Child Therapy Needs Assessment Survey:
Thank you for participating in this survey. Your responses will help determine if your child might benefit from therapy. Please select the option that best describes your child’s behavior or experiences.
- How would you describe your child’s mood most of the time?
- A. Generally happy and content (0 points)
- B. Sometimes happy, sometimes moody (1 point)
- C. Frequently sad or anxious (2 points)
- D. Often angry or irritable (3 points)
- How well does your child cope with stress or changes in routine?
- A. Copes well, adjusts easily (0 points)
- B. Has some difficulty, but manages with support (1 point)
- C. Often becomes overwhelmed or upset (2 points)
- D. Has extreme reactions, tantrums, or meltdowns (3 points)
- How does your child interact with peers?
- A. Makes friends easily and enjoys socializing (0 points)
- B. Has a few friends but struggles with social situations at times (1 point)
- C. Has difficulty making or maintaining friendships (2 points)
- D. Avoids social situations or conflicts with peers (3 points)
- How does your child perform academically?
- A. Above average, excels in school (0 points)
- B. Average, sometimes needs extra help with certain subjects (1 point)
- C. Below average, struggles to keep up with schoolwork (2 points)
- D. Has significant difficulties with learning or behavior in school (3 points)
- How does your child communicate their feelings or emotions?
- A. Openly expresses feelings and emotions (0 points)
- B. Sometimes has difficulty expressing emotions clearly (1 point)
- C. Rarely talks about feelings, keeps emotions bottled up (2 points)
- D. Expresses emotions in extreme or inappropriate ways (3 points)
- How does your child react to changes or transitions?
- A. Adapts easily to changes and transitions (0 points)
- B. Needs some time to adjust but eventually adapts (1 point)
- C. Becomes upset or resistant to changes/transitions (2 points)
- D. Has extreme reactions, refusal, or panic attacks (3 points)
- How does your child behave at home?
- A. Generally well-behaved and cooperative (0 points)
- B. Occasionally has behavioral issues but responds to discipline (1 point)
- C. Frequently exhibits challenging behaviors at home (2 points)
- D. Shows severe or disruptive behaviors regularly (3 points)
- Does your child have any recurring physical complaints (e.g., headaches, stomachaches) without medical cause?
- A. No, rarely complains of physical discomfort (0 points)
- B. Occasionally complains of minor physical discomfort (1 point)
- C. Frequently complains of physical discomfort (2 points)
- D. Often complains of severe or chronic physical discomfort (3 points)
- How does your child handle conflict or disagreements with family members?
- A. Handles conflicts calmly and respectfully (0 points)
- B. Sometimes struggles but can resolve conflicts with guidance (1 point)
- C. Reacts emotionally or aggressively to conflicts (2 points)
- D. Often avoids conflicts or escalates them into arguments (3 points)
- Have there been any significant life events or traumas that may have impacted your child (e.g., divorce, loss of a loved one, relocation)?
- A. No significant life events or traumas (0 points)
- B. Minor events that may have caused some stress (1 point)
- C. One major event or trauma that significantly impacted my child (2 points)
- D. Multiple major events or traumas that have had a lasting impact on my child (3 points)
Scoring Guide:
- 0-10 points: Low likelihood that your child may need therapy at this time.
- 11-20 points: Moderate likelihood that your child may benefit from therapy, consider consulting with a mental health professional for further evaluation.
- 21-30 points: High likelihood that your child may benefit from therapy, it’s recommended to seek guidance from a mental health professional as soon as possible.
*Please note that this scoring guide is a general assessment tool and should not replace a thorough evaluation by a qualified mental health professional.