Adolescent Wellbeing – Scale A Form

Parents please answer these questions about your young person

Parents Name*

Name of young person*

Date of birth of young person* (DD/MM/YYYY)

Does your young person look forward to things as much as they used to?*
OftenSometimesNever

Do they sleep very well?*
OftenSometimesNever

Do they feel like crying?*
OftenSometimesNever

Do they feel like going out?*
OftenSometimesNever

Do they feel like leaving home?*
OftenSometimesNever

Do they get stomach aches and cramps?*
OftenSometimesNever

Do they have lots of energy?*
OftenSometimesNever

Do they enjoy their food?*
OftenSometimesNever

Do they stick up for themselves?*
OftenSometimesNever

Do they think life isn't worth living?*
OftenSometimesNever

Do they think they are good at things that they do?*
OftenSometimesNever

Do they enjoy things as much as they used to?*
OftenSometimesNever

Do they like talking to friends and family?*
OftenSometimesNever

Do they have horrible dreams?*
OftenSometimesNever

Do they feel very lonely?*
OftenSometimesNever

Do they have an adult they can confide in?*
OftenSometimesNever

Are they easily cheer up?*
OftenSometimesNever

Do they ever feel very bored?*
OftenSometimesNever

Do they feel like they can hardly bear it?*
OftenSometimesNever

Do you think self-harming helps them to deal with their problems?*
OftenSometimesNever

Group leaders email address*
This is where your form will be sent, please check spelling

Your email address
This is optional, please fill out if you wish to recieve a copy for your records.