Ohio Youth Problem, Functioning, and Satisfaction Scales - Y - MONARCH THERAPEUTIC SERVICES, LLC TRANSFORMS DISTRESS INTO HOPE

OHIO YOUTH PROBLEM, FUNCTIONING AND SATISFACTION SCALES - Y

Ohio Youth Problem, Functioning and Satisfaction Scales - Y TO BE COMPLETED BY YOUTH 11-17 YO

* Indicates required field

Full Name of Client *

First

Last

Client's Date of Birth (MM/DD/YYYY) *

Please rate the degree to which you have experienced the following problems in the past 30 days.

Arguing with others *

Can't seem to sit still, having too much energy *

Getting into fights *

Hurting self (cutting or scratching self, taking pills) *

Yelling, swearing, or screaming at others *

Talking or thinking about death *

Fits of anger *

Feeling worthless or useless *

Refusing to do things teachers or parents ask *

Feeling lonely and having no friends *

Causing trouble for no reason *

Feeling anxious or fearful *

Using drugs or alcohol *

Worrying that something bad is going to happen *

Breaking rules or breaking the law (out past curfew, stealing) *

Feeling sad or depressed *

Skipping school or classes *

Nightmares *

Lying *

Eating Problems *

Section 2: Below are some ways your problems might get in the way of your ability to do everyday activities. Read each item select the answer that best describes your current situation.

Getting along with friends *

Completing household chores (cleaning rooms, other chores) *

Getting along with family *

Attending school and getting passing grades in school *

Dating or developing relationships with boyfriends or girlfriends *

Learning skills that will be useful for future jobs *

Getting along with adults outside the family (teachers, principal) *

Feeling good about self *

Keeping neat and clean, looking good *

Thinking clearly and making good decisions *

Caring for health needs and keeping good health habits (taking medicines or brushing teeth) *

Concentrating, paying attention, and completing tasks *

Controlling emotions and staying out of trouble *

Earning money and learning how to use money wisely *

Being motivated and finishing projects *

Doing things without supervision or restrictions *

Participating in hobbies (baseball cards, coins, stamps, art) *

Accepting responsibility for actions *

Participating in recreational activities (sports, swimming, bike riding) *

Ability to express feelings *

Section 3a - Please select your response to each question

Section 3b - Please select your response to each question

Overall, how satisfied are you with your life right now? *

How satisfied are you with the mental health services you have received so far? *

How energetic and healthy do you feel right now? *

How much are you included in deciding your treatment? *

How much stress or pressure is in your life right now? *

Mental health workers involved in my case listen to me and know what I want. *

How optimistic are you about your future right now? *

I have a lot of say about what happens in my treatment. *

Name of Monarch Staff/Clinician *

Date of Assessment (MM/DD/YYYY) *

Submit