Teen Self-Assessment

First name

Last name

Date of Birth

For each statement listed below, check the box that tells how the statement applies to you.

I find it difficult to sit still.

Not true for me Sometimes true for me Always true for me

I am easily distracted.

Not true for me Sometimes true for me Always true for me

I have trouble waiting my turn.

Not true for me Sometimes true for me Always true for me

It’s hard for me to follow instructions.

Not true for me Sometimes true for me Always true for me

It’s hard for me to pay attention.

Not true for me Sometimes true for me Always true for me

It’s hard for me to relax.

Not true for me Sometimes true for me Always true for me

I talk a lot.

Not true for me Sometimes true for me Always true for me

I interrupt others, without realizing it.

Not true for me Sometimes true for me Always true for me

I don’t listen to my teacher or parents.

Not true for me Sometimes true for me Always true for me

I lose things.

Not true for me Sometimes true for me Always true for me

I start things, but don’t finish them.

Not true for me Sometimes true for me Always true for me

Pencils fly out of my hands.

Not true for me Sometimes true for me Always true for me

I lose my temper.

Not true for me Sometimes true for me Always true for me

I argue with adults.

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I like to annoy people.

Not true for me Sometimes true for me Always true for me

Most mistakes are someone else’s fault.

Not true for me Sometimes true for me Always true for me

I’m easily annoyed.

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I get angry.

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I like to “get even”.

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I use bad language.

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If I get mad, I stay that way a long time.

Not true for me Sometimes true for me Always true for me

I take things that don’t belong to me, if no one else is around.

Not true for me Sometimes true for me Always true for me

I have run away from home.

Not true for me Sometimes true for me Always true for me

I tell lies.

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I like to set fires.

Not true for me Sometimes true for me Always true for me

I skip school without my parent’s permission.

Not true for me Sometimes true for me Always true for me

I have broken into someone else’s house.

Not true for me Sometimes true for me Always true for me

I have destroyed someone’s property.

Not true for me Sometimes true for me Always true for me

I like to tease animals.

Not true for me Sometimes true for me Always true for me

I have forced someone to have sex with me/ someone forced me to have sex.

Not true for me Sometimes true for me Always true for me

I have used a weapon in a fight.

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I start fights.

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I have stolen something from someone using force.

Not true for me Sometimes true for me Always true for me

I’m cruel to other people.

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I like to hurt other people.

Not true for me Sometimes true for me Always true for me

It doesn’t bother me if I hurt someone else.

Not true for me Sometimes true for me Always true for me

I worry about something bad happening to the people I love.

Not true for me Sometimes true for me Always true for me

I worry that something bad might separate me from my family.

Not true for me Sometimes true for me Always true for me

I refuse to go to school.

Not true for me Sometimes true for me Always true for me

I refuse to sleep alone.

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I try to never be alone.

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I have nightmares about being separated from my family.

Not true for me Sometimes true for me Always true for me

I get a lot of stomach aches and headaches.

Not true for me Sometimes true for me Always true for me

I’m afraid if my parents go somewhere without me.

Not true for me Sometimes true for me Always true for me

I’m afraid when I have to go somewhere without my parents.

Not true for me Sometimes true for me Always true for me

I worry about things that might happen in the future.

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I worry that I acted badly in the past.

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I feel that I don’t do anything right.

Not true for me Sometimes true for me Always true for me

I feel self-conscious.

Not true for me Sometimes true for me Always true for me

I need people to tell me when I am doing something good.

Not true for me Sometimes true for me Always true for me

It’s hard for me to relax.

Not true for me Sometimes true for me Always true for me

I try to make everything perfect.

Not true for me Sometimes true for me Always true for me

I’m shy.

Not true for me Sometimes true for me Always true for me

I get embarrassed easily.

Not true for me Sometimes true for me Always true for me

I feel bad if someone criticizes or corrects me.

Not true for me Sometimes true for me Always true for me

I bite my fingernails.

Not true for me Sometimes true for me Always true for me

I feel sad most of the day.

Not true for me Sometimes true for me Always true for me

Things that used to be fun are not much fun anymore.

Not true for me Sometimes true for me Always true for me

I don’t feel like eating at all.

Not true for me Sometimes true for me Always true for me

I feel like I want to eat all the time.

Not true for me Sometimes true for me Always true for me

I have gained a lot of weight recently.

Not true for me Sometimes true for me Always true for me

I have lost weight without dieting.

Not true for me Sometimes true for me Always true for me

I have trouble sleeping.

Not true for me Sometimes true for me Always true for me

I would sleep all day if my parents would let me.

Not true for me Sometimes true for me Always true for me

I need to be constantly moving.

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I feel like I’m moving in slow motion.

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I have no energy, even when I’m rested.

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I feel worthless.

Not true for me Sometimes true for me Always true for me

I feel guilty, even when I haven’t done anything wrong.

Not true for me Sometimes true for me Always true for me

It’s hard for me to concentrate.

Not true for me Sometimes true for me Always true for me

I have thought about killing myself.

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I have tried to kill myself.

Not true for me Sometimes true for me Always true for me

My moods seem to change all the time.

Not true for me Sometimes true for me Always true for me

I would rather be alone than with other people.

Not true for me Sometimes true for me Always true for me

I cry easily.

Not true for me Sometimes true for me Always true for me

I think most other people are better than me.

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It’s hard for me to make decisions.

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Life does not seem worth living.

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I have felt sad most of the day, for at least a year.

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I have not been happy for more than two months in the last year.

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I get stuck on the same thoughts over and over again.

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I do things (like washing my hands) many, many times in a row.

Not true for me Sometimes true for me Always true for me

I need to keep everything in order, and get upset if they are not.

Not true for me Sometimes true for me Always true for me

I repeat things a lot (like opening and closing doors).

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I avoid places that might be dirty (like public restrooms).

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I start one conversation and end up on a totally different subject.

Not true for me Sometimes true for me Always true for me

I sometimes see things that other people say are not there.

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I sometimes hear things that other people do not hear.

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I sometimes can’t figure out where I am or how I got there.

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Sometimes I mumble or use words that people don’t understand.

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Sometimes I get very happy or very sad, for no apparent reason.

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Sometimes my temper blows, for no apparent reason.

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I need to be with my parents or other adult at all times.

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I’m afraid of things that other people are not afraid of.

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I avoid things that other people think are okay.

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I feel panicky.

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I don’t really care about anything.

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I sometimes laugh or cry at weird times.

Not true for me Sometimes true for me Always true for me

I don’t care to hang out with kids my own age.

Not true for me Sometimes true for me Always true for me

I don’t like changes in my routine.

Not true for me Sometimes true for me Always true for me

I physically hurt myself.

Not true for me Sometimes true for me Always true for me

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