Rating Scales Instructions

Please complete the seven attached rating scales to help us prepare for your evaluation.

The student seeking the evaluation should complete the following:

 The BAARS-IV: Self-Report: Current Symptoms requires you to rate your behaviors
from the past 6 months.
 The BAARS-IV: Self-Report: Childhood Symptoms requires you to rate your
behaviors from when you were between ages 5 and 12.
 The SCT: Self-Report: Childhood Symptoms requires you to rate your behaviors from
when you were between ages 5 and 12.
 The Adult Reading History Questionnaire has no specified time frame.

A parent of the student should complete the following:

 The BAARS-IV: Other-Report: Current Symptoms requires your parent to rate your
behaviors from the past 6 months.
 The BAARS-IV: Other-Report: Childhood Symptoms requires your parent to rate
your behaviors from when you were between ages 5 and 12.
 The SCT: Other Report: Childhood Symptoms requires your parent to rate your
behaviors from when you were between ages 5 and 12.

The information gathered from the rating scales is very important as it helps the assessment team
make preparations for your evaluation. Please note the following when completing the scales:

 Because the scales cannot be used unless they are fully completed, please respond to each
item of each scale.
 Provide only one answer for each item.
 If unsure of an answer to an item, please give your best estimate.
 Please complete the scales independently. Whereas it may be tempting to discuss the
items with each other as you complete the scales, we are interested in both respondents’
independent perceptions. The only exception is the Adult Reading History Questionnaire,
which you are encouraged to complete with a parent’s assistance.

If a parent is not available to complete the parent versions of the forms, it is acceptable to have
someone different complete them. The person should know you well (e.g., sibling, relative),
preferably for many years, and have regular contact with you. If a parent is not available, finding
someone to complete the “childhood symptoms” versions of the forms can be challenging. Please
attempt to find someone who knew you well in childhood (e.g., sibling) that can complete the
form.

Please return the completed scales with your referral packet. Your input is essential in order to
fully understand your presenting concerns.

Thank you.
 1

BAARS-IV: Self-Report: Current Symptoms

Name: __________________________________ Date: ____________________

Sex: (circle one) Male Female Age: _____________________

For the first 27 items, please circle the number next to each item below that best describes your behavior
DURING THE PAST 6 MONTHS. Then answer the remaining three questions. Please ignore the
sections marked “Office Use Only.”

Never Some- Often Very

Section 1 (Inattention) or rarely times often
1. Fail to give close attention to details or make careless 1 2 3 4
mistakes in my work or other activities
2. Difficulty sustaining my attention in tasks or fun activities 1 2 3 4

3. Don’t listen when spoken to directly 1 2 3 4

4. Don’t follow through on instructions and fail to finish work 1 2 3 4

or chores.
5. Have difficulty organizing tasks and activities 1 2 3 4

6. Avoid, dislike, or am reluctant to engage in tasks that 1 2 3 4

require sustained mental effort
7. Lose things necessary for tasks or activities 1 2 3 4

8. Easily distracted by extraneous stimuli or irrelevant 1 2 3 4

thoughts.
9. Forgetful in daily activities 1 2 3 4

Office Use Only (Section 1)

Total Score: ______ Symptom Count: ______

Never Some- Often Very

Section 2 (Hyperactivity) or rarely times often
10. Fidget with hands or feet or squirm in seat 1 2 3 4

11. Leave my seat in classrooms or in other situations in which 1 2 3 4

remaining seated is expected
12. Shift around excessively or feel restless or hemmed in 1 2 3 4

13. Have difficulty engaging in leisure activities quietly (feel 1 2 3 4

uncomfortable, or am loud or noisy)
14. I am “on the go” or act as if “driven by a motor” (or I feel 1 2 3 4
like I have to be busy or always doing something)
Office Use Only (Section 2)
Total Score: ______ Symptom Count: ______

(continued)

BAARS-IV: Self-Report: Current Symptoms Rev. 05.04.16

 2

Never Some- Often Very

Section 3 (Impulsivity) or rarely times often
15. Talk excessively (in social situations) 1 2 3 4

16. Blurt out answers before questions have been completed, 1 2 3 4

complete others’ sentences, or jump the gun
17. Have difficulty awaiting my turn 1 2 3 4

18. Interrupt or intrude on others (butt into conversations or 1 2 3 4

activities without permission or take over what others are
doing)
Office use only (Section 3)
Total Score: ______ Symptom Count: ______

