Telos Family Assessment

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Instructions for Parents

Please answer each question based on your child's behavior and functioning during the past 7 days.

There are no perfect answers. The goal of this assessment is simply to better understand your child's current level of emotional distress, behavioral functioning, and overall stability.

For each statement, select the response that best reflects how often the behavior or concern has occurred.

This assessment looks at:

-Emotional distress
-Anxiety and mood concerns
-Safety risks
-Behavioral struggles
-Family and social functioning
-Daily functioning
-Executive functioning
-Substance use or compulsive behaviors

Please answer honestly and thoughtfully. Higher scores do not mean your child is "bad" or "broken." They simply indicate a higher level of distress or impairment that may deserve additional support.

Most parents complete this assessment in approximately 5 minutes.

Disclaimer

This assessment is a screening tool designed to help identify emotional distress, behavioral concerns, and functional impairment. It is not a diagnosis and does not replace evaluation by a licensed mental health professional.

Results should be interpreted in the context of a comprehensive clinical assessment, including family history, medical factors, safety concerns, and professional judgment.

If your child is in immediate danger, expressing suicidal thoughts, threatening harm to self or others, or experiencing a mental health crisis, call 911, contact emergency services, or seek immediate professional help.

Emotional Distress

Rate your child over the past 7 days.

Never or not at allRarely / mildSometimes / moderateOften / significantAlmost always / severe

Seems sad, discouraged, or emotionally heavy.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Appears anxious, tense, or worried.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Has trouble calming down once upset.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Shows low motivation or little interest in normal activities.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Expresses guilt, shame, worthlessness, or being a burden.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Has mood swings that are hard to predict.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Becomes overwhelmed by ordinary demands.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Seems emotionally numb, shut down, or disconnected.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Safety Risk

Rate your child over the past 7 days.

Never or not at allRarely / mildSometimes / moderateOften / significantAlmost always / severe

Talks about death, not wanting to live, or disappearing.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Has thoughts of suicide or self-harm.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Has harmed self, attempted self-harm, or engaged in unsafe self-injury.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Makes threats toward others.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Behaves in ways that create serious safety concerns.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Runs away, leaves supervision, or disappears without permission.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Acts impulsively in ways that could result in serious harm.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Behavioral Dysregulation

Rate your child over the past 7 days.

Never or not at allRarely / mildSometimes / moderateOften / significantAlmost always / severe

Has intense anger outbursts.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Refuses reasonable direction from adults or caregivers.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Argues, escalates, or provokes conflict.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Destroys property or becomes physically intimidating.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Lies, hides information, or manipulates situations.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Blames others and has difficulty taking responsibility.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Breaks important rules despite consequences.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Executive Functioning

Rate your child over the past 7 days.

Never or not at allRarely / mildSometimes / moderateOften / significantAlmost always / severe

Struggles to complete school, work, or daily responsibilities.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Has difficulty organizing tasks, time, or belongings.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Avoids hard things or gives up easily.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Needs repeated prompting to follow through.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Makes poor decisions in the moment.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Has difficulty transitioning from one activity or expectation to another.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Struggles with hygiene, sleep routine, nutrition, or basic self-care.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Social and Family Functioning

Rate your child over the past 7 days.

Never or not at allRarely / mildSometimes / moderateOften / significantAlmost always / severe

Withdraws from family or peers.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Has frequent conflict with parents, caregivers, or siblings.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Has difficulty maintaining healthy friendships.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Misreads social situations or reacts in socially inappropriate ways.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Feels lonely, rejected, or disconnected.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Is overly dependent on one person, group, device, or online community.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Has difficulty repairing relationships after conflict.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

School, Work, and Daily Functioning

Rate your child over the past 7 days.

Never or not at allRarely / mildSometimes / moderateOften / significantAlmost always / severe

Avoids school, work, therapy, or important obligations.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Performance at school, work, or home has declined.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Spends excessive time sleeping, gaming, scrolling, isolating, or avoiding life.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Has difficulty participating in normal family, school, work, or community life.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Needs more structure or supervision than expected for age.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Substance Use / Compulsive Behavior

Rate your child over the past 7 days.

Never or not at allRarely / mildSometimes / moderateOften / significantAlmost always / severe

Uses substances, pornography, gaming, food, screens, or other behaviors to escape distress.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Hides, minimizes, or lies about substance use or compulsive behavior.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Continues harmful behavior despite consequences.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Cravings, urges, or compulsive patterns interfere with functioning.*

Never or not at all

Rarely / mild

Sometimes / moderate

Often / significant

Almost always / severe

Want to talk through the results?

Please leave your name and email. We will only reach out if you request it.

Parent Name*

Email*

Phone

Would you like someone from Telos Admissions to reach out to you?*

Yes

No, not yet

What type of help are you needing?

Residential Treatment

Outpatient Services

Who are you seeking residential treatment for?

Residential treatment for my adolescent son (13-17)

Residential treatment for me or my young adult son (18-26)

Residential treatment for my young adult daughter (17-26)

We are unable to take adolescent girls ages 16 and younger.

What type of outpatient service are you interested in?

Intensive Outpatient Treatment (9-19 hours of help per week)

Partial Hospitalization (20+ hours of help per week)

Transcranial Magnetic Stimulation (TMS)

Please share a little about what brings you here.

Which of the following best describes your situation?

Insurance Only: I am only able to cover costs paid by insurance.

Insurance Plus Private Pay: I am able to continue private payment if insurance coverage ends before treatment is complete.

Private Pay Only: I do not plan to use insurance benefits.

Other

Telos Family Assessment

Instructions for Parents

Disclaimer

Emotional Distress

Safety Risk

Behavioral Dysregulation

Executive Functioning

Social and Family Functioning

School, Work, and Daily Functioning

Substance Use / Compulsive Behavior

Want to talk through the results?

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