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Child Behavior Patterns and Parent Concern Survey

Captures how often common childhood behaviors (tantrums, defiance, anxiety, focus struggles, sleep issues) show up at home, school, and in public, and which ones worry parents most. An AI follow-up interview digs into the history and triggers behind the single behavior causing the most concern, going beyond a checkbox rating. Built for pediatric practices, school counselors, and parenting researchers.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

13 questions · ~7 min
Q01
Message

Thanks for taking a few minutes to share how your child has been doing lately. There are no right or wrong answers here — honest, everyday observations are the most useful. This should take about 5 minutes.

Q02
Multiple ChoiceRequired

What is your child's current age range?

  • 2-4 years
  • 5-7 years
  • 8-10 years
  • 11-13 years
  • 14-17 years
Q03
MatrixRequired

In the last 30 days, how often has your child shown each of these behaviors?

7 rows × 5 columns
  • Tantrums or meltdowns
  • Defiance or refusal to follow instructions
  • Aggression toward others (hitting, biting, pushing)
  • Anxiety or excessive worry
  • Difficulty focusing or sitting still
  • +2 more
Columns: Never · Rarely (a few times a month) · Sometimes (weekly) · Often (several times a week) · Very often (daily)
Q04
Opinion ScaleRequired

Overall, how manageable would you say your child's behavior has been recently?

Scale: 1 – 7
Min:Completely unmanageableMax:Very manageable
Q05
Best–Worst Trade-off (MaxDiff)Required

From the behaviors below, which is most concerning to you right now, and which concerns you least?

  • Tantrums or meltdowns
  • Defiance or refusal to follow instructions
  • Aggression toward others
  • Anxiety or excessive worry
  • Difficulty focusing or sitting still
  • Sleep problems
  • Screen time conflicts
Pick best & worst per setBest:Most concerningWorst:Least concerning
Q06
Multiple Choice

In which settings does the behavior you're most concerned about tend to happen?

  • Home
  • School or daycare
  • Public places (stores, restaurants)
  • With peers or friends
  • During transitions (bedtime, leaving somewhere)
Q07
Multiple Choice

Which of these have you tried to address it?

  • Time-outs or consequences
  • Reward charts or incentives
  • Calmly talking it through
  • Ignoring the behavior
  • Consulted a pediatrician or counselor
  • Haven't tried anything specific yet
Q08
Opinion ScaleRequired

How confident do you feel in your ability to manage this behavior when it happens?

Scale: 1 – 5
Min:Not at all confidentMax:Extremely confident
Q09
AI Interview

Focus on the single behavior the respondent flagged as most concerning in the trade-off question. Ask when it first started or noticeably worsened, what tends to trigger it, and how it's changed over the last few months. Probe what they've already tried and whether it helped, made no difference, or backfired. If they mention a specific incident, ask them to walk through exactly what happened right before, during, and after it.

Q10
Long Text

Is there anything else about your child's behavior you'd like us to know that the questions above didn't cover?

Q11
Multiple Choice

What is your relationship to the child?

  • Parent or guardian
  • Grandparent
  • Other primary caregiver
  • Prefer not to say
Q12
Multiple Choice

Child's gender (optional, for grouping responses only)

  • Boy
  • Girl
  • Non-binary / other
  • Prefer not to say
Q13
Message

Thank you for sharing these observations. Your responses help us understand common behavior patterns and build better support and follow-up conversations for families like yours.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • A matrix question tracks how often tantrums, defiance, anxiety, focus struggles, and sleep issues show up at home, school, and in public — not just a single overall rating.
  • A max-diff question pinpoints the single behavior causing the most concern, then an AI follow-up interview digs into its history and triggers, going beyond a checkbox or scale.
  • Opinion scales on manageability and confidence, plus multiple-choice on settings and prior attempts to address it, add context before the AI interview narrows in.
  • Built with pediatric practices, school counselors, and parenting researchers in mind, with an auto-generated report — on a platform with a free tier and $50/mo Business plan (no academic pricing tier).

SurveyMonkey

Behavior Surveys For Kids & Children

A fielding-ready template covering common childhood behavior questions, built on SurveyMonkey's mainstream survey platform. It's suited to general behavior tracking but relies on fixed question sets rather than any conversational follow-up. Best for teams that already use SurveyMonkey's broader survey and reporting tools.

What it does well

  • Quick to deploy using a large, well-known survey platform
  • Simple customization of question wording and answer choices
  • Built-in basic analytics and reporting dashboards

Where it falls short

  • No adaptive AI follow-up to probe the history or triggers behind a specific concerning behavior
  • No voice AI interview option
  • No automated per-response quality scoring or transparent prompt methodology

Jotform

Child Concerns Report Form Template

A ready-to-use form for documenting concerns about a child, built on Jotform's drag-and-drop form builder. It's designed for structured intake/reporting rather than an in-depth conversation about why a behavior is happening. Useful for capturing a written summary of concerns, but branching is limited to static conditional logic.

What it does well

  • Easy to customize fields and layout without coding
  • Supports conditional logic to show/hide fields based on answers
  • Integrates with Jotform's wider form and workflow ecosystem

Where it falls short

  • No adaptive AI interview to dig deeper into the most concerning behavior's history or triggers
  • No voice AI interview capability
  • No automated quality scoring of responses or auto-generated analysis report

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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