Never Some- Often Very

Section 4 (Sluggish Cognitive Tempo) or rarely times often
19. Prone to daydreaming when I should have been 1 2 3 4
concentrating on something or working
20. Have trouble staying alert or awake in boring situations 1 2 3 4

21. Easily confused 1 2 3 4

22. Easily bored 1 2 3 4

23. Spacey or “in a fog” 1 2 3 4

24. Lethargic, more tired than others 1 2 3 4

25. Underactive or have less energy than others 1 2 3 4

26. Slow moving 1 2 3 4

27. I don’t seem to process information as quickly or as 1 2 3 4

accurately as others.
Office use only (Section 4)
Total Score: ______ Symptom Count: ______

Total Scores for Entire Scale:

Sum of Sections Raw Scores 1 – 3 Total ADHD Score __________
Section 1 Symptom Count __________
Sum of Sections 2 and 3 Symptom Counts __________
Total ADHD Symptom Count __________ (Sum of 1 – 3)
SCT Symptom Count __________

(continued)

BAARS-IV: Self-Report: Current Symptoms Rev. 05.04.16

 3

Section 5

28. Did you experience any of these 27 symptoms at least “Often” or more frequently (Did you
circle a 3 or a 4 above)? No Yes (Circle one)

29. If so, how old were you when these symptoms began? (Fill in the blank)

I was ___________________ years old.

30. If so, in which of these settings did those symptoms impair your functioning? Place a check
mark () next to all of the areas that apply to you.

_______ School
_______ Home
_______ Work
_______ Social Relationships

If you checked any of the domains in item # 30 indicating settings in which symptoms impair your
functioning, please provide examples of your current difficulties in the appropriate spaces below.

School: __________________________________________________________________________

_________________________________________________________________________________

Home:___________________________________________________________________________

_________________________________________________________________________________

Work:___________________________________________________________________________

_________________________________________________________________________________

Social Relationships:_______________________________________________________________

_________________________________________________________________________________

FEEL FREE TO ATTACH ADDITIONAL PAGES TO FULLY ANSWER THESE QUESTIONS IF NECESSARY.

BAARS-IV: Self-Report: Current Symptoms Rev. 05.04.16

 1

BAARS-IV: Self-Report: Childhood Symptoms

Name: __________________________________ Date: ____________________

Sex: (circle one) Male Female Age: _____________________

For the first 18 items, please circle the number next to each item below that best describes your behavior
when you were a child BETWEEN 5 AND 12 YEARS OF AGE. Then answer the remaining two
questions. Please ignore the sections marked “Office Use Only.”

Never Some- Often Very

Section 1 (Inattention) or rarely times often
1. Failed to give close attention to details or made careless 1 2 3 4
mistakes in my work or other activities
2. Had difficulty sustaining my attention in tasks or fun 1 2 3 4
activities
3. Didn’t listen when spoken to directly 1 2 3 4

4. Didn’t follow through on instructions and failed to finish 1 2 3 4

work or chores.
5. Had difficulty organizing tasks and activities 1 2 3 4

6. Avoided, disliked, or was reluctant to engage in tasks that 1 2 3 4

required sustained mental effort
7. Lost things necessary for tasks or activities 1 2 3 4

8. Was easily distracted by extraneous stimuli or irrelevant 1 2 3 4

thoughts.
9. Was forgetful in daily activities 1 2 3 4

Office Use Only (Section 1)

Total Score: ______ Symptom Count: ______

Never Some- Often Very

Section 2 (Hyperactivity-Impulsivity) or rarely times often
10. Fidgeted with hands or feet or squirmed in seat 1 2 3 4

11. Left my seat in classrooms or in other situations in which 1 2 3 4

remaining seated was expected
12. Shifted around excessively or felt restless or hemmed in 1 2 3 4

13. Had difficulty engaging in leisure activities quietly (felt 1 2 3 4

uncomfortable, or was loud or noisy)
14. Was “on the go” or acted as if “driven by a motor” 1 2 3 4

15. Talked excessively 1 2 3 4

(continued)

BAARS-IV: Self-Report: Childhood Symptoms Rev. 05.04.16

 2

16. Blurted out answers before questions had been completed, 1 2 3 4

completed others’ sentences, or jumped the gun
17. Had difficulty awaiting my turn 1 2 3 4

18. Interrupted or intruded on others (butted into conversations 1 2 3 4

or activities without permission or took over what others
were doing)
Office Use Only (Section 2)
Total Score __________ Symptom Count __________
Sum of Sections 1 – 2 for Total Scores __________
Sum of Sections 1 – 2 for Symptom Counts __________
Section 3

19. Did you experience any of these 18 symptoms at least “Often” or more frequently (Did you
circle a 3 or a 4 above)? No Yes (Circle one)

20. If so, in which of these settings did those symptoms impair your functioning? Place a check
mark () next to all of the areas that apply to you.

