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Grounded Check-In for Parents

Child’s Age

Email

Over the past two weeks, how often has your child shown little interest or pleasure in doing things?

A
B
C
D

Over the past two weeks, how often has your child felt down, depressed, or hopeless?

A
B
C
D

Over the past two weeks, has your child had trouble falling asleep, staying asleep, or sleeping too much?

A
B
C
D

Does your child struggle with transitions, showing intense emotional outbursts or total shut-downs when changing tasks?

A
B
C
D

Over the past two weeks, has your child's appetite or weight changed noticeably?

A
B
C
D

Over the past two weeks, has your child often felt bad about themselves or like a failure?

A
B
C
D

Does your child struggle with age-appropriate social skills, such as sharing, cooperation, or resolving peer conflicts?

A
B
C
D

Over the past two weeks, has your child moved or spoken more slowly than usual, or been fidgety and restless?

A
B
C
D

Over the past two weeks, has your child thought about death or that they would be better off dead?

A
B
C
D

How often does your child experience intense fear or worry that interferes with daily activities?

A
B
C
D

Does your child avoid certain situations, like school or social events, due to anxiety?

A
B
C
D

Has your child had sudden episodes of panic or intense fear?

A
B
C
D

How well does your child get along with other children their age?

A
B
C
D

Does your child bully others or get bullied by peers?

A
B
C
D

How is your child's behavior at school (e.g., following rules, completing tasks)?

A
B
C
D

Has your child shown aggressive behavior, like hitting or yelling?

A
B
C
D

Does your child seem overly withdrawn or shy in social situations?

A
B
C
D

How consistent is your child's eating routine?

A
B
C
D

How would you rate your child's overall physical health?

A
B
C
D

Has your child experienced any major stressful events recently (e.g., family changes, moves)?

A
B
C
D

How often do you spend quality one-on-one time with your child?

A
B
C
D

On a scale of 1-5, how would you rate your child's emotional well-being?

Any prayer requests or additional comments about your child's mental health?