Child Behavior Initial Assessment

Today's Date

Child's Name

First Last

Child's Date of Birth

Parent's Name

Parent's Phone Number

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 behaviors in the past 6 months.

Is this evaluation based on a time when the child

was on medication
was not on medication
not sure?

Symptoms

1. Does not pay attention to details or makes careless mistakes with, for example, homework.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

2. Has difficulty keeping attention to what needs to be done.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

3. Does not seem to listen when spoken to directly.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand).

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

5. Has difficulty organizing tasks and activities.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books).

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

8. Is easily distracted by noises or other stimuli.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

9. Is forgetful in daily activities.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

10. Fidgets with hands or feet or squirms in seat.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

11. Leaves seat when remaining seated is expected.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

12. Runs about or climbs too much when remaining seated is expected.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

13. Has difficulty playing or beginning quiet play activities.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

14. Is “on the go” or often acts as if “driven by a motor”.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

15. Talks too much.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

16. Blurts out answers before questions have been completed.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

17. Has difficulty waiting his or her turn.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

18. Interrupts or intrudes in on others’ conversations and/or activities.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

19. Argues with adults.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

20. Loses temper.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

21. Actively defies or refuses to go along with adults’ requests or rules.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

22. Deliberately annoys people .

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

23. Blames others for his or her mistakes or misbehaviors.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

24. Is touchy or easily annoyed by others.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

25. Is angry or resentful.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

Child Behavior Initial Assessment

Step 1 of 2 - NICHQ Vanderbilt Assessment - PARENT Informant

Symptoms

Performance