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Please enable JavaScript in your browser to complete this form.RCADS47 Youth FormFull Name *Date of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AddressAddress Line 1CityState / Province / RegionPostal CodeThis service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.Please select the word that shows how often each of these things happens to you. There are no right or wrong answers.RCADS47 NeverSometimesOftenAlways I worry about thingsNeverI worry about things NeverSometimesI worry about things SometimesOftenI worry about things OftenAlwaysI worry about things AlwaysI feel sad or emptyNeverI feel sad or empty NeverSometimesI feel sad or empty SometimesOftenI feel sad or empty OftenAlwaysI feel sad or empty AlwaysWhen I have a problem, I get a funny feeling in my stomachNeverWhen I have a problem, I get a funny feeling in my stomach NeverSometimesWhen I have a problem, I get a funny feeling in my stomach SometimesOftenWhen I have a problem, I get a funny feeling in my stomach OftenAlwaysWhen I have a problem, I get a funny feeling in my stomach AlwaysI worry when I think I have done poorly at somethingNeverI worry when I think I have done poorly at something NeverSometimesI worry when I think I have done poorly at something SometimesOftenI worry when I think I have done poorly at something OftenAlwaysI worry when I think I have done poorly at something AlwaysI would feel afraid of being on my own at homeNeverI would feel afraid of being on my own at home NeverSometimesI would feel afraid of being on my own at home SometimesOftenI would feel afraid of being on my own at home OftenAlwaysI would feel afraid of being on my own at home AlwaysNothing is much fun anymoreNeverNothing is much fun anymore NeverSometimesNothing is much fun anymore SometimesOftenNothing is much fun anymore OftenAlwaysNothing is much fun anymore AlwaysI feel scared when I have to take a testNeverI feel scared when I have to take a test NeverSometimesI feel scared when I have to take a test SometimesOftenI feel scared when I have to take a test OftenAlwaysI feel scared when I have to take a test AlwaysI feel worried when I think someone is angry with meNeverI feel worried when I think someone is angry with me NeverSometimesI feel worried when I think someone is angry with me SometimesOftenI feel worried when I think someone is angry with me OftenAlwaysI feel worried when I think someone is angry with me AlwaysI worry about being away from my parentsNeverI worry about being away from my parents NeverSometimesI worry about being away from my parents SometimesOftenI worry about being away from my parents OftenAlwaysI worry about being away from my parents AlwaysI get bothered by bad or silly thoughts or pictures in my mindNeverI get bothered by bad or silly thoughts or pictures in my mind NeverSometimesI get bothered by bad or silly thoughts or pictures in my mind SometimesOftenI get bothered by bad or silly thoughts or pictures in my mind OftenAlwaysI get bothered by bad or silly thoughts or pictures in my mind AlwaysI have trouble sleepingNeverI have trouble sleeping NeverSometimesI have trouble sleeping SometimesOftenI have trouble sleeping OftenAlwaysI have trouble sleeping AlwaysI worry that I will do badly at my school workNeverI worry that I will do badly at my school work NeverSometimesI worry that I will do badly at my school work SometimesOftenI worry that I will do badly at my school work OftenAlwaysI worry that I will do badly at my school work AlwaysI worry that something awful will happen to someone in my familyNeverI worry that something awful will happen to someone in my family NeverSometimesI worry that something awful will happen to someone in my family SometimesOftenI worry that something awful will happen to someone in my family OftenAlwaysI worry that something awful will happen to someone in my family AlwaysI suddenly feel as if I can't breathe when there is no reason for thisNeverI suddenly feel as if I can't breathe when there is no reason for this NeverSometimesI suddenly feel as if I can't breathe when there is no reason for this SometimesOftenI suddenly feel as if I can't breathe when there is no reason for this OftenAlwaysI suddenly feel as if I can't breathe when there is no reason for this AlwaysI have problems with my appetiteNeverI have problems with my appetite NeverSometimesI have problems with my appetite SometimesOftenI have problems with my appetite OftenAlwaysI have problems with my appetite AlwaysI have to keep checking that I have done things right (like the switch is off, or the door is locked)NeverI have to keep checking that I have done things right (like the switch is off, or