Child's Behavior Assessment form

Vanderbilt Assessment-PARENT Informant
Today's Date*

MonthDayYear
Child's Name*

First NameLast Name
Today's Date*

MonthDayYear
Parent's Phone Number*
Parent's Name*

First NameLast Name
Is this evaluation based on a time when the child:*

was on medicationwas not on medicationnot sure?

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

	Never	Occasionally	Often	Very Often
1. Does not pay attention to details or makes careless mistakes, such as in home-work
2. Has difficulty keeping 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 schoolwork (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
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when remaining in seated is expected
12. Runs about or climbs excessively when 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 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 (butts into conversations or games)
19. Argues with adults
20. Loses temper
21. Actively defies or refuses to comply 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
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 other's 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
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

Performance*

	Problematic		Average		Above Average
Overall School Perfomance
Reading
Writing
Mathematics
Relationship w/ parents
Relationship w/ siblings
Relationship w/ peers
Participation in organized activities (e.g. teams)

Should be Empty:

Vanderbilt Assessment-PARENT Informant