Childhood Behaviour Assessment – Parent Report

Assessment 1 of 29

Form Instructions & Things to Know

How to fill this form:
  • Read each question carefully before selecting an answer.
  • Select the most accurate option based on your observations.
  • Do not skip questions; every response helps in the assessment.
Things to know:
10-15 Mins

Estimated completion time.

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Note: This is a screening and assessment tool, not clinical (medical).

First, please provide your contact information.

Information about the individual being assessed.

1. Failed to give close attention to details or made careless mistakes.
2. Had difficulty sustaining attention in tasks or fun activities.
3. Didn’t listen when spoken to directly.
4. Didn’t follow through on instructions and failed to finish work.
5. Had difficulty organising tasks and activities.
6. Avoided, disliked, or was reluctant to engage in activities that required sustained mental effort.
7. Lost things necessary for tasks or activities.
8. Easily distracted.
9. Forgetful in daily activities.
10. Fidgeted with hands or feet or squirmed in seat.
11. Left seat in classroom or other situations in which sitting was expected.
12. Restless in the “squirmy” sense.
13. Had difficulty engaging in leisure activities or doing fun things quietly
14. Was “on the go all the time” or acted as if “driven by a motor”
15. Talked excessively.
16. Blurted out answers before questions had been completed.
17. Had difficulty awaiting turn.
18. Interrupted or intruded on others.
19. To what extent did the problems you identify interfere his/her home life with immediate family.
20. To what extent did the problems you identify interfere his/her social interactions with other children.
21. To what extent did the problems you identify interfere his/her activities or dealings in the community.
22. To what extent did the problems you identify interfere In school.
23. To what extent did the problems you identify interfere In sports, clubs, or other organisations
24. To what extent did the problems you identify interfere in learning to take care of themselves.
25. To what extent did the problems you identify interfere in his/her play, leisure or recreational activities.
26. To what extent did the problems you identify interfere in his/her handling of daily chores or other responsibilities.