Skip to content
About
Programs & Services
Get Involved
Careers
Urgent Crisis Center
Patient Forms
Patient Portal
Donate
Phone:
860-437-4550
Search
Close Search
About
Programs & Services
Menu
Forms – Ohio Youth
Ohio Scales Youth (rev 20220607)
(revised 20220607)
Step
1
of
2
50%
Ohio Mental Health Consumer Outcomes System
Ohio Youth Problem, Functioning, and Satisfaction Scales
Youth Rating – Short Form (Ages 12-18)
Name
*
First
Last
Date
*
MM slash DD slash YYYY
Grade
*
Enter grade number
Date of Birth
*
MM slash DD slash YYYY
Sex
*
Male
Female
Race
*
Please rate the degree to which you have experienced the following problems in the past 30 days.
1. Arguing with others
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
2. Getting into fights
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
3. Yelling, swearing, or screaming at others
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
4. Fits of anger
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
5. Refusing to do things teachers or parents ask
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
6. Causing trouble for no reason
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
7. Using drugs or alcohol
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
8. Breaking rules or breaking the law (out past curfew, stealing)
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
9. Skipping school or classes
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
10. Lying
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
11. Can't seem to sit still, having too much energy
*
All the time
Most of the time
Often
Several times
Once or twice
Not at all
12. Hurting self (cutting or scratching self, taking pills)
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
13. Taking or thinking about death
*
All of the time
Most of the time
often
Several times
Once or twice
Not at all
14. Feeling worthless or useless
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
15. Feeling lonely and having no friends
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
16. Feeling anxious or fearful
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
17. Worrying that something bad is going to happen
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
18. Feeling sad or depressed
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
19. Nightmares
*
All of the time
Most of the time
Often
Several times
Once in a while
Not at all
20. Eating problems
*
All of the time
Most of the time
Often
Several times
Once or twice
Not at all
Problem total
Calculated- do not edit
Instructions:
Please select your response to each question.
1. Overall, how satisfied are you with your life right now?
*
Extremely satisifed
Moderately satisfied
Somewhat satisifed
Somewhat dissatisfied
Moderately dissatisfied
Extremely dissatisfied
2. How energetic and healthy do you feel right now?
*
Extremely healthy
Moderately healthy
Somewhat healthy
Somewhat unhealthy
Moderately unhealthy
Extremely unhealthy
3. How much stress or pressure is in your life right now?
*
Very little stress
Some stress
Quite a bit of stress
A moderate amount of stress
A great deal of stress
Unbearable amount of stress
4. How optimistic are you about the future?
*
The future looks very bright
The future looks somewhat bright
The future looks OK
The future looks both good and bad
The future looks bad
The future looks very bad
Hopefulness total
Calculated- do not edit
Please select your response to each question.
1. How satisfied are you with the mental health services you have received so far?
*
Extremely satisfied
Moderately satisfied
Somewhat satisfied
Somewhat dissatisfied
Moderately dissatisfied
Extremely dissatisfied
2. How much are you included in deciding your treatment?
*
A great deal
Moderately
Quite a bit
Somewhat
A little
Not at all
3. Mental health workers involved in my case listen to me and know what I want.
*
A great deal
Moderately
Quite a bit
Somewhat
A little
Not at all
4. I have a lot to say about what happens in my treatment.
*
A great deal
Moderately
Quite a bit
Somewhat
A little
Not at all
Treatment satisfaction total
Calculated- do not edit
Below are some ways your problems might get in the way of your ability to do everyday activities. Read each item and select the response that best describes your situation.
1. Getting along with friends
*
Doing very well
OK
Some trouble
Quite a few troubles
Extreme troubles
2. Getting along with family
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
3. Dating or developing relationships with boyfriends or girlfriends
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
4. Getting along with adults outside the family (teachers, principal)
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
5. Keeping neat and clean, look good
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
6. Caring for the health needs and keeping good health habits (taking medicines or brushing teeth)
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
7. Controlling emotions and staying out of trouble
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
8. Being motivated and finishing projects
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
9. Participating in hobbies (baseball cards, coins, stamps, art)
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
10. Participating in recreational activities (sports, swimming, bike riding)
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
11. Completing household chores (cleaning room, other chores)
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
12. Attending school and getting passing grades in school
*
Doing very well
OK
Some toubles
Quite a few troubles
Extreme troubles
13. Learning skills that will be useful for future jobs
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
14. Feeling good about self
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
15. Thinking clearly and making good decisions
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
16. Concentrating, paying attention, and completing tasks
*
Doing very wel
OK
Some troubles
Quite a few troubles
Extreme troubles
17. Earning money and learning how to use money wisely
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
18. Doing things without supervision or restrictions
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
19. Accepting responsibility for actions
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
20. Ability to express feelings
*
Doing very well
OK
Some troubles
Quite a few troubles
Extreme troubles
Functioning total
Calculated- do not edit
