Juvenile Symptom Questionnaire

Please use the paper copy provided to you by your client to complete the form below. Once this form is completed, scores will be calculated, and you will receive an email with follow up strategies and interventions to be used for addressing areas of concern. This information will be emailed to you by MINDSOURCE - Brain Injury Network.

Unique Case ID or Client Identifier

NOTE: please avoid use of any Protected Health Information (PHI)
Date
MM slash DD slash YYYY
Name of Person Completing this Form on Behalf of the Client
First Last
Email of Person Completing this Form on Behalf of the Client*
State*
Type of Agency*
- Criminal/Juvenile Justice/Corrections
- Mental Health
- Child Welfare
- Housing/Homelessness
- Education/School
- Medical Clinic
Name of Site/Agency
Please fill in the following based on the form you received from the client.

Section 1 - Memory concerns*

	N/A I don't have this problem	I have this problem but it never bothers me	I am slightly bothered by this problem	I am very bothered by this problem	I am extremely bothered by this problem
I lose or misplace important items (homework, backpack, phone)
I forget what people tell me
I forget what I've read
I lose track of time
I forget what I did yesterday
I forget things I've just learned
I forget meetings and appointments
I forget to turn off the lights or my electronics (computer, game devices, etc.)

Section 2 - Delayed processing*

	N/A I don't have this problem	I have this problem but it never bothers me	I am slightly bothered by this problem	I am very bothered by this problem	I am extremely bothered by this problem
I have a hard time following conversations
I can remember only one or two steps of instructions or directions
I take too long figuring out what someone is trying to tell me

Section 3 - Attention problems*

	N/A I don't have this problem	I have this problem but it never bothers me	I am slightly bothered by this problem	I am very bothered by this problem	I am extremely bothered by this problem
I have a hard time concentrating
I am easily distracted
I have a hard time concentrating in noisy places
I have a hard time following conversations
I have a hard time concentrating on challenging tasks (for example: homework or chores)

Section 4 - Inhibition problems*

	N/A I don't have this problem	I have this problem but it never bothers me	I am slightly bothered by this problem	I am very bothered by this problem	I am extremely bothered by this problem
I say things without thinking
I do things without thinking
I do not follow directions
I dominate conversations (for example: I talk more than other people in a conversation)
I interrupt when others are speaking

Section 5 - Physical & sensorimotor problems*

	N/A I don't have this problem	I have this problem but it never bothers me	I am slighly bothered by this problem	I am very bothered by this problem	I am extremely bothered by this problem
My body hurts a lot of the time
I don't get enough sleep
I feel tired
I am bothered by light
I have a hard time focusing my eyes
I have a hard time telling how near or far away objects are from me

Section 6 - Language problems*

	N/A I don't have this problem	I have this problem but it never bothers me	I am slightly bothered by this problem	I am very bothered by this problem	I am extremely bothered by this problem
I have a hard time understanding what people tell me
I have a hard time understanding what I've read
I have a hard time finding the right word when speaking
I have a hard time getting people to understand what I am trying to say
I have a hard time finding the right words when writing

Section 7 - Organization problems*

	N/A I don't have this problem	I have this problem but it never bothers me	I am slightly bothered by this problem	I am very bothered by this problem	I am extremely bothered by this problem
I have a hard time keeping to a schedule (class, therapy, meetings)
I have a hard time deciding which of my daily tasks I should do first
I have a hard time starting tasks
I have a hard time switching from one task to another
I have a hard time completing tasks
I have a hard time completing tasks correctly
I have a hard time completing tasks on time (homework, chores)

Section 8 - Mental flexibility problems*

	N/A I don't have this problem	I have this problem but it never bothers me	I am slightly bothered by this problem	I am very bothered by this problem	I am extremely bothered by this problem
I have a hard time figuring out how to handle new problems
I have a hard time changing my mind when things change
I have a hard time learning new ways of doing things
I don’t understand why people do things differently than me

Section 9 - Emotional problems*

	N/A I don't have this problem	I have this problem but it never bothers me	I am slightly bothered by this problem	I am very bothered by this problem	I am extremely bothered by this problem
I feel anxious
I feel irritated
I cry easily
I feel depressed
I feel traumatized
I overreact to things

Notes (ex: tell us about any words or phrases within the form that were challenging for the client)

Juvenile Symptom Questionnaire

Please fill in the following based on the form you received from the client.