CDB

The birthdate of your child is needed for us to identify your data while keeping it anonymous to others. Your data will be transmitted securely as scrambled numbers without any text labels.
Birthday of child year
Name of therapist (primary therapist)
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Please rate your child's behavior over the last six months. Select 2 if the item is very true or often true of your child. Select 1 if the item is somewhat or sometimes true. Select 0 if the item is not true of your child. Answer all items as best as you can, even if you are not absolutely certain.
    0 = Not True (as far as you know)
    1 = Somewhat or Sometimes True
    2 = Very True or Often True

Not
True 1 2
1. Feels unloved
2. Feels misunderstood
3. Disobedient at home
4. Disobedient at school
5. Drinks alcohol
6. Argues excessively
7. Physically damages or destroys things
8. Fights with other kids
9. Hangs around with others who get in trouble
10. Acts impulsively or without thinking
11. Lying
12. Nightmares
13. Rejected by other kids
14. Feels excessively guilty
15. Physically attacks other people
16. Threatens to physically attack other people
17. Repeats certain acts over and over again (compulsions)
18. Away from home without permission after curfew
19. Screams or yells a lot
20. Sets fires
21. Sexual problems
22. Steals at home
23. Steals outside the home
24. Uses unacceptable language (e.g., swearing or obscene language)
25. Talks about harming or killing self
26. Temper tantrums or rage
27. Vandalism
28. Poor grades at school

In the last 6 months how many times have the following occurred?
30. Child's behavior led to police intervention
31. Went to a hospital for a psychiatric emergency
32. Physically harmed self with minimal risk of death
33. Attempted suicide by taking pills
34. Attempted suicide in other ways
35. Physically attacked another person or an animal
36. Physically damaged or destroyed something
37. Away from home without permission after curfew

39. In the last 6 months have the difficulties burdened either parent or the family as a whole?
Not at all
Only a little
Quite a lot
Extremely

40. During the last 4 weeks of school homework completion was:
more than 80%
60-80%
about 50%
20-40%
less than 20%
there has been no school for over a month

41. During the last 4 weeks of school average grades on homework assignments were:
more than 80%
60-80%
about 50%
20-40%
less than 20%
there has been no school for over a month

During the last 4 weeks of school (20 school days):
how many full days of school were missed?
how many times has your child left school without permission?

On the last 5 school days:
how many days late for school (for any reason)?
how many hours of school were missed (for any reason)

In the last 7 days, on how many days did the following occur?
Talked about harming or killing self
Threatened to physically attack another person or an animal
Screamed or yelled at other people
Used unacceptable language (e.g., swearing or obscene language)
less than 8 hours of sleep
less than 7 hours of sleep
less than 6 hours of sleep
awake before 8 am
awake after 10 am