I-14. Anxiety (PAST 30 DAYS) No evidence or concern about History or suspicion of Anxiety with significant Clear evidence of anxiety. Any concerns are age anxiety problems or mild to fearfulness that has debilitating level of anxiety / developmentally moderate anxiety. Infant / interfered significantly in that makes it virtually appropriate or this child may appear anxious in ability to function. impossible for the child to child’s information is unknown to me. certain situation but has the Child may be irritable, over function in any area of life. ability to be soothed / reactive to stimuli, calmed. uncontrollable crying and significant separation anxiety. If the needs / functioning fall within a shaded box, explain why: child’s B. BEHAVIORAL CHARACTERISTICS (Ages Birth to 5) II-1. in His / Her Current Living Situation (PAST 30 DAYS) Child’s Functioning No evidence of problems Mild problems functioning in Moderate to severe Profound problems with functioning in current living current home. Caregiver problems functioning at functioning at home. Child situation. Any concerns are has concerns about home. behavior is is in immediate risk of being child’s Child’s age appropriate or this behavior at home. creating significant removed due to his/her information is unknown to me. difficulties for others in the behavior. home. If the needs / functioning fall within a shaded box, explain why: child’s B. BEHAVIORAL CHARACTERISTICS (Ages Birth to 5) (Continued) II-2. Social Functioning (PAST 30 DAYS) Child’s Child has positive social Child is having minor Child is having moderate Child is experiencing severe relationships. Any concerns problems in social problems in social disruption in social are age appropriate or this relationships. Toddlers may relationships. Toddlers may relationships. Toddlers are information is unknown to me. need support to interact with be aggressive and resist excessively withdrawn and peers and preschoolers may parallel play. Preschoolers unable to relate to familiar resist social situations. may argue excessively and adults. Preschoolers show be unable to play in groups no joy or sustained even with adult support. interaction with peers or adults. If the needs / functioning fall within a shaded box, explain why: child’s
I-14. Anxiety (PAST 30 DAYS) No evidence or concern about anxiety. Any concerns are age / developmentally appropriate or this information is unknown to me. History or suspicion of anxiety problems or mild to moderate anxiety. Infant / child may appear anxious in certain situation but has the ability to be soothed / calmed. Anxiety with significant fearfulness that has interfered significantly in child’s ability to function. Child may be irritable, over reactive to stimuli, uncontrollable crying and significant separation anxiety. Clear evidence of debilitating level of anxiety that makes it virtually impossible for the child to function in any area of life. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages Birth to 5) II-1. Child’s Functioning in His / Her Current Living Situation (PAST 30 DAYS) No evidence of problems functioning in current living situation. Any concerns are age appropriate or this information is unknown to me. Mild problems functioning in current home. Caregiver has concerns about child’s behavior at home. Moderate to severe problems functioning at home. Child’s behavior is creating significant difficulties for others in the home. Profound problems with functioning at home. Child is in immediate risk of being removed due to his/her behavior. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages Birth to 5) (Continued) II-2. Child’s Social Functioning (PAST 30 DAYS) Child has positive social relationships. Any concerns are age appropriate or this information is unknown to me. Child is having minor problems in social relationships. Toddlers may need support to interact with peers and preschoolers may resist social situations. Child is having moderate problems in social relationships. Toddlers may be aggressive and resist parallel play. Preschoolers may argue excessively and be unable to play in groups even with adult support. Child is experiencing severe disruption in social relationships. Toddlers are excessively withdrawn and unable to relate to familiar adults. Preschoolers show no joy or sustained interaction with peers or adults. If the child’s needs / functioning fall within a shaded box, explain why: