LIST OF CHILDREN BEHAVIORS


Name of child: __________________________________________ DOB: __________

Name of rater: __________________________________________ Date: ___________


Please read the following list and rate your child on each behavior.
Indicate how often your child displays that behavior by circling the number which best describes the frequency of each behavior.

Please use the following scale:
1_____________2_____________3___________________4_______________5
Never_________Rarely________Occasionally__ _____Frequently______Very Frequently

GROUP A

1 2 3 4 5 Has trouble sleeping or sleeps excessively
1 2 3 4 5 Has poor appetite
1 2 3 4 5 Seems sad or unhappy
1 2 3 4 5 Talks about feeling stupid or wo rthless
1 2 3 4 5 Loses interest in having fun
1 2 3 4 5 Easily irritable
1 2 3 4 5 Negative, cynical or pessimistic.
1 2 3 4 5 Moody
1 2 3 4 5 Prefers playing or being alone rather than with peers.
1 2 3 4 5 Cries easily
1 2 3 4 5 Seems tired, lethargic, low energy


GROUP B

1 2 3 4 5 Complains of physical problems, like headaches or stomachaches
1 2 3 4 5 Worries
1 2 3 4 5 Lacks confidence in his/her abilities
1 2 3 4 5 Needs lots of reassurance
1 2 3 4 5 Needs to be perfect
1 2 3 4 5 Seems fearful and anxious
1 2 3 4 5 Seems shy or timid
1 2 3 4 5 Easily embarrassed
1 2 3 4 5 Sensitive to criticism
1 2 3 4 5 Bites fingernails


GROUP C

1 2 3 4 5 Always on the go
1 2 3 4 5 Can’t sit still
1 2 3 4 5 Doesn’t seem to listen
1 2 3 4 5 Often fails to finish things
1 2 3 4 5 Has poor concentration and attention when it comes to school work
1 2 3 4 5 Often fidgets with hands/feet or squirms in seat or physically restless
1 2 3 4 5 Easily distracted
1 2 3 4 5 Has a hard time playing quietly
1 2 3 4 5 Talks excessively
1 2 3 4 5 Often interrupts or “butts in” to other’s games or conversations
1 2 3 4 5 Seems disorganized, loses things they need for school, binder is a mess
1 2 3 4 5 Takes risks without considering the danger involved (e.g. running into the street without looking)
1 2 3 4 5 Blurts out answers to questions before they have been completed


GROUP D

1 2 3 4 5 Refuses to follow rules or do chores
1 2 3 4 5 Loses temper
1 2 3 4 5 Argues with parents or teachers
1 2 3 4 5 Blames others for their mistakes
1 2 3 4 5 Swears
1 2 3 4 5 Deliberately does things to annoy other people
1 2 3 4 5 Is angry or resentful
1 2 3 4 5 Carries a grudge. Seems to have a “chip on their shoulder”
1 2 3 4 5 Touchy, easily annoyed by others


GROUP E

1 2 3 4 5 Steals
1 2 3 4 5 Runs away overnight
1 2 3 4 5 Lies
1 2 3 4 5 Cuts school
1 2 3 4 5 Is cruel to animals
1 2 3 4 5 Destroys property
1 2 3 4 5 Gets into fights
1 2 3 4 5 Has been physically cruel to other people
1 2 3 4 5 Doesn’t seem sorry for hurting others
1 2 3 4 5 Sets fires
1 2 3 4 5 Has broken into someone else’s house or car


GROUP F

1 2 3 4 5 Excessive or senseless worrying.
1 2 3 4 5 Disorganized or superorganized
1 2 3 4 5 Oppositional, argumentative
1 2 3 4 5 Strong tendency to get locked into negative thoughts, having the same thought over and over
1 2 3 4 5 Tendency toward compulsive behavior
1 2 3 4 5 Intense dislike for change
1 2 3 4 5 Tendency to hold grudges
1 2 3 4 5 Trouble shifting attention from one subject to another
1 2 3 4 5 Difficulties seeing options in situations
1 2 3 4 5 Tendency to hold on to own opinion and not listen to others
1 2 3 4 5 Tendency to get locked into a course of action whether or not it is good for the person
1 2 3 4 5 Needing to have things done a certain way or becoming very upset
1 2 3 4 5 Others complain they worry too much.

GROUP G

1 2 3 4 5 Short fuse or periods of extreme irritability
1 2 3 4 5 Periods of rage with little provocation
1 2 3 4 5 Often misinterprets comments as negative when they are not
1 2 3 4 5 Irritability tends to build, then explodes, then recedes, often tired
after a rage
1 2 3 4 5 Periods of spaciness or confusion
1 2 3 4 5 Periods of panic and/or fear for no specific reason
1 2 3 4 5 Visual changes, such as seeing shadows or objects changing shape
1 2 3 4 5 Frequent periods of de ja vu (feelings of being somewhere before
even though he/she never has)
1 2 3 4 5 Sensitivity or mild paranoia
1 2 3 4 5 Headaches or abdominal pain of uncertain origin
1 2 3 4 5 History of a head injury or family history of violence or explosiveness
1 2 3 4 5 Dark thoughts, may involve suicidal or homicidal thoughts
1 2 3 4 5 Periods of forgetfulness or memory problems


GROUP H

1 2 3 4 5 Difficulties with reading.
1 2 3 4 5 Difficulties with math.
1 2 3 4 5 Difficulties with written expression.
1 2 3 4 5 Poor performance on tests.
1 2 3 4 5 Poor handwriting.
1 2 3 4 5 Not completing or turning in homework assignments.
1 2 3 4 5 Lying about not having homework.
1 2 3 4 5 Power struggles around doing homework.
1 2 3 4 5 Takes hours to complete homework.
1 2 3 4 5 Poor grades.
1 2 3 4 5 Strong dislike for school.
1 2 3 4 5 Strong dislike or conflicts with certain teachers.
1 2 3 4 5 Behavior or discipline problems at school.
1 2 3 4 5 Problems with peers at school.
1 2 3 4 5 Tardy or attendance problems at school.

yes no My child has been tested for learning difficulties.

yes no My child is or has been on an IEP or 504 plan for learning difficulties.

yes no My child is or has been on an IEP or 504 plan for behavioral difficulties.

Average grades: __________

Least liked subjects: _________________________________________________________________________
Most liked subjects:
_________________________________________________________________________


GROUP I

yes no Do you have knowledge or suspicion of your child using alcohol or drugs in the past?

If yes, please describe: _____________________________________________

yes no Do you have knowledge or suspicion of your child currently using alcohol or drugs?

If yes, please describe: _____________________________________________________________________________


yes no Are you concerned that alcohol or drug use may currently be having a negative effect on your child in term of behavior, responsibilities and/or relationships with others?


GROUP J

What are the strengths of your child? ______________________________________________________________________________________________________________________________________________________________

What are the interests of your child? ______________________________________________________________________________________________________________________________________________________________


Comments or other concerns: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you very much.