_______ School
_______ Home
_______ Social Relationships

If you checked any of the domains in item # 20 indicating settings in which symptoms impaired
your functioning, please provide examples of those childhood difficulties in the appropriate spaces
below.

School: __________________________________________________________________________

_________________________________________________________________________________

Home:___________________________________________________________________________

_________________________________________________________________________________

Social Relationships:_______________________________________________________________

_________________________________________________________________________________

FEEL FREE TO ATTACH ADDITIONAL PAGES TO FULLY ANSWER THESE QUESTIONS IF NECESSARY.

BAARS-IV: Self-Report: Childhood Symptoms Rev. 05.04.16

 1

SCT: Self-Report: Childhood Symptoms

Name: __________________________________ Date: ____________________

Sex: (circle one) Male Female Age: _____________________

For the first 9 items, please circle the number next to each item below that best describes your behavior
when you were a child BETWEEN 5 AND 12 YEARS OF AGE. Then answer the remaining two
questions. Please ignore the sections marked “Office Use Only.”

Never Some- Often Very

Section 1 (Sluggish Cognitive Tempo) or rarely times often
1. Prone to daydreaming when I should have been 1 2 3 4
concentrating on something or working
2. Had trouble staying alert or awake in boring situations 1 2 3 4

3. Easily confused 1 2 3 4

4. Easily bored 1 2 3 4

5. Spacey or “in a fog” 1 2 3 4

6. Lethargic, more tired than others 1 2 3 4

7. Underactive or had less energy than others 1 2 3 4

8. Slow moving 1 2 3 4

9. I didn’t seem to process information as quickly or as 1 2 3 4

accurately as others.
Office use only

Total Score: ______ Symptom Count: ______

Section 2

10. Did you experience any of these 9 symptoms at least “Often” or more frequently (Did you circle
a 3 or a 4 above)? No Yes (Circle one)

11. If so, in which of these settings did those symptoms impair your functioning? Place a check
mark () next to all of the areas that apply to you.

_______ School
_______ Home
_______ Social Relationships

(continued)

SCT: Self-Report: Childhood Symptoms Rev. 05.18.16

 2

If you checked any of the domains in item # 11 indicating settings in which symptoms impaired
your functioning, please provide examples of those childhood difficulties in the spaces below.

School: __________________________________________________________________________

_________________________________________________________________________________

Home:___________________________________________________________________________

_________________________________________________________________________________

Social Relationships:_______________________________________________________________

_________________________________________________________________________________

FEEL FREE TO ATTACH ADDITIONAL PAGES TO FULLY ANSWER THESE QUESTIONS IF NECESSARY.

SCT: Self-Report: Childhood Symptoms Rev. 05.18.16

 Adult Reading History Questionnaire

Name:___________________________________________________

Please Note: You are encouraged to work with a parent when completing this questionnaire.

Please circle the number of the response that most nearly describes your attitude or experience
for each of the following questions or statements. Please respond to each item. It is okay to
estimate and to give your best guess.

1. Which of the following most nearly describes your attitude toward school when you were a
child:

Loved school; Hated school; Tried

Favorite activity to get out of going
0 1 2 3 4

2. How much difficulty did you have learning to read in elementary school?

None A great deal

0 1 2 3 4

3. How much extra help did you need when learning to read in elementary school?
Help from: Tutors or special Tutors or special class:
No help Friends Teachers/Parents class: 1 Year 2 or more years
0 1 2 3 4

4. Did you ever reverse the order of letters or numbers when you were a child?

No A great deal
0 1 2 3 4

5. Did you have difficulty learning letter and/or color names when you were a child?

No A great deal
0 1 2 3 4

6. How would you compare your reading skill to that of others in your elementary classes?

Above average Average Below average

0 1 2 3 4

CONTINUED ON BACK SIDE (TURN OVER)

7. All students struggle from time to time in school. In comparison to others in your classes, how
much did you struggle to complete your work?

