Associated Therapists Inc.
Julio J. Guerra, Ph.D.

(714) 898-0362 Corporate Office
(714) 893-3267 Fax
www.associatedtherapists.com
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Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child’s behavior since the beginning of the school year.

Is this evaluation based on a time when the child was:
Symptoms
 NeverOccasionallyOftenVery Often
1. Fails to give attention or makes careless mistakes in schoolwork.
2. Has difficulty sustaining attention to tasks or activities.
3. Does not seem to listen when spoken to directly.
4. Does not follow through on instruction and fails to finish school work (not due to oppositional behavior or failure to understand).
5. Has difficulty organizing tasks and activities.
6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort.
7. Loses things necessary for tasks or activities (school assignments, pencils, or books).
8. Is easily distracted by extraneous stimuli.
9. Is forgetful in daily activities.
 NeverOccasionallyOftenVery Often
10. Fidgets with hands or feet or squirms in seat.
11. Leaves seat in classroom or in other situations in which remaining seated is expected.
12. Runs about or climbs excessively in situations in which remaining seated is expected.
13. Has difficulty playing or engaging in leisure activities quietly.
14. Is "on the go" or often acts as if "driven by a motor".
15. Talks excessively.
16. Blurts out answers before questions have been completed.
17. Has difficulty waiting in line.
18. Interrupts or intrudes on others (e.g., butts into conversations/games).
 NeverOccasionallyOftenVery Often
19. Loses temper.
20. Actively defies or refuses to comply with adult's requests or rules.
21. Is angry or resentful.
22. Is spiteful and vindictive.
23. Bullies, threatens, or intimidates others.
24. Initiates physical fights.
25. Lies to obtain goods for favors or to avoid obligations (e.g., "cons" others).
26. Is physically cruel to people.
27. Has stolen items of nontrivial value.
28. Deliberately destroys other's property.
 NeverOccasionallyOftenVery Often
29. Is fearful, anxious, or worried.
30. Is self-conscious or easily embarrassed.
31. Is afraid to try new things for fear of making mistakes.
32. Feels worthless or inferior.
33. Blames self for problems; feels guilty.
34. Feels lonely, unwanted, or unloved; complains that "no one loves him/her".
35. Is sad, unhappy, or depressed.
Academic Performance
 ExcellentAbove AverageAverageSomewhat of a problemProblematic
36. Reading
37. Mathematics
38. Written Expression
Classroom Behavioral Performance
 ExcellentAbove AverageAverageSomewhat of A ProblemProblematic
39. Relationship with peers
40. Following directions
41. Disrupting class
42. Assignment completion
43. Organizational skills
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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 Dr. Guerra.