Associated Therapists Inc.
(714) 898-0362 Corporate Office
(714) 893-3267 Fax

Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child's behavior in the past 6 months.

Is this evaluation based on a time when the child was:
 NeverOccasionallyOftenVery Often
1. Does not pay attention to details or makes careless mistakes with, for example, homework.
2. Has difficulty keeping attention to what needs to be done.
3. Does not seem to listen when spoken to directly.
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand).
5. Has difficulty organizing tasks and activities.
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort.
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books).
8. Is easily distracted by noises or other stimuli.
9. Is forgetful in daily activities.
 NeverOccasionallyOftenVery Often
10. Fidgets with hands or feet or squirms in seat.
11. Leaves seat when remaining seated is expected.
12. Runs about or climbs too much when remaining seated is expected.
13. Has difficulty playing or beginning quiet play activities.
14. Is “on the go” or often acts as if “driven by a motor”.
15. Talks too much.
16. Blurts out answers before questions have been completed.
17. Has difficulty waiting his or her turn.
18. Interrupts or intrudes in on others’ conversations and/or activities
 NeverOccasionallyOftenVery Often
19. Argues with adults.
20. Loses temper.
21. Actively defies or refuses to go along with adults’ requests or rules.
22. Deliberately annoys people.
23. Blames others for his or her mistakes or misbehaviors.
24. Is touchy or easily annoyed by others.
25. Is angry or resentful.
26. Is spiteful and wants to get even.
 NeverOccasionallyOftenVery Often
27. Bullies, threatens, or intimidates others.
28. Starts physical fights.
29. Lies to get out of trouble or to avoid obligations (ie, “cons” others).
30. Is truant from school (skips school) without permission.
31. Is physically cruel to people.
32. Has stolen things that have value.
33. Deliberately destroys others’ property.
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun).
35. Is physically cruel to animals.
36. Has deliberately set fires to cause damage.
37. Has broken into someone else’s home, business, or car.
38. Has stayed out at night without permission.
39. Has run away from home overnight.
40. Has forced someone into sexual activity.
 NeverOccasionallyOftenVery Often
41. Is fearful, anxious, or worried.
42. Is afraid to try new things for fear of making mistakes.
43. Feels worthless or inferior.
44. Blames self for problems, feels guilty.
45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”.
46. Is sad, unhappy, or depressed.
47. Is self-conscious or easily embarrassed.
 ExcellentAbove AverageAverageSomewhat of a problemProblematic
48. Overall school performance.
49. Reading.
50. Writing.
51. Mathematics.
52. Relationship with parents.
53. Relationship with siblings.
54. Relationship with peers.
55. Participation in organized activities (eg, teams)
0/500 characters
Form by NICHQ
National Inititative for Children's Healthcare Quality (2002).

Thank you for your time and information. The information will be securely sent to the Associated Therapists Office and will be forwarded to the appropriate doctor, nurse or therapist.