Please provide the following information which will be used to prepare the rating report

First Name of Child:	Be sure to enter something here or a report will not be generated.
Age of Child:	(enter number of years only, no months, dashes, etc.)
Sex of Child:	male female
Does this child have any of these diagnosed conditions?	None ADD/ADHD Depression Anxiety Disorder Conduct DisorderOppositional-Defiant Disorder Obsessive-Compulsive Disorder Thought Disorder Autism Spectrum
Does this child have any of these suspected (but not diagnosed) conditions?	None ADD/ADHD Depression Anxiety Disorder Conduct DisorderOppositional-Defiant Disorder Obsessive-Compulsive Disorder Thought Disorder Autism Spectrum
Do you believe that this child currently has serious emotional or behavioral difficulties which interfere in his/her life?	yes no
Ethnic Origin:	White Black Asian Hispanic American Indian Mixed Race
State in which you live:	---- Select a State ----- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennesee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other (not in US)

Directions: For the following items please select the rating that best describes your child. Note, there are 110 items, please complete them all for an accurate rating.

Be sure to click the "Submit Rating" button at the bottom of the page. Please allow time for internal calculations before the rating report is displayed.

Item		Rating 1 2 3 Not True Somewhat True Very True
1	Fails to give close attention to details	1 2 3
2	Fidgety or squirmy	1 2 3
3	Seems easily embarrassed	1 2 3
4	Seems to have delusions - believes things to be true which are not	1 2 3
5	Seems sad or depressed	1 2 3
6	Spreads rumors about others	1 2 3
7	Is physically cruel to animals	1 2 3
8	Can't get mind off of certain thoughts or mental images	1 2 3
9	Has difficulty organizing tasks or activities	1 2 3
10	Is constantly moving or "on the go"	1 2 3
11	Easily annoyed by others	1 2 3
12	Sleeps too much during the day	1 2 3
13	Seems to perform certain actions over and over to relieve stress	1 2 3
14	Becomes angry or upset when ignored	1 2 3
15	Avoids talking or interacting with peers	1 2 3
16	Attempts to get others in trouble	1 2 3
17	Complains of headaches	1 2 3
18	Is reluctant to engage in tasks which require sustained attention or effort	1 2 3
19	Talks too much	1 2 3
20	Seems angry and/or resentful	1 2 3

Item		Rating 1 2 3 Not True Somewhat True Very True
21	Follows negative peer influence	1 2 3
22	Has a strong preference for being alone or isolated rather than with others	1 2 3
23	Perceives criticism or teasing when it was not intended	1 2 3
24	Seeks attention from others	1 2 3
25	Loses things which are necessary to complete tasks (such as pencils, paper, books, etc.)	1 2 3
26	Blurts out answers even before a question has been competed	1 2 3
27	Vindictive - wants to "get back at" someone	1 2 3
28	Slow or delayed body movements	1 2 3
29	Does not participate in sports, clubs, or other group activities	1 2 3
30	Easily distracted by noises or activities	1 2 3
31	Has difficulty waiting for his/her turn	1 2 3
32	Seems tired or lacking energy	1 2 3
33	Seems generally anxious or nervous	1 2 3
34	Does not follow or obey rules	1 2 3
35	Seems forgetful	1 2 3
36	Interrupts others	1 2 3
37	Appears to feel guilty or worthless	1 2 3
38	Gets angry when teased	1 2 3
39	Has difficulty concentrating or making decisions	1 2 3
40	Vandalizes property	1 2 3

Item		Rating 1 2 3 Not True Somewhat True Very True
41	Expresses thoughts of suicide or death	1 2 3
42	Appears shy	1 2 3
43	Bullies, threatens, or intimidates others	1 2 3
44	Starts fires with intent to cause damage	1 2 3
45	Has broken into someone's house, building, locker, car, etc.	1 2 3
46	Stays out at night beyond curfew	1 2 3
47	Makes careless mistakes	1 2 3
48	Leaves seat in classroom or other situations when expected to be seated	1 2 3
49	Verbal arguments with adults	1 2 3
50	Hallucinations - reports hearing or seeing things which others do not	1 2 3
51	Seems to lack interest in or pleasure for most daily activities	1 2 3
52	Tends to overreact to criticism or embarrassment	1 2 3
53	Complains of stomachaches	1 2 3
54	Bites or picks at fingernails, hair, or skin	1 2 3
55	Frequent excused absences from school	1 2 3
56	Withdraws or "shuts down" when embarrassed	1 2 3
57	Gets angry when embarrassed	1 2 3
58	Appears nervous when speaking or performing in front of others	1 2 3
59	Starts fights with others	1 2 3
60	Deliberately destroys the property of others	1 2 3

