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Referral Screening – 1.2

Choose how much of a problem the behaviour has been in the LAST 7 DAYS on this scale:

Not at all = never happens

Mild = present occasionally and/or does not cause too much of a problem

Moderate = happens less than half the time and/or causes some problems

Severe = happens at least half of time and/or substantially interferes

Very Severe = almost always happens and/or causes a serious problem

Full name (of parent completing questionnaire):

Full name (of child)

Has trouble calming themselves down

Has extreme or intense emotional reactions

Emotions go from 0 to 100 instantly

Reactions are usually more severe than the situation calls for

Hard to calm them down when mad or upset

Has explosive outbursts

Cries or stays angry for 5 minutes or longer

EDI Dysphoria

Does not seem to enjoy anything

Very little makes them happy

Appears uneasy through the day

Seems sad or unhappy

Not responsive to praise or good things happening

Refuses to leave the house or go to school or activities unless forced