Referral Screening – 1.1

In the last SEVEN (7) DAYS and compared to others of the same age, how well does each of the following statements describe the behaviour/feelings of your child? Please try to answer all questions.

Full name (of parent completing the questionnaire):

Full name (of child):

Is easily annoyed by others.

Not True

Somewhat True

Certainly True

Often loses their temper.

Not True

Somewhat True

Certainly True

Stays angry for a long time.

Not True

Somewhat True

Certainly True

Is angry most of the time.

Not True

Somewhat True

Certainly True

Gets angry frequently.

Not True

Somewhat True

Certainly True

Loses temper easily.

Not True

Somewhat True

Certainly True

Overall, irritability causes them problems.

Not True

Somewhat True

Certainly True