Adult ADHD Collateral Assessment Form
Please answer based on your current observations of the patient. Leave items blank if unsure. Include full names, contact info, relationship, and date. Refer to school-based wording as work or daily responsibilities. Complete the rating scales accordingly.
Respondent and Patient Information
Answer based on your own current observations of the patient, not the patient’s answers. If you are unsure about any item, leave it blank. School-based wording should be interpreted for adult functioning as work, home responsibilities, deadlines, meetings, appointments, organization, and current daily functioning.
Patient full name
*
Respondent full name
*
First Name
Middle Name
Last Name
Respondent email
*
example@example.com
Relationship to patient
*
Please Select
Spouse
Partner
Close family member
Close friend
Other
Today’s date
*
-
Month
-
Day
Year
Date
WFIRS-P Current Adult Observer Impairment Scale
Family
Has the adult’s behavior caused tension or conflict within the family?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Does the adult’s behavior make family routines harder to manage?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Does the adult’s behavior affect family relationships or closeness?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
School/Work equivalent
Does the adult’s functioning interfere with work performance or job responsibilities?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Does the adult have difficulty meeting deadlines, staying organized, or completing tasks at work?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Does the adult’s behavior cause problems with supervisors, coworkers, or workplace expectations?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Life Skills
Does the adult have difficulty managing daily responsibilities such as finances, appointments, or household tasks?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Does the adult have trouble keeping track of belongings, bills, or important items?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Does the adult need more help than expected to stay on top of everyday life skills?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Self-Concept
Does the adult seem frustrated, discouraged, or negatively affected by their functioning?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Does the adult’s current functioning appear to affect their confidence or self-esteem?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Does the adult seem embarrassed or ashamed about their difficulties?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Social Activities
Does the adult have difficulty keeping up with social plans or commitments?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Does the adult’s behavior interfere with friendships or social relationships?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Does the adult avoid social activities because of their current difficulties?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Risky Activities
Does the adult act impulsively in ways that could lead to harm or problems?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Does the adult take unnecessary risks in daily life, driving, work, or relationships?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
Does the adult’s current behavior create safety concerns for themselves or others?
*
Never or not at all
Sometimes or somewhat
Often or much
Very often or very much
N/A
BAARS-IV Collateral Report
Fails to give close attention to details or makes careless mistakes in work or other activities
*
Never or rarely
Sometimes
Often
Very often
Has difficulty sustaining attention in tasks or activities
*
Never or rarely
Sometimes
Often
Very often
Does not seem to listen when spoken to directly
*
Never or rarely
Sometimes
Often
Very often
Does not follow through on instructions or fails to finish tasks
*
Never or rarely
Sometimes
Often
Very often
Has difficulty organizing tasks and activities
*
Never or rarely
Sometimes
Often
Very often
Avoids or is reluctant to engage in tasks that require sustained mental effort
*
Never or rarely
Sometimes
Often
Very often
Loses things necessary for tasks or activities
*
Never or rarely
Sometimes
Often
Very often
Is easily distracted by extraneous stimuli
*
Never or rarely
Sometimes
Often
Very often
Is forgetful in daily activities
*
Never or rarely
Sometimes
Often
Very often
Fidgets with hands or feet or squirms in seat
*
Never or rarely
Sometimes
Often
Very often
Leaves seat in situations when remaining seated is expected
*
Never or rarely
Sometimes
Often
Very often
Feels restless or has difficulty remaining still
*
Never or rarely
Sometimes
Often
Very often
Has difficulty engaging in leisure activities quietly
*
Never or rarely
Sometimes
Often
Very often
Is often "on the go" or acts as if driven by a motor
*
Never or rarely
Sometimes
Often
Very often
Talks excessively
*
Never or rarely
Sometimes
Often
Very often
Blurts out answers before questions have been completed
*
Never or rarely
Sometimes
Often
Very often
Has difficulty waiting for his or her turn
*
Never or rarely
Sometimes
Often
Very often
Interrupts or intrudes on others
*
Never or rarely
Sometimes
Often
Very often
Submit
Should be Empty: