Child Behavior Checklist for Ages 6-18

Child's Full Name *
Child's Gender * Child's Age *
Today's Date* Child's Birth date *
Not Attending School* Grade in school *
Compare to others of the same age,about how much time does he/she spen in each? Compare to others of the same age,about how well does he/she do each one?
None Less than average Average More than average Don't know Below average Average Above average Don't know
1. Please list the sports your child most likes to take part in (For Example:swimming,baseball,skating,skate boarding,bike riding,fishing.etc.)
2. Please list your child favorite hobbies,activities,and games,other then sports(For Example:video games,dolls,reading,piano crafts,cars,computers,singing,etc.)
3. Please list any organizations,clubs,teams, or groups your child belongs to.
4. Please list any jobs or chores your child has.
5. a. About how many close friends does your child have ?(Do not include brothers & sisters)
5. b. About how many times a week does your child do things with any friends outside of regular school hours?(Do not include brothers & sisters).
Worse Average Better Has no brothers or sisters
6. Compare to others of his/her age,how well does your child
a. Get along with his/her brothers & sisters ?
b. Get along with other kids?
c. Behave with his/her parents?
d. Play and work alone?
b. Get along with other kids?
7. Perfomance in academics
Check a box for each subject that child takes
Failing Below Average Average Above Average
a. Reading, English or Languages Arts
b. History or Social Studies
c. Arithmetic or Math
d. Science
What concerns you most about your child?
Please describe the best things about your child.
Below is a list of items that describe children and youths. For each item that describes your child now or with in the past 6 months, please circle the 2 if the item is very true or often true of your child.Circle the 1 if the item is somewhat or sometimes true of your child. If the item is not true of your child, circle the 0. Please answer all items as well as you can,even if some do not seem to apply to your child.

Not True (as far as you know ) Somewhat or Sometimes True Very True or Often True
1.Acts too young for his/her age
2.Drinks alcohol without parents' approval(describe):
3.Argues a lot
4.Fails to finish things he/she starts
5.There is very little he/she enjoys
6.Bowel movements outside toilet
7.Bragging,boasting
8.Can't concentrate, can't pay attention for long
9.Can't get his/her mind off certain thoughts; obessions(describes:)
10. Can,t sit still,restless,or hyperactive
11.Clings to adults or too dependent
12.Complains of loneliness
13.Confused or seems to be in a fog
14.Cries a lot
15.Cruel to Animals
16.Cruelty,bullying,or meanness to others
17.Daydreams or gets lost in his/her thoughts
18.Delibertaly harms self or attempts suicide
19.Demands a lot attention
20.Destorys his/her own things
21.Destroys things belonging to his/her family or others
22.Disobedient at others
23.Disobedient at school
24.Does'nt eat well
25.Does'nt get along with other kids
26.Does'nt seem to feel guilty after misbehaving
27.Easily jealous
28.Breaks rules at home, school, or elsewhere
29.Fears certain animals,situations,or places, other than school(describe):
30.Fears going to school
31.Fears he/she might think or do something bad
32.Feel he/she has to be perfect
33.Feels or complains that no one loves him/her
34.Feels others are out to get him/her
35.Feels worthless or inferior
36.Gets hurt a lot, accident-prone
37.Gets in many fights
38.Gets teased alot
39.Hangs around with others who get in trouble
40.Hears sound or voices that aren't there (describe):
41.Impulsive or acts without thinking
42.Would rather be alone than with others
43.Lying or cheating
44.Bites fingernails
45.Nervous,highstrung,or tense
46.Nervous movements or twitching(describe):
47.Nightmares
48.Not liked by other kids
49.Constipated,doesn't move bowels
50.Too fearful or anxious
51.Feels dizzy or lightheaded
52.Feels to guilty
53.Overeating
54.Overtired without good reason
55.Overweight
56.Physical problems without known medial cause:
57.Physically attacks people
58.Picks nose,skin,or other parts of body(describe):
59.Plays with own sex parts in public
60.Plays with own sex parts too much
61.Poor school work
62.Poorly coordinated or clumsy
63.Prefers being with older kids
64.Prefers being with younger kids
65.Refuses to talk
66.Repeats certain acts over and over, compulsions(describe):
67.Runs away from home
68.Sreams a lot
69.Secretive, keeps things to self
70.Sees things that aren't there (describe):
71.Self-conscious or easily embarrassed
72.Sets fires
73.Sexual problems(describe):
74.Showing off or cloning
75.Too shy or timid
76.Sleeps less than most kids
77.Sleeps more than most kids during day and/or night(describe):
78.Inattentive or easily distracted
79.Speech problem(describe):
80.Stares blankly
81.Steals at home
82.Steals outside the home
83.Stores up too many things he/she doesn't need (describe):
84.Strange behaviour(describe):
85.Strange ideas(describe):
86.Stubborn,sullen, or irritable
87.Sudden changes in mood or feelings
88.Sulks a lot
89.Suspicious
90.Swearing or obscene language
91.Talks about killing self
92.Talks or walks in sleep(describe):
93.Talks too much
94.Teases a lot
95.Temper tantrums or hot temper
96.Thinks about sex too much
97.Threaten people
98.Thumb-sucking
99.Smokes,chews,or sniffs tobacco
100.Trouble sleeping(describe):
101.Trauncy ,skips school
102.Underactive,slow moving, or lacks energy
103.Unhappy, sad,or depressed
104.Unusually loud
105.Uses drugs for nonmedical purposes(don't include acohol or tobacco)(describe):
106.Vandalism
107. Wets self during the day
108.Wets the bed
109.Whining
110.Wishes to be a opposite sex
111.Withdrawn,does'nt get involved with others
112.Worries
113.Please write in any problems your child has that were not listed above: