Please print

CHILD’S FULL NAME First

CHILD BEHAVIOR CHECKLIST FOR AGES 6-18
Middle Last CHILD’S AGE CHILD’S ETHNIC GROUP MOTHER’S OR RACE

For office use only ID #

CHILD’S GENDER Boy Girl

PARENTS’ USUAL TYPE OF WORK, even if not working now. (Please be specific — for example, auto mechanic, high school teacher, homemaker, laborer, lathe operator, shoe salesman, army sergeant.) FATHER’S TYPE OF WORK ___________________________________________
TYPE OF WORK ___________________________________________ THIS FORM FILLED OUT BY: (print your full name)

TODAY’S DATE Mo. ____ Day ____ Year ______ GRADE IN SCHOOL ___________ NOT ATTENDING SCHOOL

CHILD’S BIRTHDATE Mo. ____ Day ____ Year ____

____________________________________________________
Your gender: Male Female

Please fill out this form to reflect your view of the child’s behavior even if other people might not agree. Feel free to print additional comments beside each item and in the space provided on page 2. Be sure to answer all items.

Your relation to the child: Biological Parent Adoptive Parent Step Parent Foster Parent Grandparent Other (specify)

I. Please list the sports your child most likes to take part in. For example: swimming, baseball, skating, skate boarding, bike riding, fishing, etc. None

Compared to others of the same age, about how much time does he/she spend in each?
Less Than Average More Than Average Don’t Know

Compared to others of the same age, how well does he/she do each one?
Below Average Above Average Don’t Know

a. _________________________ b. _________________________ c. _________________________

II. Please list your child’s favorite hobbies, activities, and games, other than sports. For example: stamps, dolls, books, piano, crafts, cars, computers, singing, etc. (Do not include listening to radio or TV.) None

a. _________________________ b. _________________________ c. _________________________

III. Please list any organizations, clubs, teams, or groups your child belongs to. None

le p m a S
Average Average

Compared to others of the same age, about how much time does he/she spend in each?
More Than Average

Compared to others of the same age, how well does he/she do each one?
Above Average Don’t Know

Less Than Average

Average

Don’t Know

Below Average

Average

Compared to others of the same age, how active is he/she in each?
Average More Active Don’t Know

Less Active

a. _________________________ b. _________________________ c. _________________________

IV. Please list any jobs or chores your child has. For example: paper route, babysitting, making bed, working in store, etc. (Include both paid and unpaid jobs and chores.) None a. _________________________ b. _________________________ c. _________________________

Compared to others of the same age, how well does he/she carry them out?
Below Average Average Above Average Don’t Know

Be sure you answered all items. Then see other side.
Copyright 2001 T. Achenbach ASEBA, University of Vermont 1 South Prospect St., Burlington, VT 05401-3456 www.ASEBA.org

UNAUTHORIZED COPYING IS ILLEGAL
PAGE 1 6-1-01 Edition - 201

V. Do not include gym. how well does your child: Worse Average Better a. foreign language. Behave with his/her parents? d. Has your child had any academic or other problems in school? When did these problems start? _______________ Have these problems ended? No Yes–when? No Yes—please describe: Does your child have any illness or disability (either physical or mental)? No Yes—please describe: What concerns you most about your child? Please describe the best things about your child. driver’s ed. About how many close friends does your child have? (Do not include brothers & sisters) None 1 2 or 3 4 or more 2. Get along with other kids? c. Play and work alone? VII. History or Social Studies c. class. About how many times a week does your child do things with any friends outside of regular school hours? (Do not include brothers & sisters) Less than 1 1 or 2 3 or more VI. Science Other academic subjects–for example: computer courses. PAGE 2 Be sure you answered all items. Get along with his/her brothers & sisters? b. Performance in academic subjects. ____________________________ g. or school: Yes—grades and reasons: 3. Reading. Does your child receive special education or remedial services or attend a special class or special school? No Yes—kind of services. Compared to others of his/her age. 1. Arithmetic or Math d. or other nonacademic subjects. Be sure to answer all items. or Language Arts b. ____________________________ f. business. shop. ____________________________ No 4. 1. Has your child repeated any grades? le p m a S Failing Below Average Average Above Average Does not attend school because ______________________________ _________________________________________________________ e..Please print. Has no brothers or sisters Check a box for each subject that child takes a. English. 2. .