Not at all Less than most About the same More than most Much more than most
0 1 2 3 4

8. Did you experience difficulty in high school or college English classes?

No; Enjoyed A great deal;
and did well Some Did poorly
0 1 2 3 4

9. What is your current attitude toward reading?

Very positive Very negative

0 1 2 3 4

10. How much reading do you do for pleasure?

A great deal Some None

0 1 2 3 4

11. How would you compare your current reading speed to that of others the same age and
education?
Above average Average Below average
0 1 2 3 4

12. How much reading do you do in conjunction with your work? (If retired or not working, how
much did you read when you were working?)
A great deal Some None
0 1 2 3 4

13. How much difficulty did you have learning to spell in elementary school?

None Some A great deal

0 1 2 3 4

14. How would you compare your current spelling to that of others of the same age and
education?
Above average Average Below average
0 1 2 3 4
15. Did your parents ever consider having you repeat any grades in school due to academic
failure (not illness)?
Talked about it, Repeated one Repeated two
No but didn’t do it grade grades Dropped out

0 1 2 3 4

16. Do you ever have difficulty remembering people’s names or names of places?

No A great deal
0 1 2 3 4

17. Do you have difficulty remembering addresses, phone numbers, or dates?

No A great deal

0 1 2 3 4

18. Do you have difficulty remembering complex verbal instructions?

A great deal
No
0 1 2 3 4

19. Do you currently reverse the order of letters or numbers when you read or write?

No A great deal
0 1 2 3 4

20. How many books do you read for pleasure each year? (Note: audiobooks that are listened to
should not be recorded here; books read via an electronic device [e.g., Kindle, iPad] should be
recorded here).

More than 10 6-10 2-5 1-2 None

0 1 2 3 4

21. How many magazines do you read for pleasure each month? (Note: magazines read on the
Internet should be recorded here).

5 or more 3-4 regularly 1-2 regularly 1-2 irregularly None

0 1 2 3 4

CONTINUED ON BACK SIDE (TURN OVER)

22. Do you read daily (Monday-Friday) newspapers? (Note: newspapers read on the Internet
should be recorded here).

Every day Once a week Once in a while Rarely Never

0 1 2 3 4

23. Do you read a newspaper on Sunday? (Note: newspapers read on the Internet should be
recorded here).
Completely; Scan each Once in
Every Sunday Rarely Never
week a while
0 1 2 3 4

24. Do you use audiobooks? (circle one)

Yes No

25. How many audiobooks do you listen to for pleasure each year?

More than 10 6-10 2-5 1-2 None

0 1 2 3 4

26. When reading for school, do you use assistive technology (e.g., screen reader, digital text
files)? (circle one)

Yes No

27. When reading for pleasure, do you use assistive technology (e.g., screen reader, digital text
files)? (circle one)

Yes No

28. Do you have a membership with Recordings for the Blind and Dyslexic? (circle one)

Yes No

29. Did a parent help you fill out this questionnaire? (circle one)

Yes No
 1

BAARS-IV: Other-Report: Current Symptoms

Name of person to be rated: ______________________________ Date: ____________________

Your name: ________________________________________________________________________

Your relationship to person being rated: (Circle one)

Mother Father Brother/sister Spouse/partner Friend Other (specify): _____________

Instructions

You are being asked to describe the behavior of someone whom you know well. How often does that
person experience each of these problems? For the first 27 items, please circle the number next to each
item below that best describes the person’s behavior DURING THE PAST 6 MONTHS. Then answer
the remaining three questions. Please ignore the sections marked “Office Use Only.”

Never Some- Often Very

Section 1 (Inattention) or rarely times often
1. Fails to give close attention to details or makes careless 1 2 3 4
mistakes in his/her work or other activities
2. Has difficulty sustaining his/her attention in tasks or fun 1 2 3 4
activities
3. Doesn’t listen when spoken to directly 1 2 3 4

4. Doesn’t follow through on instructions and fails to finish 1 2 3 4

work or chores
5. Has difficulty organizing tasks and activities 1 2 3 4

6. Avoids, dislikes, or is reluctant to engage in tasks that 1 2 3 4

require sustained mental effort
7. Loses things necessary for tasks or activities 1 2 3 4

8. Is easily distracted by extraneous stimuli or irrelevant 1 2 3 4

thoughts
9. Is forgetful in daily activities 1 2 3 4

Office Use Only (Section 1)

Total Score: ______ Symptom Count: ______

Never Some- Often Very

Section 2 (Hyperactivity) or rarely times often
10. Fidgets with hands or feet or squirms in seat 1 2 3 4

11. Leaves his/her seat in classrooms or in other situations in 1 2 3 4

which remaining seated is expected
12. Shifts around excessively or feels restless or hemmed in 1 2 3 4

(continued)

