B. Questions About the Person Being Evaluated
*Required response
*Required response
*Highest degree:
None
High School
Associates
College
Masters
Doctorate
*Race/ethnicity:
White
Black
Hispanic
Asian
American Indian
Other
*Gender:
Male
Female
Other
*Sexual orientation:
Straight
Gay or lesbian
Bisexual
Other
Unsure
*With whom does he or she live?
with my parents
in a foster home
in a group home or facility
with relatives
with roommates
with my partner or spouse
on my own
in a shelter
in a dormitory
in an assisted living facility or nursing home
in jail, prison, or a juvenile detention facility
homeless
other
C. Test Items
Click the open boxes below to select items that you feel are applicable. There are no right or wrong answers. If an item does not apply to the individual's life, just skip it.
*1. Within the past year, he or she has thought about running away from home, talked about running away, or run away.
*2. Within the past year, he or she has been fired from one or more jobs.
*3. Within the past six months, he or she has been depressed for a period of at least two weeks with no apparent cause.
*4. He or she spends most or all waking hours with images, icons, idols, or products of teen culture.
*5. He or she sometimes behaves like a mature individual and sometimes like a young child, and the shift between these two states can occur suddenly and with little or no apparent cause.
*6. He or she sometimes goes to extreme lengths to express his or her individuality by imitating eccentric teen icons (for example, by wearing baggy pants, dying his or her hair a neon color, shaving off his or her eyebrows, or getting multiple tattoos or piercings).
*7. He or she has little respect for rules or laws and may have broken the law within the past six months (for example, by violating a curfew or committing vandalism, arson, or theft).
*8. He or she is in contact with peers during most waking hours through face-to-face contact or electronic communication.
*9. His or her mood changes frequently (more than once a day, or every few days), even when events do not seem to call for a change in mood.
*10. He or she sometimes engages in risky behavior often seen as inappropriate for young people (although perhaps common among adults), such as sexual behavior, smoking, gambling, or drinking.
*11. He or she sometimes feels like hurting him- or herself (for example, by cutting or burning) and has done so or tried to do so within the past six months.
*12. Within the past year, he or she has been violent, planned violence, or possessed or used weapons.
*13. He or she has a poor self-image or low self-esteem, is very self-conscious, or is overly concerned about his or her image, weight, or body type.
*14. Within the past year, he or she has had thoughts of committing suicide, has spoken of committing suicide, has planned a suicide, or has attempted suicide.
*15. At least once a week, he or she is in conflict with his or her parents, teachers, or other authority figures.
*16. Over the past six months, and for a period lasting at least two weeks, he or she has felt lonely, has felt awkward or anxious around other people, or has withdrawn from other people.
*17. He or she gets into trouble at school at least once a month, or has been suspended or expelled from school within the past year.
*18. He or she feels that he or she has little or no control over his or her life.
*19. He or she is very dependent on and involved with peers (possibly but not necessarily through gang activity).
*20. He or she uses psychoactive substances (recreational drugs, alcohol, or non-prescribed prescription drugs) at least once a month, and sometimes that has negative consequences.
To get your test results, click the SUBMIT button.
Click the open boxes below to select items that you feel are applicable. There are no right or wrong answers. If an item does not apply to the individual's life, just skip it.
*1. Within the past year, he or she has thought about running away from home, talked about running away, or run away.
*2. Within the past year, he or she has been fired from one or more jobs.
*3. Within the past six months, he or she has been depressed for a period of at least two weeks with no apparent cause.
*4. He or she spends most or all waking hours with images, icons, idols, or products of teen culture.
*5. He or she sometimes behaves like a mature individual and sometimes like a young child, and the shift between these two states can occur suddenly and with little or no apparent cause.
*6. He or she sometimes goes to extreme lengths to express his or her individuality by imitating eccentric teen icons (for example, by wearing baggy pants, dying his or her hair a neon color, shaving off his or her eyebrows, or getting multiple tattoos or piercings).
*7. He or she has little respect for rules or laws and may have broken the law within the past six months (for example, by violating a curfew or committing vandalism, arson, or theft).
*8. He or she is in contact with peers during most waking hours through face-to-face contact or electronic communication.
*9. His or her mood changes frequently (more than once a day, or every few days), even when events do not seem to call for a change in mood.
*10. He or she sometimes engages in risky behavior often seen as inappropriate for young people (although perhaps common among adults), such as sexual behavior, smoking, gambling, or drinking.
*11. He or she sometimes feels like hurting him- or herself (for example, by cutting or burning) and has done so or tried to do so within the past six months.
*12. Within the past year, he or she has been violent, planned violence, or possessed or used weapons.
*13. He or she has a poor self-image or low self-esteem, is very self-conscious, or is overly concerned about his or her image, weight, or body type.
*14. Within the past year, he or she has had thoughts of committing suicide, has spoken of committing suicide, has planned a suicide, or has attempted suicide.
*15. At least once a week, he or she is in conflict with his or her parents, teachers, or other authority figures.
*16. Over the past six months, and for a period lasting at least two weeks, he or she has felt lonely, has felt awkward or anxious around other people, or has withdrawn from other people.
*17. He or she gets into trouble at school at least once a month, or has been suspended or expelled from school within the past year.
*18. He or she feels that he or she has little or no control over his or her life.
*19. He or she is very dependent on and involved with peers (possibly but not necessarily through gang activity).
*20. He or she uses psychoactive substances (recreational drugs, alcohol, or non-prescribed prescription drugs) at least once a month, and sometimes that has negative consequences.
To get your test results, click the SUBMIT button.