BRIEF PROBLEM CHECKLIST - CHILD

Child’s Name:__________________________________________________________________

Preferred Phone Number: ________________________________________________________

Preferred Call Time(s): (1) ________________ (2) ________________ (3) ________________

Phone Log
Date Notes Date Notes

Note. Attach additional sheets for phone log as needed.

© 2010 Chorpita, Reise, Weisz. All rights reserved. Revised 2010-02-22

 BRIEF PROBLEM CHECKLIST - CHILD
Date: ________________ Caller: __________________________ Respondent: __________________________
Note. Informed consent will have been obtained prior to first call to prepare families for this check-in. For first calls, callers should obtain
the top three choices of times to be called each week if this has not been done already during the consent and orientation procedures.
If these call times are already available, they should be reviewed for accuracy on the first call.

Introduction
Hi, my name is ____, and I am calling (again) from _____ to check on how things are going. Is this an OK time to ask a
few questions? Just as a reminder, I am going to ask you a short set of questions; your exact answers will not be shared
with your therapist. If you have any questions about your therapy, please talk to your therapist or your parents. If you feel
you do not know the answer to any questions, please try to give your best guess. OK?

Problems
I am now going to read you the top three problems you and your family told us about in your first meeting with us. For
each, I want you to rate how much of a problem it still is, from 0 “not at all a problem” to 10 “a huge problem.” OK?
Problem Rating Notes
1.

2.

3.

Items
Now I’m going to read you a list of items that describe kids. For each item, I just need you to tell me how true you think it
is of you in the last week, either “very true,” “somewhat true,” or “not true.” And remember, I am just asking about how
things have been this week. OK?
Item Answers Notes
4. I argue a lot Not True Somewhat true Very True

5. I destroy things belonging to others Not True Somewhat true Very True

6. I disobey my parents or people at school Not True Somewhat true Very True

7. I feel too guilty Not True Somewhat true Very True

8. I feel worthless or inferior Not True Somewhat true Very True

9. I am self-conscious or easily embarrassed Not True Somewhat true Very True

10. I am stubborn Not True Somewhat true Very True

11. I have a hot temper Not True Somewhat true Very True

12. I threaten to hurt people Not True Somewhat true Very True

13. I am too fearful or anxious Not True Somewhat true Very True

14. I am unhappy, sad, or depressed Not True Somewhat true Very True

15. I worry a lot Not True Somewhat true Very True

Closing
Are there any other things you would like to tell me at this time about how things are going? YES NO
(If yes, please use space below to make note. If you need additional space, turn page over and make notes on the back of this form
and make a clear notation to turn page over. Please put dates next to all notes.)

Thanks for answering these questions. I will call you again next week at the same time.

© 2010 Chorpita, Reise, Weisz. All rights reserved. Revised 2010-02-22