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Child's Name (First Middle Last) *

Date *

Birth Date *

School *

Grade Level *

Sexual Orientation of the Child *

Age *

Your Name (First Middle Last) *

How long have you known this child? *

Do you have any concerns about this child's: *

	Yes	No
Vision
Hearing

Read each phrase and select the best description of how the child has behaved recently. Click N = Never, S=Sometimes, O = Often, A = Almost Always *

	N	S	O	A
1. Is easy to please
2. Pays attention
3. Refuses to talk
4. Is overly active
5. Argues when denied own way
6. Congratulates others when good things happen to them
7. Turns in work on time
8. Is irritable
9. Avoids making friends
10. Is fearful
11. Is overly aggressive
12. Has strange ideas
13. Performs poorly on school assignment
14. Is easily distracted
15. Is easily stressed
16. Finds ways to solve problems
17. Speaks out of turn during class
18. Says, "please" and "thank you"
19. Finds fault with everything
20. Adjust well to changes in plans
21. Plans well
22. Has panic attacks
23. Is negative about things
24. Gets into trouble
25. Tries to help others be their best
26. Is overly emotional
27. Eats things that are not food
28. Works well under pressure
29. Accepts people who are different from his or her self
30. Is unclear when presenting ideas
31. Has good study habits
32. Has trouble staying seated
33. Complains of pain
34. Deceives others
35. Spreads rumors about others
36. Tracks down information when needed
37. Transitions well
38. Misses deadlines
39. Reacts negatively
40. Communicates clearly
41. Disrupts the schoolwork of other adolescents
42. Is usually chosen as leader
43. Accepts things as they are
44. Breaks the rules
45. Offers hep to other adolescents
46. Refuses advice
47. Has headaches
48. Demonstrates critical thinking skills
49. Is creative
50. Seems out of touch with reality
51. Overreacts to stressful situations
52. Annoys others on purpose
53. Has a short attention span
54. Is afraid of getting sick
55. Puts others down
56. Seems lonely
57. Adjusts well to new teachers
58. Stays on task
60. Uses foul language
59. Is clear when telling about personal experiences