Item		Rating 1 2 3 Not True Somewhat True Very True
61	Lies to or otherwise manipulates others to gain favors or avoid obligations	1 2 3
62	Runs away from home	1 2 3
63	Has difficulty staying focused on tasks or activities	1 2 3
64	Loses temper	1 2 3
65	Skips class or school	1 2 3
66	Uses tobacco, alcohol, or other "street drugs"	1 2 3
67	Runs about or climbs on things inappropriately	1 2 3
68	Disorganized speech - difficult for others to follow or understand	1 2 3
69	Significant weight change (gain or loss)	1 2 3
70	Perfectionistic	1 2 3
71	Complains of body aches or pains	1 2 3
72	Teases others	1 2 3
73	Does not complete schoolwork	1 2 3
74	Is a negative leader among peers	1 2 3
75	Gets angry when criticized	1 2 3
76	Swears or uses obscene language	1 2 3
77	Has used a weapon which could cause serious harm to others (like a knife, gun, bat, etc.)	1 2 3
78	Has stolen from home, school or elsewhere (like shoplifting)	1 2 3
79	Frequent unexcused absences from school	1 2 3
80	Does not seem to listen when spoken to	1 2 3

Item		Rating 1 2 3 Not True Somewhat True Very True
81	Seems restless	1 2 3
82	Deliberately annoys others	1 2 3
83	Grossly disorganized or unpredictable behavior without an apparent purpose	1 2 3
84	Frequently visits the doctor or school nurse	1 2 3
85	Seems irritable	1 2 3
86	Verbal arguments with peers	1 2 3
87	Complains of eye problems (not related to a need for glasses)	1 2 3
88	Makes disruptive noises	1 2 3
89	Does not complete chores	1 2 3
90	Appears to resent authority	1 2 3
91	Uses behavior to conceal frustration	1 2 3
92	Has a high need for social acceptance	1 2 3
93	Physical cruelty to other people	1 2 3
94	Does not follow instructions or finish assigned tasks	1 2 3
95	Has difficulty quietly engaging in leisure activities	1 2 3
96	Writes threatening letters or notes	1 2 3
97	Displays very little emotion or "affect"	1 2 3
98	Complains of difficulty sleeping at night	1 2 3
99	Seems tense	1 2 3

Item		Rating 1 2 3 Not True Somewhat True Very True
100	Seems to have a compulsive need to repeat certain behaviors (i.e. hand washing, counting steps, saying a series of words silently or aloud, et.)	1 2 3
101	Appears to have skin problems (rashes, etc.)	1 2 3
102	Likes to be the "center of attention"	1 2 3
103	Is often difficult to find - hides or disappears	1 2 3
104	Doesn't like being told what to do	1 2 3
105	Gets more upset if punished or criticized in front of others	1 2 3
106	Likes to be "in charge"	1 2 3
107	Tendency to engage is a certain impulsive reaction over and over	1 2 3
108	Holds a grudge	1 2 3
109	Inflexible - needing to always do things in a certain way	1 2 3
110	Blames others for his/her mistakes or misbehavior	1 2 3

Item		Rating 1 2 3 Not True Somewhat True Very True
111	Seems unable to make or keep friends	1 2 3
112	Has considerable difficulty relating to other people	1 2 3
113	Misinterprets social cues or the behavior of others	1 2 3
114	Has difficulty using or understanding nonverbal communication (such as gestures, facial expressions, tone of voice, etc.)	1 2 3
115	Demonstrates very unusual speech patterns (such as tone, rhythm, or rate)	1 2 3
116	Has considerable difficulty initiating or maintaining a conversation	1 2 3
117	Insists on following certain rules, routines, or rituals	1 2 3
118	Seems very resistant to changes in activity	1 2 3
119	Seems overly preoccupied with a specific area of interest	1 2 3
120	Is highly sensitive to certain sensory stimuli (such as light, sound, texture, smell, etc.)	1 2 3

 Please allow time for internal calculations before the rating report is displayed.