please circle the 2 if the item is very true or often true of your child. Can’t get his/her mind off certain thoughts. Gets in many fights 0 1 0 1 0 1 0 1 0 1 0 1 0 1 2 2 2 2 2 2 2 7. Be sure to answer all items. If the item is not true of your child. Too fearful or anxious 51. Daydreams or gets lost in his/her thoughts 18. Cries a lot 15. Feels others are out to get him/her 35. Demands a lot of attention 20. school. doesn’t move bowels 0 1 0 1 2 2 56. Circle the 1 if the item is somewhat or sometimes true of your child. or places. Bragging. accident-prone 37. Doesn’t seem to feel guilty after misbehaving 27. Constipated. Nightmares 48. Problems with eyes (not if corrected by glasses) (describe): _____________ _____________________________ e. Breaks rules at home. Stomachaches g. other than school (describe): ______ _____________________________ 30. Overeating 54. Nausea. Feels he/she has to be perfect 33. Please answer all items as well as you can. Cruel to animals 16. Other (describe): _______________ _____________________________ Be sure you answered all items. situations. Can’t sit still. Bowel movements outside toilet 32. Deliberately harms self or attempts suicide 19. Physical problems without known medical cause: a. Confused or seems to be in a fog 14. Cruelty. Feels or complains that no one loves him/ her 34. feels sick d. Acts too young for his/her age 2. Destroys things belonging to his/her family or others 22. bullying. Hangs around with others who get in trouble 40. Fears he/she might think or do something bad 46. Nervous movements or twitching (describe): ____________________ _____________________________ _____________________________ 47. Vomiting. Then see other side. can’t pay attention for long 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 9. Complains of loneliness 13. Gets teased a lot 39. Easily jealous 28. Hears sound or voices that aren’t there (describe): ____________________ _____________________________ 41. 0 = Not True (as far as you know) 0 1 0 1 2 2 1 = Somewhat or Sometimes True 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 2 2 2 2 2 2 2 2 2 2 = Very True or Often True 1. even if some do not seem to apply to your child. obsessions (describe): ___________ _____________________________ 10. boasting 8. Feels dizzy or lightheaded 52. Disobedient at home 23. Would rather be alone than with others 43. Lying or cheating 17. . Feels too guilty 53. Destroys his/her own things 21. Overweight 0 0 0 0 1 1 1 1 2 2 2 2 0 0 0 0 1 1 1 1 2 2 2 2 PAGE 3 38. Bites fingernails 45. Fears going to school 31. Impulsive or acts without thinking 42. Fears certain animals. Gets hurt a lot. There is very little he/she enjoys 6. or meanness to others le p m a S 0 1 0 1 0 1 0 1 0 1 0 1 2 2 2 2 2 2 44. Aches or pains (not stomach or headaches) b. Drinks alcohol without parents’ approval (describe): _____________________ _____________________________ 3. Headaches c. Disobedient at school 24. restless. Overtired without good reason 55. Fails to finish things he/she starts 5.Please print. Nervous. or hyperactive 11. Clings to adults or too dependent 12. throwing up h. highstrung. Doesn’t get along with other kids 26. For each item that describes your child now or within the past 6 months. or elsewhere 29. Not liked by other kids 49. Can’t concentrate. Below is a list of items that describe children and youths. Argues a lot 4. Doesn’t eat well 25. or tense 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1 2 2 2 2 2 2 2 2 2 50. circle the 0. Feels worthless or inferior 36. Rashes or other skin problems f.

skin. Poorly coordinated or clumsy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 84. Plays with own sex parts in public 60. Steals outside the home 83. chews. Strange ideas (describe): ____________ ________________________________ 86. Physically attacks people 58. Inattentive or easily distracted 79. Wets the bed 109. sad. Worries 113. Talks or walks in sleep (describe): _____ ________________________________ 93. Stores up too many things he/she doesn’t need (describe): ___________________ ________________________________ ________________________________ 110. Thumb-sucking 99. 0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True 0 0 1 1 2 2 57. Sleeps more than most kids during day and/or night (describe): ______________ ________________________________ 78. Speech problem (describe): __________ ________________________________ 80. Sulks a lot 89. Threatens people 0 0 0 0 0 0 0 1 1 1 1 1 1 1 2 2 2 2 2 2 2 106. Picks nose. Trouble sleeping (describe): _________ ________________________________ 101. Vandalism 107. Stubborn. Suspicious 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 63. Steals at home 82. Secretive. Truancy. slow moving. Poor school work 62. Withdrawn. Please write in any problems your child has that were not listed above: ________________________________ ________________________________ ________________________________ Please be sure you answered all items. Talks about killing self 94. Temper tantrums or hot temper 96. compulsions (describe): _____________ ________________________________ 67. Self-conscious or easily embarrassed 72. Wets self during the day 108. Underactive. Uses drugs for nonmedical purposes (don’t include alcohol or tobacco) (describe): _ ________________________________ ________________________________ 0 0 0 0 0 0 1 1 1 1 1 1 2 2 2 2 2 2 77. Stares blankly 81. Wishes to be of opposite sex 111. skips school 102. Sudden changes in mood or feelings 88. Sleeps less than most kids le p m a S 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 90.Please print. Whining 0 0 0 1 1 1 2 2 2 PAGE 4 92. or irritable 87. keeps things to self 70. Sees things that aren’t there (describe): _ ________________________________ ________________________________ 71. Unusually loud 105. doesn’t get involved with others 112. Swearing or obscene language 91. Teases a lot 95. Sexual problems (describe): __________ ________________________________ ________________________________ 74. Runs away from home 68. Prefers being with younger kids 65. or other parts of body (describe): ________________________ ________________________________ 59. Be sure to answer all items. Showing off or clowning 75. Repeats certain acts over and over. Smokes. Strange behavior (describe): __________ ________________________________ 85. Prefers being with older kids 64. Plays with own sex parts too much 61. sullen. or lacks energy 103. Thinks about sex too much 97. Screams a lot 0 0 0 0 1 1 1 1 2 2 2 2 69. Too shy or timid 76. Talks too much 98. or sniffs tobacco 100. Sets fires 0 0 0 1 1 1 2 2 2 0 0 0 0 1 1 1 1 2 2 2 2 73. . Unhappy. or depressed 104. Refuses to talk 66.

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