Behavioural Assessment (Adult Self-Report) - Vindland

Assessment 1 of 39

Form Instructions & Things to Know

How to fill this form:
  • Read each question carefully before selecting an answer.
  • Select the most accurate option based on your observations.
  • Do not skip questions; every response helps in the assessment.
Things to know:
10-15 Mins

Estimated completion time.

Secure

Your data is fully encrypted.

Note: This is a screening and assessment tool, not clinical (medical).

First, please provide your contact information.

Information about the individual being assessed.

1. I overly needy or dependent. Examples: Insists on help even when he/she does not need it, clings to parent or teacher.
2. I have eating problems. Examples: Overeats, refuses to eat, will only eat one or two things, hoards food.
3. I have sleeping problems. Examples: Walks in his/her sleep, has a lot of nightmares, sleeps way more or less than others his/her age.
4. I refuses to go to school or work, or has to come home, because of worrying, sadness, nervousness, etc.
5. I am extremely anxious or nervous.
6. I cry or I am sad for no clear reason.
7. I avoids interacting with others (withdraws, prefers to be alone, etc.).
8. I lack interest in doing things that he/she enjoys or used to enjoy.
9. I am extremely fearful of one or more common objects or situations. Examples: Heights, snakes, elevators.
10. I am worried for no clear reason.
11. I am very irritable or moody.
12. I feels helpless or hopeless. Example: Says that things are bad and will never get better.
13. I always complains of feeling sick, exhausted, or in pain, even though there is no medical reason
14. I have temper outbursts: Screams, cries, kicks, etc.
15. I disobeys those in authority.
16. I bullies others physically or with words.
17. I Lie, cheats, or steals.
18. I am physically aggressive. Examples: Hits, kicks, bites.
19. I am stubborn or I argues.
20. I am verbally abusive: Hurts others on purpose with insults, put-downs, etc.
21. I breaks rules or laws because of peer pressure.
22. I am much more active or restless than others his/her age. Examples: Moves all the time, cannot sit still, fidgets.
23. I take or uses school or work property when not allowed. Examples: Books, office supplies.
24. I destroy my own or someone else's possessions on purpose.
25. I gets obsessed on objects or parts of objects. Examples: Stares at spinning wheels or fan blades, lines up objects, flips light switches over and over.
26. I talk about hearing voices that others do not hear, or seeing things that others do not see.
27. I harm mself. Examples: Bangs his/her head, hits or bites self, cuts self, tears at skin, pulls out his/her hair.
28. I use strange or repetitive speech. Examples: Has conversations with myself in public, says things that make no sense, repeats the same thing over and over.
29. I repeats physical movements over and over. Examples: Rocks back and forth, spins, flaps hands.
30. I eats non-food items such as dirt, paste, or soap.
31. I get so obsessed on a particular topic that it annoys others. Examples: Trains, reptiles, maps, subway systems.
32. I talk about killing myself or has tried to kill myself.
33. I leaves home, school, or care suddenly or runs off without thinking about safety.
34. I threatens to hurt or kill someone.
35. I am tricked by others into doing something that could seriously harm him or her, or someone else.
36. Use this space for any general comments you want to make about yourself.