ADHD Assessment-Teacher Interview

Student Name: ______________________________ Grade: _______ Interview Date: ______________

Teacher: ______________________________

1. Do you have to make sure that the student is paying attention before giving instructions, directions, or asking
questions? Yes or No (circle one)

2. What redirection to task method works best for you and the student?
___________________________________________________________________________________________

3. Do you have to check if the student understood directions and material being taught? Yes or No (circle one)

4. Which "checking for understanding” method works best for you and the student?
___________________________________________________________________________________________

5. Does the student follow directions / instructions?

1 2 3 4
Not at all Occasionally Frequently Nearly all the time

6. Does the student complete school/home assignments to the best of his ability?
1 2 3 4
Not at all Occasionally Frequently Nearly all the time

7. Does the student avoid or is he/she reluctant to maintain attention/focus on instructional material presented?
Yes or No (circle one)

8. How frequently do you have to redirect his/her attention to task during a lesson?
1 2 3 4
Not at all Occasionally Frequently Nearly all the time
(0 -1) (2-3) (4) (5 + )

9. Do you attempt to engage the student in the lesson by asking questions that he/she can answer?
Yes or No (circle one)

10. Is the material instructionally appropriate for the student? Yes or No (circle one))
If no please, explain:
___________________________________________________________________________________________
___________________________________________________________________________________________

11. Does the student claim to forget things or have difficulty keeping track of his/her belongings, school materials,
and school assignments? Yes or No (circle one))

12. How often would you have to organize, supply or find materials for the student during a day?
1 2 3 4
Not at all Occasionally Frequently Nearly all the time
(0 -1) (2-3) (4) (5 + )
13. Which distracting/disrupting behavior(s) does the student present? (please check all that apply)
 playing with objects
 staring/inactivity
 loses place/things
 slow to begin task
 blurt out answers
 excessive fidgeting/movements
 excessive noises
 out of seat
Other ____________________________________________________________________

14. What are your best methods to handle distracting/disruptive behaviors?

____________________________________________________________________________

15. Does the student display appropriate social interactions?

Student – Teacher
1 2 3 4
Not at all Occasionally Frequently Nearly all the time
Student – Student
1 2 3 4
Not at all Occasionally Frequently Nearly all the time

16. How would you rank the student in social skills?

1 2 3
Highest quarter of class Average range Lowest quarter of class

17. Is there a time of day or setting that the student appears to have more difficulty attending or presents more
distracting/disruptive behaviors? Yes or No (circle one) If yes, time of day:__________________

18. Are there any factors that seem to make the behavior worse? Yes or No (circle one))
If yes, what are the factors:_________________________________________

19. Describe any physical symptoms of concern? (stomach pains, excessive sleepiness, headaches)
_____________________________________________________________________________

20. What are some of the activities, experiences, or opportunities the student sees as rewarding or positively
reinforcing in school?
_____________________________________________________________________________

Additional Comments:
__________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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