BAARS-IV OTHER-REPORT CHILDHOOD ONLY

Date

Name of Person Being Rated (the client)

First Name Last Name

Name of Person Completing Form (your name)

First Name Last Name

What is your relationship to the person being rated?

Mother Father Brother/Sister Other

If other, please describe your how you knew the person being rated between the ages of 5-12.

You are being asked to describe the behavior of someone whom you know well. How often did that person experience each of these problems? Please check the circle next to each item below that best describes their behavior when they were a child BETWEEN 5 AND 12 YEARS OF AGE

	Never or Rarely;	Sometimes;	Often;	Very Often;
Failed to give close attention to details or made careless mistakes in work or other activities:
Had difficulty sustaining attention in tasks or fun activities:
Didn’t listen when spoken to directly:
Didn’t follow through on instructions and failed to finish work or chores:
Had difficulty organizing tasks and activities:
Avoided, disliked, or was reluctant to engage in tasks that required sustained mental effort:
Lost things necessary for tasks or activities:
Easily distracted by extraneous stimuli or irrelevant thoughts:
Forgetful in daily activities:
Fidgeted with hands or feet or squirmed in seat:
Left seat in classrooms or in other situations in which remaining seated was expected:
Shifted around excessively or felt restless or hemmed in:
Had difficulty engaging in leisure activities quietly (felt uncomfortable, or was loud or noisy):
Was “on the go” or acted as if “driven by a motor” (or felt like they had to be busy or always doing something):
Talked excessively (in social situations):
Blurted out answers before questions had been completed, completed others’ sentences, or jumped the gun:
Had difficulty awaiting their turn:
Interrupted or intruded on others (butt into conversations or activities without permission or took over what others were doing):

Did the person experience any of these symptoms at least “Often” or more frequently prior to age 18?

Yes No

If so, in which of these settings did those symptoms impair the person's functioning? Place a check mark next to all of the areas that apply.

School Home Social Relationships

If you checked any of the domains indicating settings in which symptoms impair your functioning, please provide examples of your current difficulties in the appropriate spaces below.

School:

Home:

Social Relationships:

Inattention Score

Hyperactive Impulsivity Score

BAARS-IV CHILDHOOD OTHER-REPORT