CHILD VERSION - TEEN SCREENS

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Below is a list of sentences that describe how people feel. Read each phrase and for each sentence, check the box that corresponds to the response that seems to describe you for the last 3 months.

Email *

CHILD'S NAME *

Untitled Question *

NOT TRUE OR HARDLY EVER TRUE

SOMEWHAT TRUE OR SOMETIMES TRUE

VERY TRUE OR OFTERN TRUE

When I feel frightened, it is hard to breathe.

I get headaches when I am at school.

I don't like to be with people I don't know well.

I get scared if I sleep away from home.

I worry about other people liking me.

When I get frightened, I feel like passing out.

I am nervous.

I follow my mother or father wherever they go.

People tell me that I look nervous.

I feel nervous with people I don't know well.

I get stomachaches at school.

When I get frightened, I feel like I am going crazy.

I worry about sleeping alone.

I worry about being as good as other kids.

When I get frightened, I feel like things are not real.

I have nightmares about something bad happening to my parents.

I worry about going to school.

When I get frightened, my heart beats fast.

I get shaky.

I have nightmares about something bad happening to me.

I worry about things working out for me.

When I get frightened, I sweat a lot.

I am a worrier.

I get really frightened for no reason at all.

I am afraid to be alone in the house.

It is hard for me to talk with people I don't know well.

When I get frightened, I feel like I am choking.

People tell me that I worry too much.

I don't like to be away from my family.

I am afraid of having anxiety (or panic) attacks.

I worry that something bad might happen to my parents.

I feel shy with people I don't know well.

I worry about what is going to happen in the future.

When I get frightened, I feel like throwing up.

I worry about how I do things.

I am scared to go to school.

I worry about things that have already happened.

When I get frightened, I feel dizzy.

I feel nervous when I am with other children or adults and I have to do something while they watch me (for example: read aloud, speak, play a game, play a sport).

I feel nervous when I am going to parties, dances, or any place where there will be people that I don't know well.

I am shy.

NOT TRUE OR HARDLY EVER TRUE

SOMEWHAT TRUE OR SOMETIMES TRUE

VERY TRUE OR OFTERN TRUE

When I feel frightened, it is hard to breathe.

I get headaches when I am at school.

I don't like to be with people I don't know well.

I get scared if I sleep away from home.

I worry about other people liking me.

When I get frightened, I feel like passing out.

I am nervous.

I follow my mother or father wherever they go.

People tell me that I look nervous.

I feel nervous with people I don't know well.

I get stomachaches at school.

When I get frightened, I feel like I am going crazy.

I worry about sleeping alone.

I worry about being as good as other kids.

When I get frightened, I feel like things are not real.

I have nightmares about something bad happening to my parents.

I worry about going to school.

When I get frightened, my heart beats fast.

I get shaky.

I have nightmares about something bad happening to me.

I worry about things working out for me.

When I get frightened, I sweat a lot.

I am a worrier.

I get really frightened for no reason at all.

I am afraid to be alone in the house.

It is hard for me to talk with people I don't know well.

When I get frightened, I feel like I am choking.

People tell me that I worry too much.

I don't like to be away from my family.

I am afraid of having anxiety (or panic) attacks.

I worry that something bad might happen to my parents.

I feel shy with people I don't know well.

I worry about what is going to happen in the future.

When I get frightened, I feel like throwing up.

I worry about how I do things.

I am scared to go to school.

I worry about things that have already happened.

When I get frightened, I feel dizzy.

I feel nervous when I am with other children or adults and I have to do something while they watch me (for example: read aloud, speak, play a game, play a sport).

I feel nervous when I am going to parties, dances, or any place where there will be people that I don't know well.

I am shy.

ADOLESCENT SUBSTANCE ABUSE (CRAFFT)

The following questions concern information about your potential involvement with alcohol and other drugs during the past 12 months. Carefully read each questions, and mark the appropriate answer.

When the word "drug" is used, it refers to the use of prescribed or over-the counter drugs that are used in excess of the directions.

YES

During the past 12 months did you drink any alcohol (more than a few sips)?

During the past 12 months did you smoke any cannabis (marijuana, hash) or vape?

During the past 12 months did you use anything else to get high?

Have you ever ridden in a car driven by someone who was "high" or had been using alcohol or drugs?

Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?

Do you ever use alcohol or drugs while you are by yourself?

Do you ever forget things you did while using alcohol or drugs?

Do your family or friends ever tell you that you should cut down on your drinking or drug use?

Have you ever gotten in to trouble while you were using alcohol or drugs?

YES

During the past 12 months did you drink any alcohol (more than a few sips)?

During the past 12 months did you smoke any cannabis (marijuana, hash) or vape?

During the past 12 months did you use anything else to get high?

Have you ever ridden in a car driven by someone who was "high" or had been using alcohol or drugs?

Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?

Do you ever use alcohol or drugs while you are by yourself?

Do you ever forget things you did while using alcohol or drugs?

Do your family or friends ever tell you that you should cut down on your drinking or drug use?

Have you ever gotten in to trouble while you were using alcohol or drugs?

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