SCREENING FOR CHILD ANXIETY

Screen for child anxiety & related disorders

Below is a list of sentences that describe how people feel. Read each phrase and decide if it is "Not true or hardly ever true" or "somewhat true or sometimes true" or "very True or Often True" for your child. Then, for each statement, select the answer that corresponds to the response to describe your child for the last 3 months. Pleae respond to all statements as well as you can, even if some do not seem to concern your child.

* Indicates required field

Your First & Last Name *

Phone *

Email *

1. When my child feels frightened, it is hard for him/her to breathe *

2. My child gets headaches when he/she is at school. *

3. My child doesn't like to be with people he/she doesn't know well. *

4. My child gets scared if he/she sleeps away from home. *

5. My child worries about other people liking him/her. *

6. When my child gets frightened, he/she feels like passing out. *

7. My child is nervous. *

8. My child follows me wherever I go. *

9. People tell me that my child looks nervous. *

10. My child feels nervous with people he/she doesn't know well. *

11. My child gets stomachaches at school. *

13. My child gets worried about sleeping alone *

15. When my child gets frightened, he/she feels like things are not real. *

17. My child worries about going to school. *

19. My child gets shaky. *

21. My child worries about things working out for him/her. *

23. My child is a worrier. *

25. My child is afraid to be alone in the house. *

27. When my child gets frightened, he/she feels like he/she is choking. *

29. My child doesn't like to be away from his/her family. *

31. My child worries that something bad might happen to his/her parents. *

33. My child worries about what is going to happen in the future. *

35. My child worries about how well he/she does things. *

37. My child worries about things that have already happened. *

39. My child feels nervous when he/she is with other children or adults and he/she has to do something while they watch him/her (for example: read aloud, speak, play a game, play a sport). *

41. My child is shy. *

12. When my child gets frightened, he/she feels like he/she is going crazy. *

14. My child worries about being as good as other kids. *

16. My child has nightmares about something bad happening to his/her parents. *

18. When my child gets frightened, his/her heart beats fast. *

20. My child has nightmares about something bad happening to him/her. *

22. When my child gets frightened, he/she sweats a lot. *

24. My child gets really frightened for no reason at all. *

26. It is hard for my child to talk with people he/she doesn't know well. *

28. People tell me that my child worries too much. *

30. My child is afraid of having anxiety (or panic) attacks. *

32. My child feels shy with people he/she doesn't know well. *

34. When my child gets frightened, he/she feels like throwing up. *

36. My child is scared to go to school. *

38. When my child gets frightened, he/she feels dizzy. *

40. My child feels nervous when he/she is going to parties, dances, or any place where there will be people that he/she doesn't know well. *

Submit

MEMBERS OF:

THERAPY WEST

37 West 65th Street, 5th Floor
New York, NY
10023
P: 212.580.0080
F: 212.580.0047

MEMBERS OF:

THERAPY WEST

FREE PHONE CONSULTATION

Call us directly at (212) 580 - 0080, or fill out the form below: