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Informal Child & Adolescent Anxiety Checklist (print to use)

The following checklist does not have a scoring key. These are, however, all important dimensions of anxiety that should be discussed with a counselor or psychologist. 

Put an “X” in the appropriate box:

Symptom

None

Just a Little

Pretty much

Very Much

 

 

 

 

 

The child says he or she is anxious or worried

 

 

 

 

The child is unusually shy or withdrawn in social situations

 

 

 

 

The child is afraid of the dark

 

 

 

 

The child has a poor sleeping pattern

 

 

 

 

The child is teased by peers or feels he or she has no friends

 

 

 

 

The child is older than 5 and wants to sleep with parents at night

 

 

 

 

The child doesn’t want to go to school

 

 

 

 

The child is fearful that someone will break into the house

 

 

 

 

The child worries several times a week that one or both of their parents will get hurt or killed in an accident

 

 

 

 

 

Everyone experiences anxiety at times.   What is important is the frequency and intensity of these feelings – and whether or not the anxiety is “reality-based” (in which case it will go away when the threat or danger goes away – this is normal anxiety) or “free-floating” (it is not tied to any particular stressor so it does not go away – this is not normal).   Any marks in the “Pretty Much” or “Very Much” columns are “red flags” that should be taken seriously.   High, chronic levels of anxiety are quite disabling and reduce the quality of life. 

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