SCARED ANXIETY SCREEN

Date: [Date]
Child: [Name or ID; age in years, 8 to 18; school grade]
Reason for screening: [Check-up, therapy intake, school refusal, physical complaints with no medical cause, or progress review]
Seen with: [Parent or caregiver present; time alone with the child or teen]

VERSIONS RETURNED
Child version: [Filled in alone, with an adult beside them, or read aloud; paper or online; language]
Parent version: [Which parent or caregiver filled it in, and the date]
Period rated: [The last 3 months, as the form asks]
Wording explained: [For ages 8 to 11, who helped with the questions; or not needed]

TOTALS
Child total: [0 to 82; below 25, 25 to 30, or above 30]
Parent total: [0 to 82; below 25, 25 to 30, or above 30]

SUBSCALES AGAINST CUTOFFS
Panic or somatic, cutoff 7: [Child score and parent score; at or above, or below]
Generalized anxiety, cutoff 9: [Child score and parent score; at or above, or below]
Separation anxiety, cutoff 5: [Child score and parent score; at or above, or below]
Social anxiety, cutoff 8: [Child score and parent score; at or above, or below]
School avoidance, cutoff 3: [Child score and parent score; at or above, or below]

HOW THE TWO REPORTS COMPARE
Where they match: [Subscales both versions put at or above the cutoff]
Where they split: [Subscales only one version puts above the cutoff, and the likely reason]

CONTEXT
Daily life: [School attendance, sleep, friendships, activities, family routines]
Physical symptoms: [Stomachaches, headaches, or racing heart, and what any medical workup found]
Other causes and conditions: [Depression screen, ADHD, trauma, caffeine, medicines, thyroid]
Safety: [Self-harm and suicidal thoughts asked about, and the answers]

IMPRESSION
Screen result: [Positive or negative, on which version]
Working diagnosis: [Type of anxiety disorder, worries below the threshold, or another cause]

PLAN
Treatment: [CBT with exposure, parent-led CBT, an SSRI, or watch and rescreen]
School: [Attendance plan, a staff contact, or classroom supports]
Rescreen: [When both versions will be repeated]

Clinician: [Name, credentials]