Please briefly describe the young person’s current situation and how they might benefit from the Connected Minds service. *
Please tell us a little about any issues the young person has around attending school (if any). *
Please tell us a little about any issues the young person has around attending school (if any). *
Does this young person have any physical health issues, disabilities, sensory or mobility impairments? *
Please provide details
Please provide any additional information about the young person that may be useful below.
I try to be nice to other people. I care about their feelings Not true Somewhat true Certainly true
I am restless, I cannot stay still for long Not true Somewhat true Certainly true
I get a lot of headaches, stomach-aches, or sickness Not true Somewhat true Certainly true
I usually share with others (food, games, pens etc.) Not true Somewhat true Certainly true
I get very angry and often lose my temper Not true Somewhat true Certainly true
I am usually on my own. I generally play alone or keep to myself Not true Somewhat true Certainly true
I usually do as I am told Not true Somewhat true Certainly true
I worry a lot Not true Somewhat true Certainly true
I am helpful if someone is hurt, upset or feeling ill Not true Somewhat true Certainly true
I am constantly fidgeting or squirming Not true Somewhat true Certainly true
I have one good friend or more Not true Somewhat true Certainly true
I fight a lot. I can make other people do what I want Not true Somewhat true Certainly true
I am often unhappy, downhearted, or tearful Not true Somewhat true Certainly true
Other people my age generally like me Not true Somewhat true Certainly true
I am easily distracted; I find it difficult to concentrate Not true Somewhat true Certainly true
I am nervous in new situations. I easily lose confidence Not true Somewhat true Certainly true
I am kind to younger children Not true Somewhat true Certainly true
I am often accused of lying or cheating Not true Somewhat true Certainly true
Other children or young people pick on me or bully me Not true Somewhat true Certainly true
I often volunteer to help others (parents, teachers, children) Not true Somewhat true Certainly true
I think before I do things Not true Somewhat true Certainly true
I take things that are not mine from home, school or elsewhere Not true Somewhat true Certainly true
I get on better with adults than with people my own age Not true Somewhat true Certainly true
I have many fears, I am easily scared Not true Somewhat true Certainly true
I finish the work I'm doing. My attention is good Not true Somewhat true Certainly true
Signed *