Child'S Evaluation Form - Age 6-12 Years Old - Nv Mental Health

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Child’s Evaluation Form
Age 6-12 Years Old
Name: ____________________ Gender: ___________ DOB: ___________ Age: ______
School: ____________________ Grade: ___________ Date: ______________________
Person completing the form: ________________________________________________
Relation to Child: _________________________________________________________
Please answer each question that describes your child’s behaviors.
1. Fails to give close attention to details or makes careless
mistakes.
2. Has difficulty paying attention to tasks or play activities.
3. Does not seem to listen when spoken to directly.
4. Has difficulty following through on instructions and fails
to finish things.
5. Has difficulty organizing tasks and activities.
6. Avoids doing tasks that require a lot of mental effort
(schoolwork, homework, etc.).
7. Loses things necessary for activities.
8. Is easily distracted by other things going on.
9. Is forgetful in daily activities.
10. Fidgets with hands or feet or squirms in seat.
11. Has difficulty remaining seated when asked to do so.
12. Runs about or climbs on things when asked not to do so.
13. Has difficulty playing quietly.
14. Is “on the go” or acts as if “driven by a motor.”
15. Talks excessively.
16. Blurts out answers to questions before they have been
completed.
17. Has difficulty waiting turn in group activities.
18. Interrupts people or butts into other children’s activities.
ADHD:
Sometimes
Never
Often
Oppositional Symptoms:
Sometimes
Never
Often
19. Loses temper
20. Argues with adults.
21. Defies or refuses what you tell him/her to do.
22. Does things to deliberately annoy others.
23. Blames others for own misbehavior or mistakes.
24. Is touchy or easily annoyed by others.
25. Is angry and resentful.
26. Takes anger out on others or tries to get even
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