X
Psychiatry
Northern California
CPY ADOLESCENT QUESTIONNAIRE (12+)
MR #:
Name:
IMPRINT AREA
PREFERRED NAME
AGE PHONE
All responses are kept confidential (between you and your provider) unless you choose to
release this form to someone, or report that you are considering seriously harming
yourself or someone else, or someone has seriously harmed you or another child.
Please check the box or boxes that most closely describe you. Please use the blank lines to provide additional
information.
WHOSE IDEA WAS IT FOR YOU TO BE SEEN HERE TODAY?
Mine Parent(s) Other
IF SOMEONE OTHER THAN YOU, ARE YOU OKAY WITH THIS IDEA? No Yes Not sure
MAIN PROBLEM/MAJOR REASONS FOR SEEKING HELP AND WHEN THE PROBLEM BEGAN:
Please check the items below that are significant current problems for you.
Is it hard for you to focus and pay attention?
No (skip section) Yes (complete items below)
Make careless mistakes
Problems paying attention/staying focused
Often do not finish homework or chores
Problems with organization
Lose things easily
Forgetful
Do you h
ave a hard time controlling your words or behaviors?
No (
skip section) Yes (complete items below)
Act
without thinking
Rest
less/Unable to sit still
Talk a lot
Probl
ems waiting my turn
Inter
rupt others
Are you feeling sad, depressed, or irritable?
No (skip section) Yes (complete items below)
Sad or depressed mood
Irritable or grouchy
Problems sleeping (falling or staying asleep)
Tired a lot
Loss of interest, pleasure, or motivation
Are you often worried or anxious?
No (skip section) Yes (complete items below)
Frequent headaches, stomachaches, or other pains
Anxiety or worry (e.g., about past behaviors, future events,
doing well)
Phobia or extreme fear (e.g., scared of flying, heights, going
over bridges)
Thoughts/ideas that repeat over and over in your head
Behaviors that you feel that you have to do ov
er and over (e.g.,
counting, washing)
Are you often angry at others?
No (skip section) Yes (complete items below)
Blame others for my mistakes
Angry most of the time
Easily annoyed by others
Go against adult requests or rules
Back talk or argue with adults
Enjoy “bugging” people
Lose temper
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Have you experienced or witnessed a traumatic event (i.e.,
car,
accident, death, earthquake)?
No (skip section) Yes (complete items below)
Ongoing n
egative thoughts about what happened
Ongoing n
egative feelings about what happened
Recur
rent distressing dreams about the event
Flashbacks about the event
Att
empts to avoid memories, thoughts, or feelings about what
happened
X
Psychiatry
Northern California
CPY ADOLESCENT QUESTIONNAIRE (12+)
MR #:
Name:
IMPRINT AREA
Do you do things that get you in trouble?
No (skip section) Yes (complete items below)
Bully or threaten others
Get in physical fights
Hurt animals
Stole things
Set fire
Destroyed property
Broke into a house, building, car
Stay out all night
Ran away
Skip school
Problems with the law or police
Do you feel that you have a problem with eating or body
image?
No (skip section) Yes (complete items below)
Fear of weight gain or being fat
Trying to lose weight
Unhappy with body weight or shape
Purging/Self-induced vomiting
Use of diet pills, laxatives, excessive exercise
Overeat/Binge
Feeling guilt, sadness, or disgust when I overeat
Feeling that I cannot control my eating
Please describe the following current or past thoughts or feelings.
Never or
not at all
In the
past
Sometimes Often
All the
I hurt or injure myself on purpose.
I feel it is too painful to keep living or that I would be
better off dead.
I think about suicide.
I thought about specific ways to kill myself.
I tried to kill myself.
I think about hurting or killing others.
I hear voices or see things that are not there.
I feel like people are out to get me.
Please describe any current or past abuse.
Verbal Physical
Sexual
(put downs,
(hits, threatens
(pressured or
None
controlling) to hit)
forced)
CHILD ABUSE
WITNESSED VIOLENCE AT HOME
DATING VIOLENCE
PEER VIOLENCE (bullying)
ONLINE VIOLENCE (sexting, cyber-bullying)
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X
MR #:
Psychiatry
Northern California
Name:
CPY ADOLESCENT QUESTIONNAIRE (12+)
IMPRINT AREA
Please describe your substance use.
Never Past use only Rarely Weekly Daily
ALCOHOL
TOBACCO
MARIJUANA
OTHER DRUGS:
EXERCISE PER DAY (average)
0
30 min.
1-2 hours
3 hours or more
MEDIA USE PER DAY (average hours)
(e.g., social media, video games, phone, computer, TV)
0 1-2 3-4 5 or more
CAFFEINE DRINKS PER DAY
(e.g.,
coffee, soda, energy drinks)
0 1-2 3-4 5 or more
SLEEP PER NIGHT (average hours)
less than 5
6-7
8-10
11-12
Please describe your family (parents, step-parents, siblings) by completing the table below
NAME RELATIONSHIP
TO YOU
OUR RELATIONSHIP IS…
Poor Average Good
OVERUSES
DRUGS/ALCOHOL
SPENDS TIME
WITH ME
Example: Mary
Sister
X
X
Please describe you and your relationships.
TOTAL NUMBER OF FRIENDS None
A few
Average A lot
NUMBER OF CLOSE FRIENDS
0 1 2-3 4 or more
HOW I FEEL ABOUT MY FRIENDSHIPS
Unsatisfied Neutral Satisfied
HOW I GET ALONG WITH PEERS
Poor
Average
Good
RELIGIOUS/SPIRITUAL SUPPORTS:
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Psychiatry
MR #:
Northern California
Name:
CPY ADOLESCENT QUESTIONNAIRE (12+)
IMPRINT AREA
X
Please describe you and your relationships.
No Yes
DATING SOMEONE
SEXUALLY ACTIVE
PREGNANCY (PAST OR CURRENT)
SEXUAL ORIENTATION (e.g., straight, gay, bi): ___________________________________________________________
GENDER IDENTITY AND PREFERRED PRONOUN (e.g., boy, he, they): _________________________________________
SCHOOL NAME: ___________________________________________________ GRADE: _____________________
SCHOOL PERFORMANCE Poor Average Above Average
SCHOOL PROBLEMS (check all that apply)
Problems with teachers Learning problems
Referrals Suspensions/Expulsions (# )
Other school problems:
SCHOOL SUPPORTS (e.g., counselor, group, teacher):
What are you hoping to get out of being here (e.g., improve mood, help with anger, work on relationships)?
How important is this change for you? (Please circle a number.)
Not at all
Completely
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Please describe yourself: