Youth Test TestQuestions DemographicInformation YourResults Pediatric Symptom Checklist - Youth Report The questionnaire that follows can be used to see if you are having emotional, attentional, or behavioral difficulties. For each item please mark how often you: Complain of aches or pains*NeverSometimesOftenSpend more time alone*NeverSometimesOftenTire easily, little energy*NeverSometimesOftenFidgety, unable to sit still*NeverSometimesOftenHave trouble with teacher*NeverSometimesOftenLess interested in school*NeverSometimesOftenAct as if driven by motor*NeverSometimesOftenDaydream too much*NeverSometimesOftenDistract easily*NeverSometimesOftenAre afraid of new situations*NeverSometimesOftenFeel sad, unhappy*NeverSometimesOftenAre irritable, angry*NeverSometimesOftenFeel hopeless*NeverSometimesOftenHave trouble concentrating*NeverSometimesOftenLess interested in friends*NeverSometimesOftenFight with other children*NeverSometimesOftenAbsent from school*NeverSometimesOftenSchool grades dropping*NeverSometimesOftenDown on yourself*NeverSometimesOftenVisit doctor with doctor finding nothing wrong*NeverSometimesOftenHave trouble sleeping*NeverSometimesOftenWorry a lot*NeverSometimesOftenWant to be with parent more than before*NeverSometimesOftenFeel that you are bad*NeverSometimesOftenTake unnecessary risks*NeverSometimesOftenGet hurt frequently*NeverSometimesOftenSeem to be having less fun*NeverSometimesOftenAct younger than children your age*NeverSometimesOftenDo not listen to rules*NeverSometimesOftenDo not show feelings*NeverSometimesOftenDo not understand other people's feelings*NeverSometimesOftenTease others*NeverSometimesOftenBlame others for your troubles*NeverSometimesOftenTake things that do not belong to you*NeverSometimesOftenRefuse to share*NeverSometimesOftenDo you have any emotional or behavioral problems for which you need help?*NoYes Please take a moment to answer the following optional questions. Your answers are totally anonymous—we won't be able to identify you based on this information. Your answers help us provide better information and support for people like you. You can answer as many or as few questions as you would like. When you are done, scroll to the bottom of the survey and click "submit" to receive your screening results.About YouAge Range4-56-89-1011-1314-1718+GenderMaleFemaleAnother GenderEnter GenderPlease check this box if you identify as transgender. Please check this box if you identify as transgender. Race/EthnicityAsian or Pacific IslanderBlack or African-American (non-Hispanic)Hispanic or LatinoNative American or American IndianWhite (non-Hispanic)More than one of the aboveOtherHousehold IncomeLess than $20,000$20,000 - $39,999$40,000 - $59,999$60,000 - $79,999$80,000 - $99,999$100,000 - $149,999$150,000+Which of the following populations describes you? Veteran or active duty military Caregiver of someone living with emotional or physical illness LGBTQ+ Student Trauma survivor New or expecting mother Healthcare worker Who are you caring for? My spouse or partner My parent My child Another relative Other Caring For - OtherAs a caregiver, what supports do you need? The person I'm helping is getting treatment but is getting worse (meds or therapy stopped working) The person I'm helping is getting treatment but also needs something else (side effects cause other problems, not sure what else to do) The person I'm helping is getting treatment but also needs something else (side effects cause other problems, not sure what else to do) The person I'm helping doesn't want treatment and I want to figure out how to help them I need help because the stress of caretaking is hard Other Caregiver Support - OtherWhich of the following best describes your sexual orientation? Lesbian Gay Bisexual Queer Pansexual Asexual Other Sexual Orientation - OtherAbout Your Mental HealthHave you ever been diagnosed with a mental health condition by a professional (doctor, therapist, etc.)?YesNoHave you ever received treatment/support for a mental health problem?YesNoAre you receiving treatment/support now?YesNoThink about your mental health test. What are the main things contributing to your mental health problems right now?Choose up to 3. Coronavirus Social life or relationships Past trauma Current events (news, politics, etc.) Loneliness or isolation Grief or loss of someone or something Family's financial problems Difficulties at school (academics or learning) Being Bullied Other… Mental Health Problems - OtherAbout Your HealthDo you currently have health insurance?YesNoDo you have any of the following general health conditions? Heart disease Diabetes Cancer Arthritis or other chronic pain COPD or other lung conditions Movement Disorders (involuntary tics, tardive dyskinesia) HIV/AIDS Other If 'Other' please specify (for general health conditions)Additional InformationStateI live outside the United StatesAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingI live in a U.S. TerritoryZip/Postal CodeWhat country do you live in?AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsPhoneThis field is for validation purposes and should be left unchanged.
