Does my child have an anxiety disorder?

The following questionnaire is based on 26 questions which will be analysed by a qualified Child Psychotherapist. The evaluation will include the severity of any difficulty, if any, and advice on how to proceed with regard to your child's anxiety.


1. Age of child









Please make a selection.


2. In which of the following situations is your child anxious? (please tick all that apply)









3. How long has anxiety been an issue for this child?






Please make a selection.


4. Have there been any significant family changes, bereavements, traumas in the child's lifetime?


Please make a selection.


5. Are there any other children in the family with similar fears/phobias?



Please make a selection.


6. Did either parent have childhood phobias, persistent nightmares or anxiety problems?

Mother



Please make a selection.

Father



Please make a selection.


7. Is the anxiety consistent or does it come and go depending on how settled the child is feeling at any stage?



Please make a selection.


8. Is the child equally anxious with any carer?





Please make a selection.


9. How severe is the anxiety at its very worst?





Please make a selection.


10. How severe is the anxiety most usually?





Please make a selection.


11. Does your child have any of the following symptoms? (please tick all that apply)











12. Does your child have any recurrent physical symptoms which do not have a known medical cause? Such as (please tick all that apply)





13. If the child is of an age to speak clearly: How able is your child to discuss their anxiety?




Please make a selection.


14. Does your child have specific persistent worries? Such as (please tick all that apply)






15. Does your child refuse to go to school or another environment which requires separation from parents?



Please make a selection.


16. Is your child reluctant to sleep away from the home without parents?



Please make a selection.


17. Is your child reluctant to sleep away from home even with the parents, for example on holiday?



Please make a selection.


18. On a scale of 1-10 how disruptive are your child's anxieties to the child's daily life?


19. On a scare of 1-10 how disruptive are these anxieties to the parent's daily life?


20. Does your child's difficulty have a significant on any area of functioning such as school work, sports ability or friendships?



Please make a selection.


21. How would you rate the parents' own anxiety levels when the child is feeling anxious on a scale of 1-10?


22. How would you rate the frustration levels of the parents when the child is feeling anxious on a scale of 1-10?


23. How would you describe your child's general temperament when they are not feeling particularly anxious? (please tick all that apply)







24. What do you think underlies your child's difficulty? (please tick all that apply)






25. How do you feel about your child's anxiety issues?(please tick all that apply)








26. Please give a brief statement (up to 100 words) of any other information you feel is relevant to your child's anxiety difficulties



A value is required.

A value is required.Invalid format.


After submitting your Assessment you will be asked to make your payment of £50 to Ask A Child Therapist through Paypal.


Webdesign by SurfDesign