Mental Health Screening for Children / Adolescent by Caregiver and Guardian
Overview of this Questionnaire
Your trust and confidence are important to us. All the information gathered through this form will be treated with the utmost confidentiality. To ensure that MindWell by CML Well-being and Psychological Services remains a trustworthy partner in this journey towards supporting the mental health and well-being of your child/student, we make every effort to comply fully with the existing laws and regulations that govern us.
Kindly read through the terms and conditions for your acceptance.
- Supplying, checking, and verifying the accuracy and correctness of the information provided on this system in connection with your registration, and consent to the collection and use of your personal information.
- You understand that in the event that you have any question, you may chat with us at https://m.me/mindwellph
- You are allowed to refuse completing this survey and we would appreciate you notify us with 24 hours after receiving this so we can address this matter accordingly.
INFORMED CONSENT: This survey questionnaire is a standardized psychological test which we have made available electronically and includes your informed consent prior completion, highlighting the following:
- You certify that you have freely participated and in the completion of this form and as applicable, for coaching/consultation, counseling/guidance/therapy session at the date and time scheduled, which you personally or a person you authorized arranged or was made known, and which you concurred. Also, you agree that your mental health professional may determine that due to certain circumstances, telepsychology could at any point of your session/s be no longer appropriate and you agree to resume sessions in-person.
- You have likewise been assured that the results of the interview, presenting issues, all other information including but not limited to test results, if any, shall be kept confidential and shall not be disclosed to anyone without your consent and approval in writing.
- You agree to the use of technology for the session/s. This is a HIPAA compliant platform that uses video and audio technology through a webcam on your device and our device to connect us securely. You understand that you are solely responsible for maintaining the strict confidentiality of your user ID and password and not allow another person to use your user ID to access the Services. You also understand that you are responsible for using this technology in a secure and private location so that others cannot hear your conversation. Furthermore, you understand that you are not allowed to do any recording, screenshots, etc. of any kind, of this form or any session, and are grounds for termination of your participation and if any, of the client-coach/counselor/therapist relationship.
- Through this form, the information gathered, assessment results, the purpose, duration, and specific instructions were clearly stated to you and you understand that MindWell, as your service provider, will determine on an on-going basis whether the condition being assessed and/or treated is appropriate for an online session.
- You understand and agree that upon completion of this form, you will participate in the planning of your child/student's care, treatment, or services and that you may withdraw consent for such care, treatment, or services at any time.
Kindly click "I Accept the Terms and Conditions" button to indicate your consent and confirming you acknowledged the terms and conditions of your session/s. By clicking the OK button of this Informed Consent, you acknowledge that you have both read and understood all the terms and information contained herein, ample opportunity has been offered to you to ask questions and seek clarification of anything unclear to you.
Please be informed that when you choose not to click the "I Accept the Terms and Conditions" button, you won't be able to proceed with the survey questionnaire and are encouraged to contact our well-being and psychological services director at [email protected] for further clarification or assistance you may need.
Instructions for Completion
Answer all items in the checklist, using the appropriate column to indicate the frequency and details of each symptom, which you may need to describe to your clinician.
For each item, check the one category that best describes your child during the PAST 6 (SIX) MONTHS.
1. The child never or very rarely exhibits this behavior.
2. The child exhibits this behavior approximately once per week, and few others notice or complain about this behavior.
3. The child exhibits this behavior at least three times per week, and others notice or comment on this behavior.
4. The child exhibits this behavior almost daily, and multiple others complain about this behavior.
5. The child used to have significant problems with this behavior, but not during the past 6 months.