Copeland ADHD

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Name of Form

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INSTRUCTIONS

Approximate time:15 minutes to respond to 63 questions

Please answer the questions according to what is true for you.

All responses are confidential.

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I-1. A short attention span, especially for low-interest activities.* This field is required.

Not at All

Sometimes

Often

Very Often

4

I-2. Difficulty competing tasks.* This field is required.

Not at All

Sometimes

Often

Very Often

5

I-3. Daydreaming.* This field is required.

Not at All

Sometimes

Often

Very Often

6

I-4. Easily distracted.* This field is required.

Not at all

Just a little

Pretty much

Very much

7

I-5. Nicknames such as: "spacey" or "dreamer".* This field is required.

Not at all

Just a little

Pretty much

Very much

8

I-6. Engages in much activity but accomplishes little.* This field is required.

Not at all

Just a little

Pretty much

Very much

9

I-7. Enthusiastic beginnings but poor endings.* This field is required.

Not at all

Just a little

Pretty much

Very much

10

II-1. Excitability.* This field is required.

Not at all

Just a little

Pretty much

Very much

11

II-2. Low frustration tolerance.* This field is required.

Not at all

Just a little

Pretty much

Very much

12

II-3. Acts before thinking.* This field is required.

Not at all

Just a little

Pretty much

Very much

13

II-4. Disorganization.* This field is required.

Not at all

Just a little

Pretty much

Very much

14

II-5. Poor planning ability.* This field is required.

Not at all

Just a little

Pretty much

Very much

15

II-6. Excessively shifts from one activity to another.* This field is required.

Not at all

Just a little

Pretty much

Very much

16

II-7. Difficulty in group situations which require patience and taking turns.* This field is required.

Not at all

Just a little

Pretty much

Very much

17

II-8. Interrupts frequently.* This field is required.

Not at all

Just a little

Pretty much

Very much

18

III-A1. Restlessness - either fidgeting or being constantly on the go.* This field is required.

Not at all

Just a little

Pretty much

Very much

19

III-A2. Diminished need for sleep.* This field is required.

Not at all

Just a little

Pretty much

Very much

20

III-A3. Excessive talking.* This field is required.

Not at all

Just a little

Pretty much

Very much

21

III-A4. Difficulty listening.* This field is required.

Not at all

Just a little

Pretty much

Very much

22

III-A5. Restlessness during sleep. Kicks covers off - moves constantly.* This field is required.

Not at all

Just a little

Pretty much

Very much

23

III-A6. Dislike of situations which require attention and being still.* This field is required.

Not at all

Just a little

Pretty much

Very much

24

III-B1. Lethargic* This field is required.

Not at all

Just a little

Pretty much

Very much

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III-B2. Daydreaming, spiciness.* This field is required.

Not at all

Just a little

Pretty much

Very much

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III-B3. Failure to complete tasks.* This field is required.

Not at all

Just a little

Pretty much

Very much

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III-B4. Inattention.* This field is required.

Not at all

Just a little

Pretty much

Very much

28

III-B5. Lacking in leadership.* This field is required.

Not at all

Just a little

Pretty much

Very much

29

III-B6. Difficulty in getting things done.* This field is required.

Not at all

Just a little

Pretty much

Very much

30

IV-1. Does not cooperate. Determined to do things own way.* This field is required.

Not at all

Just a little

Pretty much

Very much

31

IV-2. Argumentative.* This field is required.

Not at all

Just a little

Pretty much

Very much

32

IV-3. Disregards socially accepted behavioral expectations.* This field is required.

Not at all

Just a little

Pretty much

Very much

33

IV-4. "Forgets" unintentionally.* This field is required.

Not at all

Just a little

Pretty much

Very much

34

IV-5. "Forgets" as an excuse (intentionally).* This field is required.

Not at all

Just a little

Pretty much

Very much

35

V-1. Underachievement in relation to ability.* This field is required.

Not at all

Just a little

Pretty much

Very much

36

V-2. Frequent job changes.* This field is required.

Not at all

Just a little

Pretty much

Very much

37

V-3. Loses things - keys, wallet, lists, belongings, etc.* This field is required.

Not at all

Just a little

Pretty much

Very much

38

V-4. Auditory memory and auditory processing problems.* This field is required.

Not at all

Just a little

Pretty much

Very much

39

V-5. Learning disabilities or learning problems.* This field is required.

Not at all

Just a little

Pretty much

Very much

40

V-6. Poor handwriting.* This field is required.

Not at all

Just a little

Pretty much

Very much

41

V-7. "Messy" or "sloppy" work.* This field is required.

Not at all

Just a little

Pretty much

Very much

42

V-8. Work assignments are often not completed satisfactorily.* This field is required.

Not at all

Just a little

Pretty much

Very much

43

V-9. Work assignments are often not completed satisfactorily.* This field is required.

Not at all

Just a little

Pretty much

Very much

44

V-10. Works too slowly* This field is required.

Not at all

Just a little

Pretty much

Very much

45

V-11. Procrastinates. Bills, taxes, etc., put off until the last minute.* This field is required.

Not at all

Just a little

Pretty much

Very much

46

VI-1. Frequent and unpredictable mood swings.* This field is required.

Not at all

Just a little

Pretty much

Very much

47

VI-2. Irritability.* This field is required.

Not at all

Just a little

Pretty much

Very much

48

VI-3. Underreaction to pain / insensitive to danger.* This field is required.

Not at all

Just a little

Pretty much

Very much

49

VI-4. Easily overstimulated. Hard to stop once "revved" up.* This field is required.

