Houcut

What is your child gender identity?

Male Female Transgender Male Transgender Female Non-binary Gender-queer Two-spirit I don't know Others

Kindly share your child age

What is your current relationship status?

Single

Married

In a relationship

Separated

Widowed

Other

Have you and your child ever
engaged in a conversation with a
psychologist or counselor
previously?

Yes

No

Have you ever engaged in a
conversation with a psychologist or
counselor previously?

Yes

No

Do you allow your child to attend
therapy sessions?

Yes

No

I am not sure

What is your relationship with your
child?

I am the mother

I am the father

I am the guardian

Other

Who does your child live with?

With mother

With father

With guardian

Living with family father and mother

Other

How do you evaluate the relationship
with your child?

Good

Normal

Weak

Based on observations, how do they
evaluate their child's health?

Good

Normal

Weak

"Please indicate if your child have
encountered any of the following
experiences with in the past two weeks:"

"Have your child recently felt a lack of interest in your work, resulting in feelings of frustration?"

"Have your child faced any challenges with your sleep patterns, such as difficulty falling asleep, waking up during the night, or excessive sleep?"

"Have your child been experi- encing fatigue or a noticeable lack of energy recently?"

"Have there been changes in your child eating habits, such as eating less or overeating?"

"Have your child struggled to focus on activities like reading a newspaper or watching TV?"

"Do your child have negative self-perceptions or feel you're not meeting expectations?"

A leaning towards self-hurt.

Having overwhelming anxiety.

"Have these problems made it difficult to manage work, chores, and relationships?"