Behavioral & Social Well-Being Questionnaire

Understanding how you think, feel, and interact

Before We Begin

This questionnaire helps us understand experiences with attention, social situations, and daily routines. There are no right or wrong answers.

Who is completing this questionnaire?

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Child/Youth

I'm answering about myself

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Parent/Guardian

I'm a parent/caregiver

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Teacher/Educator

I'm a teacher/educator

Child's Full Name (person being assessed):

Your Full Name (person completing this form):

Your Email Address:

Progress

About Attention and Activity

This first set of questions asks about attention, focus, and activity levels.

About Social Interactions and Routines

This next set of questions asks about social situations, communication, and daily patterns.

About Social Comfort

This final set of questions asks about feelings in social situations.

Thank You

✓ Questionnaire Submitted Successfully

Thank you for taking the time to share your observations and experiences. Your responses have been received and will be carefully reviewed.

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About This Questionnaire

The information you provided will be reviewed by Aimee Mitchell, MSW, LICSW, as part of a comprehensive clinical assessment. These screening questions are one component of a thorough evaluation process that considers multiple perspectives and factors.