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

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

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

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

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