STRENGTHS & INTERESTS
GENERAL INFORMATION & HISTORY
For each behavior listed below, put a check mark in one of the four columns marked “Not Observed”,
“Mild”, “Moderate”, or “Severe” (see descriptors below)
Not Observed- behavior has not been observed in the past six months.
Mild- behavior occasionally observed in child
Moderate- behavior frequently observed in child
Severe- behavior almost always observed in child
For each behavior listed below, put a check mark in one of the four columns marked “Not Observed”,
“Mild”, “Moderate”, or “Severe” (see descriptors below)
Not Observed- behavior has not been observed in the past six months.
Mild- behavior occasionally observed in child
Moderate- behavior frequently observed in child
Severe- behavior almost always observed in child
For each behavior listed below, put a check mark in one of the four columns marked “Not Observed”,
“Mild”, “Moderate”, or “Severe” (see descriptors below)
Not Observed- behavior has not been observed in the past six months.
Mild- behavior occasionally observed in child
Moderate- behavior frequently observed in child
Severe- behavior almost always observed in child
For each behavior listed below, put a check mark in one of the four columns marked “Not Observed”,
“Mild”, “Moderate”, or “Severe” (see descriptors below)
Not Observed- behavior has not been observed in the past six months.
Mild- behavior occasionally observed in child
Moderate- behavior frequently observed in child
Severe- behavior almost always observed in child
For each behavior listed below, put a check mark in one of the four columns marked “Not Observed”,
“Mild”, “Moderate”, or “Severe” (see descriptors below)
Not Observed- behavior has not been observed in the past six months.
Mild- behavior occasionally observed in child
Moderate- behavior frequently observed in child
Severe- behavior almost always observed in child
For each behavior listed below, put a check mark in one of the four columns marked “Not Observed”,
“Mild”, “Moderate”, or “Severe” (see descriptors below)
Not Observed- behavior has not been observed in the past six months.
Mild- behavior occasionally observed in child
Moderate- behavior frequently observed in child
Severe- behavior almost always observed in child
Your information will be encrypted.