FREE ASSESSMENT - CHILDREN
Please fill out the following and submit your questionnaire - we will email you the results shortly after we receive your complete form.
Name:
Child's Name:
Age:
Email:
Please re-enter your email address:
City:
Phone number:
How severe are your child's symptoms?
1.
Difficulties sustaining focus and attention
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
2.
Disorganized
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
3.
Forgetful
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
4.
Impatient, restless, hyperactive
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
5.
Cannot listen attentively
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
6.
Difficulties completing tasks
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
7.
Getting easily distracted
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
8.
Problem with following instructions
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
9.
Daydreamer
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
10.
Underachieving academically
NEVER A PROBLEM
SOMETIMES A PROBLEM
OFTEN A PROBLEM
REGULARLY A PROBLEM
11.
Please mention any other difficulties:
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