Child Executive Function Survey Form
Please complete the Child Executive Function Survey Form to help assess key skills and behaviors related to executive functioning in children.
Please rate the child's ability to organize tasks and materials.
*
1
2
3
4
5
How often does the child remember instructions without reminders?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
How well does the child manage time when completing assignments?
*
Poorly
1
2
3
4
Very well
5
1 is Poorly, 5 is Very well
Select the statement that best describes the child's ability to start tasks independently.
*
Always starts tasks independently
Usually starts tasks independently
Sometimes needs reminders
Often needs reminders
Rarely starts tasks independently
How often does the child control impulses (e.g., waiting their turn, not interrupting)?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Please rate the child's ability to adapt to changes in plans or routines.
*
1
2
3
4
5
How well does the child manage emotional responses when frustrated or upset?
*
Not well
1
2
3
4
Very well
5
1 is Not well, 5 is Very well
How frequently does the child lose or misplace important items (e.g., homework, books)?
*
Never
Rarely
Sometimes
Often
Very often
Executive Function Skills Matrix
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Rows
Never
Rarely
Sometimes
Often
Always
Follows multi-step directions
1
2
3
4
5
Finishes tasks on time
6
7
8
9
10
Keeps track of personal belongings
11
12
13
14
15
Is there anything else you would like to share about the child's executive function skills?
Submit Survey
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