Achenbach Child Behavior Checklist for Ages 6 -18

• Child's name

• Gender

• Age

• Child's birthdate

  Date

• Form filled out by

• Relation to child

  Mother

  Father

  Other

• Please specify relation to child

• Date Conducted

  Date

General Information

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

  No

  Yes

  N/A

• 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?

  Yes

  No

  N/A

• Add a sport

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?

  Less than average

  Average

  More than average

  Don't know

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

  Less than average

  Average

  More than average

  Don't know

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

  Yes

  No

  N/A

• Add activity

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?

  Less than average

  Average

  More than average

  Don't know

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

  Less than average

  Average

  More than average

  Don't know

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

  Yes

  No

  N/A

• Add an organization, club, team or group

Organization

• 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?

  Less than average

  Average

  More than average

  Don't know

• Does your child partake in any jobs or chores?

  Yes

  No

  N/A

• 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?

  Less than average

  Average

  More than average

  Don't know

Social Behavior

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

  None

  1

  2 or 3

  4 or more

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

  None

  1

  2 or 3

  4 or more

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

• Does he/ she have any siblings?

  Yes

  No

  N/A

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

  Worse

  Average

  Better

• b. Get along with other kids?

  Worse

  Average

  Better

• c. Behave with his/ her parents?

  Worse

  Average

  Better

• d. Play and work alone?

  Worse

  Average

  Better

Academic Behavior

• Does your child attend schools?

  Yes

  No

  N/A

• If no, please specify reason

• Rate child's performance for each subject

• a. Reading, English or Language arts

  Failing

  Below Average

  Average

  Above Average

• c. Arithmetic or Math

  Failing

  Below Average

  Average

  Above Average

• d. Science

  Failing

  Below Average

  Average

  Above Average

• 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

• Subject Name

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

  Failing

  Below Average

  Average

  Above Average

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

  Yes

  No

  N/A

• Has your child repeated any grades?

  No

  Yes

  N/A

• When did the problems start?

• Have these problems ended?

  Yes

  No

  N/A

• Indicate when

General Behavior

• Acts too young for his/ her age

  Not True

  Somewhat True

  Very True

• Drinks alcohol without parents' approval

  Not True

  Somewhat True

  Very True

• Argues a lot

  Not True

  Somewhat True

  Very True

• Fails to finish things he/ she starts

  Not True

  Somewhat True

  Very True

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

  Not True

  Somewhat True

  Very True

• Bowel movements outside toilet

  Not True

  Somewhat True

  Very True

• Bragging, boasting

  Not True

  Somewhat True

  Very True

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

  Not True

  Somewhat True

  Very True

• Trouble getting his/ her mind off certain thoughts; obsessions

  Not True

  Somewhat True

  Very True

• Can't sit still, restless or hyperactive

  Not True

  Somewhat True

  Very True

• Clings to adults or too dependent

  Not True

  Somewhat True

  Very True

• Complains of loneliness

  Not True

  Somewhat True

  Very True

• Confused or seems to be in a fog

  Not True

  Somewhat True

  Very True

• Cries a lot

  Not True

  Somewhat True

  Very True

• Cruel to animals

  Not True

  Somewhat True

  Very True

• Cruelty, bullying or mean to others

  Not True

  Somewhat True

  Very True

• Daydreams or gets lost in his/ her own thoughts

  Not True

  Somewhat True

  Very True

• Deliberately harms self or attempts suicide

  Not True

  Somewhat True

  Very True

• Demands a lot of attention

  Not True

  Somewhat True

  Very True

• Destroys his/ her or others things on purpose

  Not True

  Somewhat True

  Very True

• Doesn't eat well

  Not True

  Somewhat True

  Very True

• Defiant to rules at home, school or elsewhere

  Not True

  Somewhat True

  Very True

• Doesn't socialize well with other kids

  Not True

  Somewhat True

  Very True

• Doesn't feel any guilt after misbehaving

  Not True

  Somewhat True

  Very True

• Easily jealous

  Not True

  Somewhat True

  Very True

• Fears certain animals, situations or places other than school

  Not True

  Somewhat True

  Very True

• Self-conscious

  Not True

  Somewhat True

  Very True

• Perfectionist

  Not True

  Somewhat True

  Very True

• Feels worthless

  Not True

  Somewhat True

  Very True

• Fells or complains that no one loves him/ her

  Not True

  Somewhat True

  Very True

• Accident prone

  Not True

  Somewhat True

  Very True

• Gets into many fights

  Not True

  Somewhat True

  Very True

• Gets teased a lot

  Not True

  Somewhat True

  Very True

• Hangs around people who are a bad influence

  Not True

  Somewhat True

  Very True

• Hears sound or voices that aren't there

  Not True

  Somewhat True

  Very True

• Impulsive or acts without thinking

  Not True

  Somewhat True

  Very True

• Lying or cheating

  Not True

  Somewhat True

  Very True

• Nervous movements or twitching

  Not True

  Somewhat True

  Very True

• Nightmares or Night terrors

  Not True

  Somewhat True

  Very True

• Constipated

  Not True

  Somewhat True

  Very True

• Too fearful or anxious

  Not True

  Somewhat True

  Very True

• Feels too guilty

  Not True

  Somewhat True

  Very True

• Overeating

  Not True

  Somewhat True

  Very True

• Overtired without good reason

  Not True

  Somewhat True

  Very True

• Overweight

  Not True

  Somewhat True

  Very True

• Physical problems without known medical cause

  Not True

  Somewhat True

  Very True

• Aches or pains (not stomach or headaches)

  Not True

  Somewhat True

  Very True

• headaches

  Not True

  Somewhat True

  Very True

• Nausea or feels sick

  Not True

  Somewhat True

  Very True

• Problems with eyes (not if corrected by glasses)

  Not True

  Somewhat True

  Very True

• Rashes or other skin problems

  Not True

  Somewhat True

  Very True

• Stomachaches

  Not True

  Somewhat True

  Very True

• Vomiting or throwing up

  Not True

  Somewhat True

  Very True

• Others that were not mentioned

Behavior

• Name behavior

• Rate behavior

  Worse

  Average

  Better

Completion

• Name & Signature of Parent/Caregiver

  Sign

• Name & Signature of Assigned Physician

  Sign