form10 FR0348 UBH Wellness Youth ALERT® Wellness Assessment - Youth ■ Completing this brief questionnaire will help us provide services that meet your child's needs. Answer each question as best you can and then review your responses with your child's clinician.Childs Name First Last Date of Birth MM slash DD slash YYYY Subscriber ID Authorization NumberClinician Name First Last Todays Date MM slash DD slash YYYY Clinician ID/Tax ID Clinician PhoneState State Visit #1 or 23 to 5otherRelationship to Child Mother Father Stepparent Other Relative Child/self other For the next questions, please think about your experience in the past weekDestroyed property Never Sometimes Often Was unhappy or sad Never Sometimes Often Behavior caused school problems Never Sometimes Often Had temper outbursts Never Sometimes Often Worrying prevented him/her from doing things Never Sometimes Often Felt worthless or inferior Never Sometimes Often Had trouble sleeping Never Sometimes Often Changed moods quickly Never Sometimes Often Used alcohol Never Sometimes Often Was restless, trouble staying seated Never Sometimes Often Engaged in repetitious behavior Never Sometimes Often Used drugs Never Sometimes Often Worried about most everything Never Sometimes Often Needed constant attention Never Sometimes Often Section BreakHow much have your child's problems caused:Interruption of personal time? Not at All Alittle Somewhat A lot Disruption of family routines? Not at All Alittle Somewhat A lot Any family member to suffer mental or physical problems? Not at All Alittle Somewhat A lot Less attention paid to any family member? Not at All Alittle Somewhat A lot Disruption or upset of relationships within the family? Not at All Alittle Somewhat A lot Disruption or upset of your family's social activities? Not at All Alittle Somewhat A lot How many days in the past week was your child's usual routine interrupted by their problems?Section BreakIs this your first time completing this questionnaire for this child. Yes No In general, would you say your child's health is: Excellent Very Good Good Fair Poor In the past 6 months, how many times did your child visit a medical doctor? None 1 2-3 4-5 6 + In past month, how many days were you unable to work because of your child's problems?(answer only if employed)In the past month, how many days were you able to work but had to cut back on how much you got done because of your child's problems? (answer only if employed)■ Clinician: Please fax to (800) 985-6894 Rev. 2007
