DSHS Form 10-509 "Form Psc-17 - Pediatric Symptom Checklist" - Washington

What Is DSHS Form 10-509?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2014;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Available in Arabic;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 10-509 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 10-509 "Form Psc-17 - Pediatric Symptom Checklist" - Washington

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Date
Pediatric Symptom Checklist
(PSC–17)
Name of Person Completing this Form
Child’s Name
Child’s Date of Birth
First Name
Last Name
First Name
Last Name
Please check the box under the heading that best
describes your child or you.
For Office Use
Only
(0) Never
(1) Sometimes
(2) Often
1. Feels sad, unhappy
2. Feels hopeless
3. Is down on self
Internalizing
4. Worries a lot
Total
5. Seems to be having less fun
6. Fidgety, unable to sit still
7. Daydreams too much
8. Distracted easily
Attention
9. Has trouble concentrating
Total
10. Acts as if driven by a motor
11. Fights with other children
12. Does not listen to rules
13. Does not understand other people’s feelings
14. Teases others
15. Blames others for his/her troubles
Externalizing
16. Refuses to share
Total
17. Takes things that do not belong to him/her
Total Score
A score of 15 or higher may indicate the need for an assessment by a qualified medical or mental health professional.
PSC-17
DSHS 10-509 (08/2014)
Date
Pediatric Symptom Checklist
(PSC–17)
Name of Person Completing this Form
Child’s Name
Child’s Date of Birth
First Name
Last Name
First Name
Last Name
Please check the box under the heading that best
describes your child or you.
For Office Use
Only
(0) Never
(1) Sometimes
(2) Often
1. Feels sad, unhappy
2. Feels hopeless
3. Is down on self
Internalizing
4. Worries a lot
Total
5. Seems to be having less fun
6. Fidgety, unable to sit still
7. Daydreams too much
8. Distracted easily
Attention
9. Has trouble concentrating
Total
10. Acts as if driven by a motor
11. Fights with other children
12. Does not listen to rules
13. Does not understand other people’s feelings
14. Teases others
15. Blames others for his/her troubles
Externalizing
16. Refuses to share
Total
17. Takes things that do not belong to him/her
Total Score
A score of 15 or higher may indicate the need for an assessment by a qualified medical or mental health professional.
PSC-17
DSHS 10-509 (08/2014)