the door is locked) NeverSometimesI have to keep checking that I have done things right (like the switch is off, or the door is locked) SometimesOftenI have to keep checking that I have done things right (like the switch is off, or the door is locked) OftenAlwaysI have to keep checking that I have done things right (like the switch is off, or the door is locked) AlwaysI feel scared if I have to sleep on my ownNeverI feel scared if I have to sleep on my own NeverSometimesI feel scared if I have to sleep on my own SometimesOftenI feel scared if I have to sleep on my own OftenAlwaysI feel scared if I have to sleep on my own AlwaysI have trouble going to school in the mornings because I feel nervous or afraidNeverI have trouble going to school in the mornings because I feel nervous or afraid NeverSometimesI have trouble going to school in the mornings because I feel nervous or afraid SometimesOftenI have trouble going to school in the mornings because I feel nervous or afraid OftenAlwaysI have trouble going to school in the mornings because I feel nervous or afraid AlwaysI have no energy for thingsNeverI have no energy for things NeverSometimesI have no energy for things SometimesOftenI have no energy for things OftenAlwaysI have no energy for things AlwaysI worry I might look foolishNeverI worry I might look foolish NeverSometimesI worry I might look foolish SometimesOftenI worry I might look foolish OftenAlwaysI worry I might look foolish AlwaysI am tired a lotNeverI am tired a lot NeverSometimesI am tired a lot SometimesOftenI am tired a lot OftenAlwaysI am tired a lot AlwaysI worry that bad things will happen to meNeverI worry that bad things will happen to me NeverSometimesI worry that bad things will happen to me SometimesOftenI worry that bad things will happen to me OftenAlwaysI worry that bad things will happen to me AlwaysI can't seem to get bad or silly thoughts out of my headNeverI can't seem to get bad or silly thoughts out of my head NeverSometimesI can't seem to get bad or silly thoughts out of my head SometimesOftenI can't seem to get bad or silly thoughts out of my head OftenAlwaysI can't seem to get bad or silly thoughts out of my head AlwaysWhen I have a problem, my heart beats really fastNeverWhen I have a problem, my heart beats really fast NeverSometimesWhen I have a problem, my heart beats really fast SometimesOftenWhen I have a problem, my heart beats really fast OftenAlwaysWhen I have a problem, my heart beats really fast AlwaysI cannot think clearlyNeverI cannot think clearly NeverSometimesI cannot think clearly SometimesOftenI cannot think clearly OftenAlwaysI cannot think clearly AlwaysI suddenly start to tremble or shake when there is no reason for thisNeverI suddenly start to tremble or shake when there is no reason for this NeverSometimesI suddenly start to tremble or shake when there is no reason for this SometimesOftenI suddenly start to tremble or shake when there is no reason for this OftenAlwaysI suddenly start to tremble or shake when there is no reason for this AlwaysI worry that something bad will happen to meNeverI worry that something bad will happen to me NeverSometimesI worry that something bad will happen to me SometimesOftenI worry that something bad will happen to me OftenAlwaysI worry that something bad will happen to me AlwaysWhen I have a problem, I feel shakyNeverWhen I have a problem, I feel shaky NeverSometimesWhen I have a problem, I feel shaky SometimesOftenWhen I have a problem, I feel shaky OftenAlwaysWhen I have a problem, I feel shaky AlwaysI feel worthlessNeverI feel worthless NeverSometimesI feel worthless SometimesOftenI feel worthless OftenAlwaysI feel worthless AlwaysI worry about making mistakesNeverI worry about making mistakes NeverSometimesI worry about making mistakes SometimesOftenI worry about making mistakes OftenAlwaysI worry about making mistakes AlwaysI have to think of special thoughts (like numbers or words) to stop bad things from happeningNeverI have to think of special thoughts (like numbers or words) to stop bad things from happening NeverSometimesI have to think of special thoughts (like numbers or words) to stop bad things from happening SometimesOftenI have to think of special thoughts (like numbers or words) to stop bad things from happening OftenAlwaysI have to think of special thoughts (like numbers or words) to stop bad things from happening AlwaysI worry what other people think of meNeverI worry what other people think of me NeverSometimesI worry what other people think of me SometimesOftenI worry what other people think of me OftenAlwaysI worry what other people think of me AlwaysI am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds)NeverI