Currenly Relocating - Contact us at info@familyresourcecenter.qc.ca

Program Registration

Program Registration








Background Info

Background Information


EnglishFrenchOther:



yesno


Parent Questionnaire

Parent Questionnaire








Behavioral Checklist

Behavioral Checklist

This child...
0
Not at all
1
Just a little
2
Pretty much
3
Very much
Often fails to give close attention to details or makes careless mistakes in school work, homework, or other activities
0123

Often has difficulty sustaining attention in tasks or play activities
0123

Often does not seem to listen to what is being said to him or her
0123

Often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
0123

Often has difficulties-organizing tasks and activities
0123

Often avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effort
0123

Often loses things necessary for tasks or activities (e.g. school assignments, pencils, books, tools, or toys)
0123

Is often easily distracted by extraneous stimuli
0123

Often forgetful in daily activities
0123

Often fidgets with hands or feet or squirms in seat
0123

Leaves seat in classroom or in other situations in which remaining seated is expected
0123

Often runs about or climbs excessively in situations where it is inappropriate
0123

Often has difficulty playing or engaging in leisure activities quietly
0123

Is often "on the go" or often acts as if "driven by a motor"
0123

Often talks excessively
0123

Often blurts out answers to questions before the questions have been completed
0123

Often has difficulty waiting in lines or awaiting their turn in games or group situations
0123

Often interrupts or intrudes on others (e.g. butts into conversations or games)
0123