Has your daughter had recurring problems due to:

1. Any traumatic events/changes such as abuse, divorce, or death, in her life?
           Yes             No
    
2. Inability to manage anger?
           Yes             No
    

Within the last six months, has your daughter:

1. Disregarded family rules and parental guidance?
           Yes             No
    
2. Had any changes in behavior and / or mood?
           Yes             No
    
3. Exhibited depressive symptoms, such as weight loss/gain or excessive sleep?
           Yes             No
    
4. Had problems getting along with others?
           Yes             No
    
5. Do you suspect that your daughter has used drugs or alcohol?
           Yes             No
    
6. Had problems in school such as poor grades or challenging authority?
           Yes             No
    
7. Has your daughter been able to manipulate people and situations in order to escape consequences?
           Yes             No
    
8. Been destructive to property?
           Yes             No
    
9. Intentionally frightened others?
           Yes             No
    
10. Made threatening statements in writing?
            Yes             No
     
11. Implied that they may have a plan for violent or suicidal behavior?
            Yes             No
     
12. Implied that they have identified a target for violence?
            Yes             No