am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds) NeverSometimesI am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds) SometimesOftenI am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds) OftenAlwaysI am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds) AlwaysAll of a sudden I feel really scared for no reason at allNeverAll of a sudden I feel really scared for no reason at all NeverSometimesAll of a sudden I feel really scared for no reason at all SometimesOftenAll of a sudden I feel really scared for no reason at all OftenAlwaysAll of a sudden I feel really scared for no reason at all AlwaysI worry about what is going to happenNeverI worry about what is going to happen NeverSometimesI worry about what is going to happen SometimesOftenI worry about what is going to happen OftenAlwaysI worry about what is going to happen AlwaysI suddenly become dizzy or faint when there is no reason for thisNeverI suddenly become dizzy or faint when there is no reason for this NeverSometimesI suddenly become dizzy or faint when there is no reason for this SometimesOftenI suddenly become dizzy or faint when there is no reason for this OftenAlwaysI suddenly become dizzy or faint when there is no reason for this AlwaysI think about deathNeverI think about death NeverSometimesI think about death SometimesOftenI think about death OftenAlwaysI think about death AlwaysI feel afraid if I have to talk in front of my classNeverI feel afraid if I have to talk in front of my class NeverSometimesI feel afraid if I have to talk in front of my class SometimesOftenI feel afraid if I have to talk in front of my class OftenAlwaysI feel afraid if I have to talk in front of my class AlwaysMy heart suddenly starts to beat too quickly for no reasonNeverMy heart suddenly starts to beat too quickly for no reason NeverSometimesMy heart suddenly starts to beat too quickly for no reason SometimesOftenMy heart suddenly starts to beat too quickly for no reason OftenAlwaysMy heart suddenly starts to beat too quickly for no reason AlwaysI feel like I don’t want to moveNeverI feel like I don’t want to move NeverSometimesI feel like I don’t want to move SometimesOftenI feel like I don’t want to move OftenAlwaysI feel like I don’t want to move AlwaysI worry that I will suddenly get a scared feeling when there is nothing to be afraid ofNeverI worry that I will suddenly get a scared feeling when there is nothing to be afraid of NeverSometimesI worry that I will suddenly get a scared feeling when there is nothing to be afraid of SometimesOftenI worry that I will suddenly get a scared feeling when there is nothing to be afraid of OftenAlwaysI worry that I will suddenly get a scared feeling when there is nothing to be afraid of AlwaysI have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order)NeverI have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order) NeverSometimesI have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order) SometimesOftenI have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order) OftenAlwaysI have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order) AlwaysI feel afraid that I will make a fool of myself in front of peopleNeverI feel afraid that I will make a fool of myself in front of people NeverSometimesI feel afraid that I will make a fool of myself in front of people SometimesOftenI feel afraid that I will make a fool of myself in front of people OftenAlwaysI feel afraid that I will make a fool of myself in front of people AlwaysI have to do some things in just the right way to stop bad things from happeningNeverI have to do some things in just the right way to stop bad things from happening NeverSometimesI have to do some things in just the right way to stop bad things from happening SometimesOftenI have to do some things in just the right way to stop bad things from happening OftenAlwaysI have to do some things in just the right way to stop bad things from happening AlwaysI worry when I go to bed at nightNeverI worry when I go to bed at night NeverSometimesI worry when I go to bed at night SometimesOftenI worry when I go to bed at night OftenAlwaysI worry when I go to bed at night AlwaysI would feel scared if I had to stay away from home overnightNeverI would feel scared if I had to stay away from home overnight NeverSometimesI would feel scared if I had to stay away from home overnight SometimesOftenI would feel scared if I had to stay away from home overnight OftenAlwaysI would feel scared if I had to stay away from home overnight AlwaysI feel restlessNeverI feel restless NeverSometimesI feel restless SometimesOftenI feel restless OftenAlwaysI feel restless Always Date / TimeDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NameSubmit