QbCheck Rating Form 6-17 Years

QbCheck Rating Scale 6-17 Years

The QbCheck Rating Scale adds a subjective perspective to the evaluation process. The scale is developedfrom the 18 questions in the DSM-5, a handbook used by healthcare professionals, describing patterns ofbehaviour associated with ADHD. Each behaviour is graded as Never or Rarely, Sometimes, Often and Very often.
Name of Child/Young Person*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityCounty

Postal
Gender*
Completion Date

DayMonthYear
Date
Answers Completed By*
If a third party has completed with form (e.g. teaching staff) please confirm if parental consent has been obtained/is required.
If you have answered 'not required' to the previous question please explain your answer below (e.g. child in local authority care):
Name of person who completed this form*

First NameLast Name
Phone number (in case further information is required)*

Area CodePhone Number
Email address (that you would like the results sent to)*
example@example.com

Please answer the following questions (Inattention)

	Never	Rarely	Sometimes	Often	Very Often
Has difficulty paying attention to details or makes careless mistakes unless interested
Has difficulty remaining focused on tasks or play activities unless interested
Does not seem to listen when spoken to directly
Has difficulty to follow through on tasks
Has difficulty organising and managing tasks
Avoids sustained mental effort unless interested
Loses things
Seems easily distracted by the environment
Forgetful

Please answer the following questions (Hyperactivity/Impulsivity)

	Never	Rarely	Sometimes	Often	Very Often
Fidgets or squirms
Leaves seat when remaining seated is expected
Runs about or climbs when inappropriate or appears restless
Has difficulty to engage in play or leisure activities quietly
Seems uncomfortable being still for extended time periods
Talks excessively
Blurts out answers or thoughts
Has difficulty waiting turn
Interrupts or intrudes on others

Additional Information (Parents/Carers Only)

(Needed to ensure an ADHD Assessment is appropriate)
Have the child's/young person's symptoms been similar since birth (allowing for normal childhood development)?
Does anyone else in your family have ADHD?
If your previous answer was 'yes' please describe the relationship(s) to the child/young person?
Please provide details if child/young person has experienced any trauma/traumatic events (including birth, reflux, early years trauma, etc)?
What are your reasons for requesting an ADHD-Symptom Assessment?
What strategies/Interventions tried (for example, an Early Help Assessment, therapy, parenting courses, etc)?
I have forwarded the link to this form to the child's class teacher/SENCO (or other third party - cub leader, swimming coach, etc) to complete (please note this is now a required evidence for a paediatric referral):

YesNo
Additional comments:
What outcome are you hoping for following the results of your assessment?
Thank you for completing this screening. We will get back to you with our recommendations as soon as possible.
At ABC Children's Therapy we take your privacy very seriously and only use your personal information to provide you with access to our therapy. This document will be retained for 7 years in accordance with the Data Protection Act (DPA) 1998.
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Additional Information (Parents/Carers Only)