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Home
Services
Telehealth
What We Treat
Treatment Options
For Professionals
Team
About
Choices
Locations
Insurance & Billing
Careers
Resources
Blog
Brochures
Newsletters
Press Releases
Self-Assessment Quiz
Contact
CLIENTS
Appointments
FAQs
Make a Payment
Forms
NICHQ Vanderbilt Assessment Scale-PARENT Informant
NICHQ Vanderbilt Assessment Scale-PARENT Informant
Today's Date:
*
Date Format: MM slash DD slash YYYY
Child's Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Parent's Name
*
Parent's Phone Number
*
Directions: Each rating should be considered in the context of what is appropriate for the age of your child.
When completing this form, please think about your child's behavior in the past 6 months.
Is this evaluation based on a time when the child
*
was on medication
was not on medication
not sure?
Symptoms
1. Does not pay attention to details or makes careless mistakes with, for example, homework
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
2. Has difficulty keeping attention to what needs to be done
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
3. Does not seem to listen when spoken to directly
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
5. Has difficulty organizing tasks and activities
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
6. Avoids, dislilzes, or does not want to start tasks that require ongoing mental effort
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
8. Is easily distracted by noises or other stimuli
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
9. Is forgetful in daily activities
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
10. Fidgets with hands or feet or squirms in seat
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
11. Leaves seat when remaining seated is expected
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
12. Runs about or climbs too much when remaining seated is expected
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
13. Has difficulty playing or beginning quiet play activities
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
14. Is "on the go" or often acts as if "driven by a motor"
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
15. Talks too much
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
16. Blurts out answers before questions have been completed
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
17. Has difficulty waiting his or her turn
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
18. Interrupts or intrudes in on others' conversations and/or activities
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
19. Argues with adults
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
20. Loses temper
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
21. Actively defies or refuses to go along with adults' requests or rules
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
22. Deliberately annoys people
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
23. Blames others for his or her mistakes or misbehaviors
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
24. Is touchy or easily annoyed by others
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
25. Is angry or resentful
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
26. Is spiteful and wants to get even
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
27. Bullies, threatens, or intimidates others
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
28. Starts physical fights
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
29. Lies to get out of trouble or to avoid obligations (ie, "cons" others)
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
30. Is truant from school (skips school) without permission
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
31. Is physically cruel to people
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
32. Has stolen things that have value
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
33. Deliberately destroys others' property
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
35. Is physically cruel to animals
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
36. Has deliberately set fires to cause damage
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
37. Has broken into someone else's home, business, or car
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
38. Has stayed out at night without permission
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
39. Has run away from home overnight
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
40. Has forced someone into sexual activity
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
41. Is fearful, anxious, or worried
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
42. Is afraid to try new things for fear of making mistakes
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
43. Feels worthless or inferior
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
44. Blames self for problems, feels guilty
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
45. Feels lonely, unwanted, or unloved; complains that "no one loves him or her"
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
46. Is sad, unhappy, or depressed
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
47. Is self-conscious or easily embarrassed
*
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
Performance
48. Overall school performance
*
1 - Excellent
2 - Above Average
3 - Average
4 - Somewhat of a problem
5 - Problematic
49. Reading
*
1 - Excellent
2 - Above Average
3 - Average
4 - Somewhat of a problem
5 - Problematic
50. Writing
*
1 - Excellent
2 - Above Average
3 - Average
4 - Somewhat of a problem
5 - Problematic
51. Mathematics
*
1 - Excellent
2 - Above Average
3 - Average
4 - Somewhat of a problem
5 - Problematic
52. Relationship with parents
*
1 - Excellent
2 - Above Average
3 - Average
4 - Somewhat of a problem
5 - Problematic
53. Relationship with siblings
*
1 - Excellent
2 - Above Average
3 - Average
4 - Somewhat of a problem
5 - Problematic
54. Relationship with peers
*
1 - Excellent
2 - Above Average
3 - Average
4 - Somewhat of a problem
5 - Problematic
55. Participation in organized activities (eg, teams)
*
1 - Excellent
2 - Above Average
3 - Average
4 - Somewhat of a problem
5 - Problematic
Comments:
Parent Signature (Please Type)
*
Total number of questions scored 2 or 3 in questions 1-9 _______________
Total number of questions scored 2 or 3 in questions 10-18 _______________
Total Symptom Score for questions 1-18: _______________
Total number of questions scored 2 or 3 in questions 19-26: _______________
Total number of questions scored 2 or 3 in questions 27-40:_______________
Total number of questions scored 2 or 3 in questions 41-47: _______________
Total number of questions scored 4 or 5 in questions 48-55: _______________
Average Performance Score: _______________
Email
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