Child Behavioral Health Screening Template
Basic Information
Child's Name
Date of Birth
Parent/Guardian Name
Date of Screening
Behavioral Concerns
What are the main behavioral concerns?
How long have these behaviors been present?
How frequently do these behaviors occur?
Developmental History
Any concerns regarding developmental milestones?
Family and Social History
Any family history of behavioral or mental health conditions?
How does the child interact with peers?
Education
How is the child's school performance?
Any concerns reported by teachers?
Additional Notes
Other relevant information