@ vreaseprinn CHiLp BEHAVIOR CHECKLIST FOR AGES 6-18 [Faicoomoy joe CHILDS Fist ‘Middle ‘ast [PARENTS' USUAL TYPE OF WORK, even if not working now. FULL (Peace be spel — for example, alo mechan high schoo teach, NAME ramerake abr ao cpa, she sabsman, amy epee) GHDS GENDER | GADSAGE | GRIDS TNCEROUP| ATES ony Oley Dsia ORRACE IMoTHERs 7 F WORK TODAVSDATE CHILD'S BIRTHDATE TYPE OF ee Mo, Day __ Year__|wo. __Day _. Year_ [THIS FORM FILLED OUT BY: (print your fut name) Pease fl out hi orm 0 rect euoen Tome moaneteme ina ee |aronde: vas CFenae oop might not agree. Fel ee tO | Your relation the cit: worsrrenowe | Eiaaiteraeonmerbeaeast | TT een CJeep Pu Cornu SCHOOL C1 | 2 Be sure to.answer ail ems. CAdoptive Parent ClFosterParent Cote (epecty) {Please list the sports your child most ikes Compared to others ofthe same ‘Compared to other ofthe to takepart In. For exarpie: sling, age, about how much time does same age, how well does, baseba kan, skateboarding, Dike io’she spendin each? he/she do each one? ‘cing, fishing, etc. ‘Less Than (More Than Don’t Below Above Don’t 0 Nene frenae’ avenge “Svesge’ KRoow Average Average rage Room . oo oO a ao a 0 0 > ao o 9 oO o oF oF ©@ ° _ o oF oa ao a oa iL Please ist your chia’ favorte hobbies, ‘Compared to others ofthe same ‘Compared to others ofthe same actives, and games, other than spor. age, about how much time does ‘age, how well does he/she do For example: stamps, dolls, books, plano, he/she spend In each? each one? crafts, cars, computers, singing, etc. (Do not Incude istering o ralo or TV) Less Than WoreTman Dont Slow vor ont None ‘erae’ rere “Arorue' Koon Average argo rage Koo 2 o oOo Oo oO oo) 6006 [6Ol6lUO 8 o oF oO GO oo Goo eo o o oo oo aoio il Please let any organizations, clube, teams, Compared to athere ofthe same ‘oF groups your child belongs to. age, how actve Is he/she in each? D None Ade verge Acne Koo @ oa ao a a ® o oF go a ® oo ao 0 IV. Please list any jobs or chores your child has. Compared to others of the same For example: paper route, babysitting, making age, how well does he/she carry bed, working in store, etc. (Include both paid ‘them out? and unpaid jobs and chores.) ow vows Dont None fee rere eae Kant a ao Oo 3 Ga . ao go 9 8 Be sure you answered all & aq ao ag a items. Then see other side. ‘capyigit 20017. each AGE, thivety of Uae 1Lenth Prospact &., Rciegin, VP OS 3655 wae ER UNAUTHORIZED COPYING IS ILLEGAL 641-01 Ealtion - 201 PAGE?Please print. Be sure to answer all items. \V. 1. About how many close friends does your child have? (Do not Include brothers & sisters) Cone = 1 C2ora — 4ormore 2 About how many times a week does your child do things with any friends outside of regular schoo! hours? (Po not include brothers & sisters) Clessthant = Ctior2 = 13 or more VL. Compared to others of his/her age, how well does your chi Worse Average Better 2 Get alongwith hismer broters asters? =» Hasno brothers or sisters , Get along with other kids? o oF Qa . Behave with hisiner parents? ao aoa 4. Play and work alone? oa oa a ‘Vil, 1. Pertormance in academic subjects. Ciooes not attend school because ion bore Chock a box foreach subject that child tekos Fllng vargn Avroge vag aReacng, Engish oranges «=O ‘Other academic 'b. History or Social Studies a a a a Bie ee. tet or Math o of oa coimes00" 4 sence og a oo cist gym shop, o o Go oO Guero or t a a o a Secs g, oo oOo og 2. Does your child receive special education or remedial services or attend a special class or special schoo'? CINo — Cl¥es—kind of services, class, or school: 3. Has your child repeated any grades? CNo ClYes—grades and reasons: 4, Has your child had any academie or other problems in school? CINo CYes—please describe: ‘When did these problems start? Have these problems ended? CINo ClYes-when? oes your child have any lliness or disability (either physical ormemay? C]No — Clyes—please descr ‘What concerns you mest about your child? Please describe the best things about your child. PAGE2 Be sure you answered all items.Ploase print. Be sure to answer ail items. Below is a list of items that describe chiidren and youths. For each Rem that describes your child now or within the past 6 ‘months, please circle the 2if the temis very true or often true of your child. Circe the 1 ifthe item is somewhat or sometimes ‘rue of your chid. I the em is net true ot your child, circle the 0. Please answer al items as well as you can, even if some do not 0 = Not True (as far as you know) ‘1 = Somewhat or Sometimes True 2=Very True or Otten True ‘Acts too young tor hisher aga ‘Drinks alcohol wthout parents’ approval (deserve) ‘Acgues a tot Falls to nish things hetshe stars ‘There is very lite he/she enjoys Bowel movements outside tlle Bragaing, boasting ‘Cart concentrate, can't pay attention for tong (Gant get hismer ming of certain moughts; ‘obsessions (describe): Cant sit stl, restless, or hyperactive ‘Clings to adults or too dependent ‘Complains ofionetiness ‘Confused or seems tobe ina fog Gries alot ‘Cruel to animals ‘Cruelty, bullying, or meanness to others Daydreams or gets istinhisiner thoughts Deliberately harms se or attempts suicide Demands a otof attention Destrays hismer own things. Destroys things belonging to his her family or others Disobedient at home Disobedient at school Doesnt eat well 3. Doesnt get along with other kids Doesn't seem to fee! guilty ater misbehaving Easily jealous Breaks rules at home, school, or elsewhere Fears certain animals, situations, or places, ctner than schoo! (describe): ‘seem to apply to your child. o12 1 o12 2 o12 3a o12 4 o12 5 012 6 o1r2 7 o12 8 o12 2 o1 2 10 o12 1 or 2 12 o12 19 or 2 14 o1 2 15 o1 2 16 o12 7 01 2 18 012 1 o12 04 2 24 01 2 2 012 2 O12 m 01 2 2 012 012 27 O12 2 o1 2 2 01 2 9 Fears going to school Fears he/she might think or do something bad ee ee ce ee oe 6 ee oe 8 8 ee ce ce ce ecoe ecoe 88 & 8 8 3A 35. 36. a. ae BR BRS SR 28 ses epee Fere Feels helshe has tobe perfoct Fee's or complains that no one loves hinvher Feels others are out to get himmer Feets worthiess or interior Gets hurt alot, accident-prone Gets in many fights Gets teased a lot Hangs around with others who get In trouble ears sound or volees that arent there (Geserbe): 1. impulsive or acts without thinking ‘Would rather be alone than with others Lyng or cheating Bites ingernalis "Nervous, highstrung, or tense "Nervous movements or twitching (describe): 7. Nightmares Not tked by otner kids Constipated, doesnt move bowels “Too feartul or anxious Feels dizy or ightheaded Fee's too guity Overeating vertred witnout goed reason Overweight Physical problems without known medical ‘Aches or pains (nat stomach or headaches) Headaches Nausea, feels sick Problems with eyes (notit corrected by glasses) (describe): ‘Rashes of other skin problems ‘Stomachaches Vomiting, trowing up ther (describe): PAGE3 Bo cure you anwored all tome. Thon ceo other cide.Please print. Be sure to answer all items. (= Not True (as far as you know) 1 = Somewhat or Sometimes True 2=Very True or Often True © 1 2. 57, Phystcayatacks peorte 0 1 2 64. Srangebenavor (desert: 0 1 2 58, Picks rose, skin, or other parts of body (oescrtoe): © 1 2 85. Stange Weas (Gescrbe) 0 1 2 59, Plyswinown sexpars in pubic © 1 2 86, subbom, sullen, or ible 0 1 2 60. Playswitn own sexpars too much © 1 2 87. Sudden changes in mood or feetngs 0 1 2 61. Poorschootwork 0 1 2 86, Suksalot © 1 2 62 Poorly coordinated or cumsy 0 1 2 88 Suspidous © 1 2 6 Preters being wih older kids 0 1 2 80, Swearing or obscene language 0 1 2-64, Pretersbelng with younger Kids 0 1 2 St. Taks about iting set 0 1 2 65 Retusestotak © 1 2 92, Taksorwalks in sleep (deserve): __ 0 1 2 66 Repeats cerain acts over and over; compulsions (describe): 0 1 2 98, Taksioo much 0 4 2 9%, Teasesatct © 1 2. 67, Runsawaytromnome 0 1 2. 95. Tompertantums orhot temper © 1 2 88 Screams alot © 1 2 96, Thinksabout sextoo much 0 1 2 68, Secretve, keaps things to selt 0 1 2 97, Tvestens people © 1 2 70. Seestings mat arent mere (cescro 0 1 2 e@. Tumbavoeng © 1 2 99. Smokes, chews, orsnis tobacco 0 1 2 71. Setteansclous or easly embarrassed 0 1 2 100, Trouble steeping (describe 12 72 setsm ° Setsties © 1 2 401, Truaney, expe schoo! 12 78. Sexalproblems(ceserbe) ° 7% ins (eeseoe): © 1 2 102. Underactve, sow moving or lacks eneroy © 1 2 108. Unnapoy, sad or depressed © 1 2. 74 Showing off or owning 0 1 2 104 Unusual oud 0 1 2 75 Teostyertims © 1 2 105. Uses drugs for nonmedleal puposes (dont O12 Te Seonelccs ten mostiids Include alcohol or tobacco) (describe): 0 1 2 77. Steeps more than mos kids Curing day andor ian (describe ah (cose © 1 2 106 Vandaiism 0 4 2 78, inattentive or easy cisracted 0 1 2107, Wels set autng ne diy 0 4 2 108, Wetsthe bed © 1 2 78 speech problem (ceserbe) Brobiem (cesere) 0 4 2 108. Whining 0 1 2 60. Sares lanky 0 1 2 110, Wishesto be of oppose sex 0 1 2 Bt Steasatnome © 1 2111, witnrawn, doesn get ivatved wth others 0 1 2 82 Stalsoutsie trenome 0 1 2 112 Womes 113. Please wie in ay problems your chiles 0 1 2 68. stores uptoo many trings netsne doesnt ete, tat were ne ted above: o12 012 012 PAGES Please be sure you answered all heme.