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Pediatric Symptom Checklist Contact Form

The Pediatric Symptom Checklist (PSC) is an essential tool used to help parents and caregivers assess a child’s emotional, behavioral, and developmental health. We use this checklist to identify potential concerns early on, so that children can receive the appropriate support and interventions they need to thrive. Complete the form below to speak with a representative.

Provider Information

Are you paying for your child's child care through...
Relationship to Child 

Pediatric Symptom Checklist: Please mark ONLY ONE that best fits your child.

Complains of aches/pains
Spends more time alone 
Tires easily, has little energy 
Fidgety, unable to sit still 
Has trouble with a teacher 
Less interested in school 
Acts as if driven by a motor 
Daydreams too much 
Distracted easily 
Is afraid of new situations 
Feels sad, unhappy 
Is irritable, angry 
Feels hopeless 
Has trouble concentrating 
Less interested in friends 
Fights with others 
Absent from school 
School grades dropping 
Is down on him or herself 
Visits doctor with doctor finding nothing wrong 
Has trouble sleeping 
Worries a lot 
Wants to be with you more than before 
Feels he or she is bad 
Takes unnecessary risks 
Gets hurt frequently 
Seems to be having less fun 
Acts younger than children his or her age 
Does not listen to rules 
Does not show feelings 
Does not understand other people's feelings 
Teases others 
Blames others for his or her troubles 
Takes things that do not belong to him or her 
Refuses to share 

Additional Information and Help

Does your child have any emotional/behavioral problems for which she/he needs help? 
Are there any services that you would like your child to receive for these problems?

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follow up with me and provide me with other relevant sources.