Full Name *
Gender * Age *
Today's Date Child's Birth date
Not Attending School Grade in school *

PARENTS’ USUAL TYPE OF WORK, even if not working now. (Please be specific — for example, auto mechanic, high school teacher, homemaker, laborer, lathe operator, shoe salesman, army sergeant.)

PARENT 1 (or father)

PARENT 2 (or mother)

Please list the sports you most like to take part in 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?
1. Please list the sports your child most likes to take part in (For example: swimming,baseball, skating, skate boarding, bike spend in each? riding, fishing, etc .) None Less than average Average More than average Don't know Below average Average Above average
2. Please list your favorite hobbies, activities, and games, other than sports. For example: video games, cards, reading, None Less than average Average More than average Don't know Below average Average Above average
3.Please list any organizations,clubs,teams, or groups your child belongs to. None Less Active Average More Active
4.For example: doing dishes, babysitting, making bed, working in store, etc. (Include both paid and unpaid jobs and chores.) None Less than average Average More than average
5. About how many close friends Do You Have?(Do not include brothers & sisters) 1 2 More than 2
6. About how many times a week does your child do things with any friends outside of regular school hours?(Do not include brothers & sisters). 1 2 More than 2
Worse Average Better I have no brothers or sisters
7. Compare to others of your age,how well do you :
A. Get along with Your brothers & sisters ?
B. Get along with other kids?
C. Behave with your parents?
D.Do thing by yourself?
8. 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
Do you have any ilness,disability or handicap ? yes no
Please describe any concerns or problems you have about school?
Please describe any other concern you have.
Please describe the best thing about yourself.
Not True Somewhat or Sometimes True Very True or Often True
1. I acts too young for My age
2.I drinks alcohol without my parents' approval(describe):
3.I argues a lot
4.I fails to finish things that i starts
5.There is very little he/she enjoys
6.I like animal
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.I am preety honest
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.I disobey My parents.
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):
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
54.Overtired without good reason
56.Physical problems without known medial cause:
57.Physically attacks people
58.Picks nose,skin,or other parts of body(describe):
59.I can be preety friendly.
60. I like to try new things.
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.I can work well with my hands:
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.I stand up for my rights.
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.I enjoy being with people
90.Swearing or obscene language
91.Talks about killing self
92.I like to make other laugh:
93.Talks too much
94.Teases a lot
95.Temper tantrums or hot temper
96.Thinks about sex too much
97.Threaten people
98.I like to help other
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.I like to be fair for other
107. I enjoy a good joke
108.I like to take life easy
109.I try to help other people when i can
110.Wishes to be a opposite sex
111.Withdrawn,does'nt get involved with others
113.Please write in any problems your child has that were not listed above: