General Information

Does your child have any illness or disability (either physical or mental)

Please indicate

What concerns you most about the child?

Please describe the best things about your child

Activity assessment

Does the child partake in any sports?

Add a sport


Please enter the sport your child most likes to take part in. (i.e swimming, baseball, skating etc)

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

Compared to others of the same age, how well does he/ she do each one?

Does the child partake in hobbies, activities and games other than sport?

Add activity


Please enter your child's favorite hobbies, activities and games other than sports. (i.e video games, dolls, reading, piano, arts and crafts, etc) ** Do not include listening to radio, TV, or other media

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

Compared to others of the same age, how well does he/ she do each one?

Is your child a member of any organization, club, team or group?

Add an organization, club, team or group


Please list any organizations, clubs, teams or group your child belongs to

Compared to others of the same age, how active is he/ she in each?

Does your child partake in any jobs or chores?

Add jobs or chores

Job / Chore

Please list any jobs or chores your child has. (i.e doing dishes, babysitting, make bed, etc)

Compared to others of the same age, how well does he/ she carry them out?

Social Behavior

About how many friends does your child have? (Do not include brothers & sisters)

About how many times a week does your child do things with any friends outside of regular school hours? (Do not include brothers & sisters)

Compared to others of his/ her age, how well does your child:

Does he/ she have any siblings?

a. Get along with his/ her brothers & sisters?

b. Get along with other kids?

c. Behave with his/ her parents?

d. Play and work alone?

Academic Behavior

Does your child attend schools?

If no, please specify reason

Rate child's performance for each subject

a. Reading, English or Language arts

c. Arithmetic or Math

d. Science

Other academic subjects (i.e computer courses, foreign language, business etc)
** Do not include gym, shop, driver's ed or other non-academic subject


Subject Name

How would you rate child's performance on the subject?

Does your child receive special education, remedial services, attend a special class or special school?

Has your child repeated any grades?

When did the problems start?

Have these problems ended?

Indicate when

General Behavior

Acts too young for his/ her age

Drinks alcohol without parents' approval

Argues a lot

Fails to finish things he/ she starts

There are very little or a few things that he/ she enjoys

Bowel movements outside toilet

Bragging, boasting

Trouble concentrating or can't pay attention for a longer time

Trouble getting his/ her mind off certain thoughts; obsessions

Can't sit still, restless or hyperactive

Clings to adults or too dependent

Complains of loneliness

Confused or seems to be in a fog

Cries a lot

Cruel to animals

Cruelty, bullying or mean to others

Daydreams or gets lost in his/ her own thoughts

Deliberately harms self or attempts suicide

Demands a lot of attention

Destroys his/ her or others things on purpose

Doesn't eat well

Defiant to rules at home, school or elsewhere

Doesn't socialize well with other kids

Doesn't feel any guilt after misbehaving

Easily jealous

Fears certain animals, situations or places other than school



Feels worthless

Fells or complains that no one loves him/ her

Accident prone

Gets into many fights

Gets teased a lot

Hangs around people who are a bad influence

Hears sound or voices that aren't there

Impulsive or acts without thinking

Lying or cheating

Nervous movements or twitching

Nightmares or Night terrors


Too fearful or anxious

Feels too guilty


Overtired without good reason


Physical problems without known medical cause

Aches or pains (not stomach or headaches)


Nausea or feels sick

Problems with eyes (not if corrected by glasses)

Rashes or other skin problems


Vomiting or throwing up

Others that were not mentioned


Name behavior

Rate behavior

Name & Signature of Parent/Caregiver
Name & Signature of Assigned Physician