RCADS Parent FormDr Emily Carter Child/young person's name * First Name Last Name Date of birth of child/young person * MM DD YYYY Relationship to child/young person * Date completed MM DD YYYY * Please put a circle around the word that shows how often each of these things happens to your child. There are no right or wrong answers. 1. My child worries about things Never Sometimes Often Always 2. My child feels sad or empty Never Sometimes Often Always 3. When my child has a problem, he/she gets a funny feeling in his/her stomach Never Sometimes Often Always 4. My child worries when he/she thinks he/she has done poorly at something Never Sometimes Often Always 5. My child feels afraid of being alone at home Never Sometimes Often Always 6. Nothing is much fun for my child anymore Never Sometimes Often Always 7. My child feels scared when taking a test Never Sometimes Often Always 8. My child worries when he/she thinks someone is angry with him/her Never Sometimes Often Always 9. My child worries about being away from me Never Sometimes Often Always 10. My child is bothered by bad or silly thoughts or pictures in his/her mind Never Sometimes Often Always 11. My child has trouble sleeping Never Sometimes Often Always 12. My child worries about doing badly at school work Never Sometimes Often Always 13. My child worries that something awful will happen to someone in the family Never Sometimes Often Always 14. My child suddenly feels as if he/she can’t breathe when there is no reason for this Never Sometimes Often Always 15. My child has problems with his/her appetite Never Sometimes Often Always 16. My child has to keep checking that he/she has done things right (like the switch is off, or the door is locked) Never Sometimes Often Always 17. My child feels scared to sleep on his/her own Never Sometimes Often Always 18. My child has trouble going to school in the mornings because of feeling nervous or afraid Never Sometimes Often Always 19. My child has no energy for things Never Sometimes Often Always 20. My child worries about looking foolish Never Sometimes Often Always 21. My child is tired a lot Never Sometimes Often Always 22. My child worries that bad things will happen to him/her Never Sometimes Often Always 23. My child can’t seem to get bad or silly thoughts out of his/her head Never Sometimes Often Always 24. When my child has a problem, his/her heart beats really fast Never Sometimes Often Always 25. My child cannot think clearly Never Sometimes Often Always 26. My child suddenly starts to tremble or shake when there is no reason for this Never Sometimes Often Always 27. My child worries that something bad will happen to him/her Never Sometimes Often Always 28. When my child has a problem, he/she feels shaky Never Sometimes Often Always 29. My child feels worthless Never Sometimes Often Always 30. My child worries about making mistakes Never Sometimes Often Always 31. My child has to think of special thoughts (like numbers or words) to stop bad things from happening Never Sometimes Often Always 32. My child worries what other people think of him/her Never Sometimes Often Always 33. My child is afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds) Never Sometimes Often Always 34. All of a sudden my child will feel really scared for no reason at all Never Sometimes Often Always 35. My child worries about what is going to happen Never Sometimes Often Always 36. My child suddenly becomes dizzy or faint when there is no reason for this Never Sometimes Often Always 37. My child thinks about death Never Sometimes Often Always 38. My child feels afraid if he/she have to talk in front of the class Never Sometimes Often Always 39. My child’s heart suddenly starts to beat too quickly for no reason Never Sometimes Often Always 40. My child feels like he/she doesn’t want to move Never Sometimes Often Always 41. My child worries that he/she will suddenly get a scared feeling when there is nothing to be afraid of Never Sometimes Often Always 42. My child has to do some things over and over again (like washing hands, cleaning, or putting things in a certain order) Never Sometimes Often Always 43. My child feels afraid that he/she will make a fool of him/herself in front of people Never Sometimes Often Always 44. My child has to do some things in just the right way to stop bad things from happening Never Sometimes Often Always 45. My child worries when in bed at night Never Sometimes Often Always 46. My child would feel scared if he/she had to stay away from home overnight Never Sometimes Often Always 47. My child feels restless Never Sometimes Often Always Thank you. Your responses have been submitted to your therapist.
