Web SiteMINOR - PARENT REPORT AND OBSERVATION This form will only take 8 ~ 15 minutes to complete, however you should take has long as you need to describe your concerns about your child with as much detail as you can. Today's date * Is this evaluation for a legal proceeding? * Yes No Minor's Information First Name * Last Name * Date of birth * Age * Parent or Legal Guardian's Information First Name * Last Name * Date of Birth * Age * Relationship to minor * Has the minor been evaluated in the past 10 years? * No Yes 1st question 2nd question What have you done so far to deal with these issues?Ex.: we have checked with our primary care physician and the doctor suggested we get her tested, and that he can put her on medication if we want to. Me and my husband we try to spend time with her and help her finish her homework but is becoming more and more difficult. (To see another example click here) 3rd question EMOTIONAL CONCERNS Emo_1 Seems anxious often Cries easily Seems worried Seems withdrawn Constantly seeking attention Does not respond to affection Does not seem to show emotions Is too serious emo_2 Is too concerned with cleanliness Feels inferior Is often angry Seems sad often Feels guilty easily Feels hurt easily Feels upset easily Is easily frustrated by noise emot_3 Seems afraid frequently Strongly emphasizes order Appears to be suspicious frequently Act too mature for the age Refuses to sleep alone Talks often about death Researches a lot about afterlife Has trouble relaxing emot_4 Sees things that others don't Hears things that others don't Worries a lot of getting sick Has uncommon beliefs Refuses to sleep alone Is uncomfortable in new situations Needs to be reassured frequently Feels easily embarassed SELF CONCEPT self_1 Appears to be self-critical Gives up easily does not seem interested in learning Follows other children unquestionably self_2 Has little or no self-confidence Often gives in to other children Rarely disagrees Is frequently pessimistic about himself/herself self_3 Does not show curiosity for anything Always tries to please others Appears overly-humble Seems afraid to invite children to play self_4 Rarely gives his/her best effort Worries a lot about making mistakes Is pessimistic about his/her family Tries too much to be like other children PEERS AND PLAY PP_1 Does not seem friendly with other children Has trouble making friends Has very few friends Does not like to cuddle PP_2 Does not get along with children of the same age Is teased by other children Does not share with other children Hurts other children pp_3 Rarely compromise with other children Bullies other children Is not liked by other children Is shy with other children pp_4 Has friends who are a bad influence to him/to her Takes games too seriously Has no hobbies Appears to be immature for the age LANGUAGE AND COMMUNICATION lan_1 Seems to have an overactive imagination Has difficulty recalling words Has difficulty to understand words Talks very fast Skips words when reading lan_2 Has trouble to understand direction or instructions Talks rarely/does not talk Has difficulty to pronounce words Has poor memory Forgets instructions easily lan_3 Does not seem to have good common sense Has difficulty to spell words Rarely reads Forgets things Confuses right from left Lan_4 Has trouble to understand or complete puzzles and games Has trouble to time/dates Gets confused easily Has trouble using tools Stutters Misreads words frequently SCHOOL sch_1 Does not do his/her school assignment Is considered a problem in school Does not complete homework Does not get along with children sch_2 Often blames teachers for problems in school Does not get along with teachers Does not like most of the teachers Wants a great deal of attention sch_3 Has difficulty to keep up with the class's pace Is often late for school Misses school frequently Skips school sch_4 Is in special class/education (IEP/504) Is considered an underachiever Gets poor grades Fights with other children BEHAVIORAL beh_1 Refuses to listen Is cruel to animals Does not respond to punishment Is considered a delinquent in school Drinks, smokes, and uses drugs Is secretive/resentful Acts too young for his age Argues a lot beh_2 Is disobedient at home Threatens to hurt himself/herself Complains frequently Is demanding Has attempted suicide Is cruel or mean to others Demands a lot of attention Tries to manipulate others beh_3 Has been in trouble with the police Plays with fire or matches Destroys other people's things Does not seem to feel guilty Uses bad language Too interested in sex for the age Shows unusual interest in death Is irresponsible beh_4 Plays with own sex parts in public Does not complete chores Is aggressive Runs aways from home Has a history of vandalism Has a bad temper Teases a lot other children Intentionally break things HEALTH hea_1 Has allergies Has frequent migraines Complaints stomach ache hea_2 Uses sickness to avoid school Complains of loneliness Overeats hea_3 Complains of nausea often Seems to enjoy illnesses Has skin problems/rashes hea_4 Vomits frequently Has bowel problems Has urinary probelms ATTENTION AND MOTOR-COORDINATION att_1 Gets distracted easily Is clumsy Cannot sit still Frequently drops things att_2 Bumps into things Is not coordinated Is always climbing furniture Has tics/twitches att_3 Is always running around Presence of involuntary movements Is restless Lacks energy att_4 Is uncoordinated His writing (graphia) is bad Has a lot of accidents Has trouble with balance