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Children's Depression Checklist

The following checklist will help you assess and document your child's feelings and behavior.

This information will provide your physician or therapist with a fairly good picture of your child's emotional state. Instructions: Be as objective and thorough as possible. Use additional paper if you need more space to share your observations or give examples.

 

Signs of Possible Depression
(Check all that apply)

Description
(How long, how often, give examples)


FEELINGS. DOES YOUR CHILD EXPRESS THE FOLLOWING

 

• Sadness

 

• Emptiness

 

• Hopelessness

 

• Guilt

 

• Worthlessness

 

• Not enjoying everyday pleasures

 

 

 

THINKING. IS YOUR CHILD HAVING DIFFICULTY:

 

• Concentrating

 

• Making decisions

 

• Completing school work

 

• Maintaining grades

 

 

 

PHYSICAL PROBLEMS. DOES YOUR CHILD COMPLAIN OF:

 

• Headaches

 

• Stomachaches

 

• Joint or backaches

 

• Lack of energy

 

• Sleeping problems

 

• Weight or appetite changes (gain or loss)

 

 

 

BEHAVIORAL PROBLEMS. IS YOUR CHILD:

 

• Restless

 

• Irritable

 

• Not wanting to go to school

 

• Wanting to be alone most of the time

 

• Having difficulty getting along with others

 

• Cutting classes or skipping school

 

• Dropping out of sports, hobbies or activities

 

• Drinking or using drugs

 

 

 

SUICIDE RISK. DOES YOUR CHILD TALK OR THINK ABOUT:

 

• Suicide

 

• Death

 

• Other morbid subjects

 

2000 N. Beauregard Street,
6th Floor Alexandria, VA 22311

Phone (703) 684.7722

Toll Free (800) 969.6642

Fax (703) 684.5968

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