Childhood ADHD Collateral Questionnaire

Childhood ADHD Collateral Questionnaire
Please complete this questionnaire to provide information about the child's behaviors and attention patterns. Your observations will assist in the assessment process.
Child's Full Name*
First NameLast Name
Child's Date of Birth*
MonthDayYear
Date
Your Full Name*
First NameLast Name
Your Relationship to the Child*
How long have you known the child?*
HomeSchoolExtracurricular activitiesOther

Please rate how often the child exhibits the following behaviors over the past 6 months:*

Rows	Never	Rarely	Sometimes	Often	Very Often
Fails to give close attention to details or makes careless mistakes
Has difficulty sustaining attention in tasks or play activities
Does not seem to listen when spoken to directly
Does not follow through on instructions and fails to finish tasks
Has difficulty organizing tasks and activities
Avoids or dislikes tasks that require sustained mental effort
Loses things necessary for tasks or activities
Is easily distracted by extraneous stimuli
Is forgetful in daily activities
Fidgets with hands or feet or squirms in seat
Leaves seat in situations when remaining seated is expected
Runs about or climbs excessively in inappropriate situations
Has difficulty playing or engaging in leisure activities quietly
Is often "on the go" or acts as if "driven by a motor"
Talks excessively
Blurts out answers before questions have been completed
Has difficulty awaiting turn
Interrupts or intrudes on others

Not at allA littleModeratelyQuite a bitExtremely
Are there any other concerns or observations you would like to share about the child's behavior or attention?
Should be Empty: