ESE Mental Health Parent Vanderbilt

Patient's Name

First NameLast Name

Patient's Date of Birth

Date

Your Name

First NameLast Name

Your Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

When completing this form, please think about the patient's behaviors in the PAST 6 MONTHS.

Symptoms 1-9

Rows	Never	Occasionally	Often	Very Often
Does not pay attention to details or makes careless mistakes with, for example, homework
Has difficulty keeping attention to what needs to be done
Does not seem to listen when spoken to directly
Does not follow through when given directions and fails to finish activities. (Not due to refusal or failure to understand)
Has difficulty organizing tasks and activities.
Avoids dislikes or does not want to start tasks that require ongoing mental effort
Loses things necessary for tasks or activities. (Toys, assignments, pencils or books.)
Is easily distracted by noises or other stimuli
Is forgetful in daily activities

Symptoms 10-18

Rows	Never	Occasionally	Often	Very Often
Fidgets with hands or feet or squirms in seat
Leaves seat when remaining seated is expected
Runs about or climbs too much when remaining seated is expected
Has difficulty playing or beginning quiet play activities
Is “on the go” or often acts as if “driven by a motor”
Talks too much
Blurts out answers before questions have been completed
Has difficulty waiting his or her turn
Interrupts or intrudes in others’ conversations and/or activities

Symptoms 19-26

Rows	Never	Occasionally	Often	Very Often
Argues with adults
Loses temper
Actively defies or refuses to go along with adults’ requests or rules
Deliberately annoys people
Blames others for his or her mistakes or misbehaviors
Is touchy or easily annoyed by others
Is angry or resentful
Is spiteful and wants to get even

Symptoms 27-40

Rows	Never	Occasionally	Often	Very Often
Bullies, threatens or intimidates others
Starts physical fights
Lies to get out of trouble or to avoid obligations (ie, “cons” others)
Is truant from school (skips school) without permission
Is physically cruel to people
Has stolen things that have value
Deliberately destroys others property
Has used a weapon that can cause serious harm (bat, knife, brick, gun)
Is physically cruel to animals
Has deliberately set fires to cause damage
Has broken into someone else's home, business or car
Has stayed out at night without permission
Has run away from home overnight
Has forced someone into sexual activity

Symptoms 41-47

Rows	Never	Occasionally	Often	Very Often
Is fearful, anxious or worried
Is afraid to try new things for fear of making mistakes
Feels worthless or inferior
Blames self for problems, feels guilty
Feels lonely, unwanted or unloved; Complains that “no one loves him or her”
Is sad, unhappy or depressed
Is self-conscious or easily embarrassed

Performance

Rows	Excellent	Above Average	Average	Somewhat of a Problem	Problematic
Overall school performance
Reading
Writing
Mathematics
Relationship with parents
Relationship with siblings
Relationship with peers
Participation in organized activities (eg, teams)

{symptoms19}

{typeA}

{symptoms1926}

{symptoms2740}

{symptoms4147}

{performance}