
Do the difficulties upset or distress your child?

Do the difficulties interfere with your child’s everyday life in the following areas? *

	Not at all	Only a little	A medium amount	A great deal
Home life
Friendships
Learning
Leisure Activities

Do the difficulties put a burden on you or the family as a whole? *

	Not at all	Only a little	A medium amount	A great deal
Do the difficulties put a burden on you or the family as a whole?

Client Signature (or parent/guardian) *

Clear
*

Mother Father
For Office Use Only
Clinician Name

First Name Last Name
Date

Month Day Year
Date
Clinician Signature

Clear
Thank you very much for your help

@ Robert Goodman, 2005
Should be Empty:

FAMILY CONNECTIONS

STRENGTHS AND DIFFICULTIES QUESTIONNAIRE