Does my child have a phobia?

The following questionnaire is based on 25 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 sleeping routine.


1. Age of child










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2. What is it that your child is frightened of?


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






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


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



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

Mother



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Mother



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



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8. Is the child equally anxious with any carer?





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





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10. How severe is the anxiety most usually?





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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?




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14. Does your child recognise that the fear is:



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



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16. On a scale of 1-10 how disruptive are these fears to the child's daily life?


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


18. How would you rate the parents' own anxiety levels during phobic situations on a scale of 1-10?


19. How would you rate the frustration levels of the parents during phobic situations on a scale of 1-10?


20. Does your child have any other anxiety symptoms? Such as (please tick all that apply)




21. Do any of the following apply to your child?(please tick all that apply)





22. How would you describe your child's general temperament outside of the feared situation?







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







24. How do you feel about your child's fears? (please tick all that apply)








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



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


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