Not at all

Just a little

Pretty much

Very much

50

VI-5. Low frustration tolerance. Excessive emotional reaction.* This field is required.

Not at all

Just a little

Pretty much

Very much

51

VI-6. Angry outbursts.* This field is required.

Not at all

Just a little

Pretty much

Very much

52

VI-7. Moodiness / lack of energy.* This field is required.

Not at all

Just a little

Pretty much

Very much

53

VI-8. Low self-esteem* This field is required.

Not at all

Just a little

Pretty much

Very much

54

VI-9. Immaturity.* This field is required.

Not at all

Just a little

Pretty much

Very much

55

VII-1. Difficulty following the rules of social interactions.* This field is required.

Not at all

Just a little

Pretty much

Very much

56

VII-2. Rejected or avoided by peers.* This field is required.

Not at all

Just a little

Pretty much

Very much

57

VII-3. Avoids group activity. A loner.* This field is required.

Not at all

Just a little

Pretty much

Very much

58

VII-4. "Bosses" other people. Wants to be a leader.* This field is required.

Not at all

Just a little

Pretty much

Very much

59

VII-5. Critical of others.* This field is required.

Not at all

Just a little

Pretty much

Very much

60

VIII-1. Easily frustrated with spouse or children. Overreacts. May punish children too severely.* This field is required.

Not at all

Just a little

Pretty much

Very much

61

VIII-2. Sees things from own point of view. Does not negotiate differences well.* This field is required.

Not at all

Just a little

Pretty much

Very much

62

VIII-3. Underdeveloped sense of responsibility.* This field is required.

Not at all

Just a little

Pretty much

Very much

63

VIII-4. Poor manager of money.* This field is required.

Not at all

Just a little

Pretty much

Very much

64

VIII-5. Unreasonable; demanding.* This field is required.

Not at all

Just a little

Pretty much

Very much

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VIII-6. Spends excessive amount of time at work because of inefficiency, leaving little time for family.* This field is required.

Not at all

Just a little

Pretty much

Very much

66

Your I. INATTENTION / DISTRACTIBILITY Score Is:

67

Your II. IMPULSIVITY Score Is:

68

Your III. ACTIVITY LEVEL PROBLEMS A+B:

69

Your IV. NONCOMPLIANCE Score Is:

70

Your V. UNDERACHIEVEMENT / DISORGANIZATION / LEARNING PROBLEMS Score Is:

71

Your VI. EMOTIONAL DIFFICULTIES Score Is:

72

Your VII. POOR PEER RELATIONS Score Is:

73

Your VIII. IMPAIRED FAMILY RELATIONS Score Is:

74

Note: This test does NOT produce a total or overall score.

Scores between 35-49% suggest mild to moderate difficulties.

Scores between 50-69% suggest moderate to severe difficulties.

Scores above 70% suggest major interference.

Your Scores are:

1. INATTENTION / DISTRACTIBILITY: {yourI}%

2. IMPULSIVITY: {yourI299}%

3. ACTIVITY LEVEL PROBLEMS: {yourIi}%

4. NONCOMPLIANCE: {yourIv}%

5. UNDERACHIEVEMENT / DISORGANIZATION / LEARNING PROBLEMS: {yourV306}%

6. EMOTIONAL DIFFICULTIES: {yourV303}%

7. POOR PEER RELATIONS: {yourVii}%

8. IMPAIRED FAMILY RELATIONS: {yourViii}%

What Your Scores Mean for You

This screener highlights potential ADHD-related challenges in different areas of life, but it does not provide a diagnosis. If your scores suggest moderate to severe difficulties, these struggles may be affecting your daily life, relationships, or work more than you realize.

The good news?

ADHD is manageable—and understanding your symptoms is the first step. A conversation with a neuro-informed clinician can help you determine your next steps, whether that includes strategies, coaching, or therapy.

👉 Want to make sense of your results? Schedule a consultation with one of our ADHD specialists today.

Don’t let ADHD control your life—take the next step toward clarity and support!

75

What are you interested in?* This field is required.

Neurodiverse Couples Counseling.

Neuro-informed Individual Counseling.

An Assessment and Diagnosis (only available for residents of California).

Nothing, just send my scores please

I'm not sure. I'd like to talk to a care coordinator.

76

The type of assessment that I am interested in (note only available in California):* This field is required.

Autism Assessment - $1,500

ADHD Assessment - $900

Dual Assessment (ASD and ADHD) - $1, 800

Sensory Assessment - $300 (as an add on to Autism or ADHD assessment)

Alexithymia Assessment - $300 (as an add on to Autism or ADHD assessment)

PDA Assessment (Pathological Demand Avoidance) - $300 (as an add on to the Autism or ADHD assessment)

Dyslexia Support

77

Where do you live? (This impacts what services are available to you)* This field is required.

California

Not in California

78

Session fees vary by experience and qualifications. Share what you can pay, and we’ll match you with the right professional.* This field is required.

$100 to $150 - considered "Sliding Scale". Appointments at this price are limited and may not be available.

$150 to $200

$200 to $250

$250 to $300

$300 and up

79

My name is:* This field is required.

First Name

Last Name

80

Email* This field is required.

example@example.com

81

Phone Number

Please enter a valid phone number.

82

Please add any background/additional information you'd like to include:

83

What's Next?

You will be sent a copy of your scores if you've provided your email address.

If you marked that you are interested in counseling services, our Client Care Coordinator will be in touch within 24 hours to connect you with one of our experts.

Please feel free to reach out to our Client Care Coordinator, Cassie Clayton, if you have any questions in the meantime!

Email : clientcare@newpathfamily.com

Text or Call: (408) 475-2746