YOUTH OQ-30 – Resolutions Professional Counseling

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 49849
Name*
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?*
- Yes
- No
Email
Preferred forms of communication*
- Text
- Phone
- Email
Emergency 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 Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I don’t participate in activities that used to be fun*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I argue or speak rudely to others*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I have a hard time finishing my assignments or I do them carelessly. My emotions are strong and change quickly.*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I 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 Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I steal or lie*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I have a hard time sitting still (or I have too much energy)*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I use alcohol or drugs*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I am tense and easily startled (jumpy)*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I am sad or unhappy*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I 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 Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I have threatened to, or have run away from home*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I physically fight with adults*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
My stomach hurts or I feel sick more than others my same age.*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I don’t have friends or I don’t keep friends very long*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I think about suicide or feel I would be better off dead*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I 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 Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I feel irritated*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I get angry enough to threaten others*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I destroy property on purpose*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I have a hard time concentrating, thinking clearly, or sticking to tasks. I withdraw from my family and friends*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I act without thinking and don’t worry about what will happen*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I feel like I don’t have any friends or that no one likes me*
- Never or Almost Never
- Rarely
- Sometimes
- Frequently
- Almost Always or Always
I 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 name
Date*
Date Format: MM slash DD slash YYYY