NameMINOR - PARENT REPORT AND OBSERVATION This form will only take 8 ~ 15 minutes to complete, however you should take has long as you need to describe your concerns about your child with as much detail as you can. Today's date * Is this evaluation for a legal proceeding? * Yes No Minor's Information First Name * Last Name * Date of birth * Age * Parent or Legal Guardian's Information First Name * Last Name * Date of Birth * Age * Relationship to minor * Has the minor been evaluated in the past 10 years? * No Yes 1st question 2nd question What have you done so far to deal with these issues?Ex.: we have checked with our primary care physician and the doctor suggested we get her tested, and that he can put her on medication if we want to. Me and my husband we try to spend time with her and help her finish her homework but is becoming more and more difficult. (To see another example click here) 3rd question EMOTIONAL CONCERNS Emo_1 Seems anxious often Cries easily Seems worried Seems withdrawn Constantly seeking attention Does not respond to affection Does not seem to show emotions Is too serious emo_2 Is too concerned with cleanliness Feels inferior Is often angry Seems sad often Feels guilty easily Feels hurt easily Feels upset easily Is easily frustrated by noise emot_3 Seems afraid frequently Strongly emphasizes order Appears to be suspicious frequently Act too mature for the age Refuses to sleep alone Talks often about death Researches a lot about afterlife Has trouble relaxing emot_4 Sees things that others don't Hears things that others don't Worries a lot of getting sick Has uncommon beliefs Refuses to sleep alone Is uncomfortable in new situations Needs to be reassured frequently Feels easily embarassed SELF CONCEPT self_1 Appears to be self-critical Gives up easily does not seem interested in learning Follows other children unquestionably self_2 Has little or no self-confidence Often gives in to other children Rarely disagrees Is frequently pessimistic about himself/herself self_3 Does not show curiosity for anything Always tries to please others Appears overly-humble Seems afraid to invite children to play self_4 Rarely gives his/her best effort Worries a lot about making mistakes