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 behaviors in the past 6 months.
Use the following scale when making evaluation:
0 - Never
1 - Occasionally
2 - Often
3 - Very Often
Use the scale below when making evaluations:
1 - Excellent
2 - Above Average
3 - Average
4 - Somewhat of a problem
5 - Problematic
Tic Behaviors: To the best of your knowledge, please indicate if this child displays the following behaviors:
Previous Diagnosis and Treatment: To the best of your knowledge, please answer the following questions:
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2021 Hush Communications Canada Inc.