YOUTH OQ-30 Contact Information*Resolutions Professional Counseling, PLLC Tara Fleis, LPC tfleis@resolutionsprofessionalcounseling.com 906-282-3130 9885 State Hwy. M95, Republic, MI 49879 308 Cleveland Ave., Ste 302, Ishpeming, MI 49849Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth*Gender*Phone*May I leave a message for you at this number?*YesNoEmail Preferred forms of communication*TextPhoneEmailEmergency contact (name, number, relationship):*YOUTH OQ-30*PURPOSE: This form is designed to describe a wide range of troublesome situations, behaviors, and moods that are common to adolescents. You may discover that some of the items do not apply to your current situation. If so, please do not leave these items blank but mark the “Never or almost never” category. When you begin to complete the Y-OQ® 30.2 you will see that you can easily make yourself look as healthy or unhealthy as you wish. Please do not do that. If you are as accurate as possible it is more likely that you will be able to receive the help that you are seeking. DIRECTIONS: Read each statement carefully. Decide how true this statement is during the past 7 days. Completely fill the circle that most accurately describes the past week. Fill in only one answer for each statement and erase unwanted marks clearly. DIRECTIONS FOR PARENTS OR GUARDIANS: If your child is under 12, the parent or other responsible adult is asked to complete this questionnaire. It is important that you answer as accurately as possible based on your personal observation and knowledge.I have headaches or feel dizzy*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI don’t participate in activities that used to be fun*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI argue or speak rudely to others*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI have a hard time finishing my assignments or I do them carelessly. My emotions are strong and change quickly.*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI have physical fights (hitting, kicking, biting, or scratching) with my family or others my age. I worry and can’t get thoughts out of my mind.*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI steal or lie*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI have a hard time sitting still (or I have too much energy)*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI use alcohol or drugs*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI am tense and easily startled (jumpy)*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI am sad or unhappy*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI have a hard time trusting friends, family members, or other adults. I think that others are trying to hurt me even when they are not*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI have threatened to, or have run away from home*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI physically fight with adults*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysMy stomach hurts or I feel sick more than others my same age.*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI don’t have friends or I don’t keep friends very long*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI think about suicide or feel I would be better off dead*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI have nightmares, trouble getting to sleep, oversleeping, or waking up too early. I complain about or question rules, expectations, or responsibilities. I break rules, laws, or don’t meet others’ expectations on purpose.*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI feel irritated*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI get angry enough to threaten others*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI destroy property on purpose*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI have a hard time concentrating, thinking clearly, or sticking to tasks. I withdraw from my family and friends*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI act without thinking and don’t worry about what will happen*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI feel like I don’t have any friends or that no one likes me*Never or Almost NeverRarelySometimesFrequentlyAlmost Always or AlwaysI have read the above Agreement and Policies and General Information carefully. I understand them and agree to comply with them. I consent to treatment.* I Agree Client Signature*Type your full nameDate* Date Format: MM slash DD slash YYYY