BAARS-IV: Other-Report: Current Symptoms Rev. 05.04.16

 2

13. Has difficulty engaging in leisure activities quietly (feels 1 2 3 4

uncomfortable, or is loud or noisy)
14. Is “on the go” or act as if “driven by a motor” (or he/she 1 2 3 4
feels like he/she has to be busy or always doing something)
Office Use Only (Section 2)
Total Score: ______ Symptom Count: ______

Never Some- Often Very

Section 3 (Impulsivity) or rarely times often
15. Talks excessively (in social situations) 1 2 3 4

16. Blurts out answers before questions have been completed, 1 2 3 4

completes others’ sentences, or jumps the gun
17. Has difficulty awaiting his/her turn 1 2 3 4

18. Interrupts or intrudes on others (butts into conversations or 1 2 3 4

activities without permission or takes over what others are
doing)
Office use only (Section 3)
Total Score: ______ Symptom Count: ______

Never Some- Often Very

Section 4 (Sluggish Cognitive Tempo) or rarely times often
19. Is prone to daydreaming when he/she should be 1 2 3 4
concentrating on something or working
20. Has trouble staying alert or awake in boring situations 1 2 3 4

21. Is easily confused 1 2 3 4

22. Is easily bored 1 2 3 4

23. Is spacey or “in a fog” 1 2 3 4

24. Is lethargic, more tired than others 1 2 3 4

25. Is underactive or has less energy than others 1 2 3 4

26. Is slow moving 1 2 3 4

27. Doesn’t seem to process information as quickly or as 1 2 3 4

accurately as others.
Office use only (Section 4)
Total Score: ______ Symptom Count: ______

Sum of Sections 1 – 3 for Total Scores __________

Sum of Sections 1 – 3 for Symptom Counts __________
(continued)

BAARS-IV: Other-Report: Current Symptoms Rev. 05.04.16

 3

Section 5

28. Did this person experience any of these 27 symptoms at least “Often” or more frequently (Did
you circle a 3 or a 4 above)? No Yes (Circle one)

29. If so, how old was the person when those symptoms began? (Fill in the blank)

They were ___________________ years old.

OR if you do not know, place a check mark () below

__________ I don’t know.

30. If so, in which of these settings did those symptoms impair the person’s functioning? Place a
check mark () next to all of the areas that apply to the person.

_______ School
_______ Home
_______ Work
_______ Social Relationships

If you checked any of the domains in item # 30 indicating settings in which symptoms impair the
person’s functioning, please provide examples of the person’s current difficulties in the appropriate
spaces below.

School: __________________________________________________________________________

_________________________________________________________________________________

Home:___________________________________________________________________________

_________________________________________________________________________________

Work:___________________________________________________________________________

_________________________________________________________________________________

Social Relationships:_______________________________________________________________

_________________________________________________________________________________

FEEL FREE TO ATTACH ADDITIONAL PAGES TO FULLY ANSWER THESE QUESTIONS IF NECESSARY.

BAARS-IV: Other-Report: Current Symptoms Rev. 05.04.16

 1

BAARS-IV: Other-Report: Childhood Symptoms

Name of person to be rated: ______________________________ Date: ____________________

Your name: ________________________________________________________________________

Your relationship to person being rated: (Circle one)

Mother Father Brother/sister Spouse/partner Friend Other (specify): _____________

You are being asked to describe the behavior of someone whom you know well. How often did that person
experience each of these problems? For the first 18 items, please circle the number next to each item below
that best describes their behavior when they were a child BETWEEN 5 AND 12 YEARS OF AGE. Then
answer the remaining two questions. Please ignore the sections marked “Office Use Only.”

Never Some- Often Very

Section 1 (Inattention) or rarely times often
1. Failed to give close attention to details or made careless 1 2 3 4
mistakes in his/her work or other activities
2. Had difficulty sustaining his/her attention in tasks or fun 1 2 3 4
activities
3. Didn’t listen when spoken to directly 1 2 3 4

4. Didn’t follow through on instructions and failed to finish 1 2 3 4

work or chores.
5. Had difficulty organizing tasks and activities 1 2 3 4

6. Avoided, disliked, or was reluctant to engage in tasks that 1 2 3 4

required sustained mental effort
7. Lost things necessary for tasks or activities 1 2 3 4

8. Was easily distracted by extraneous stimuli or irrelevant 1 2 3 4

thoughts.
9. Was forgetful in daily activities 1 2 3 4

Office Use Only (Section 1)

Total Score: ______ Symptom Count: ______

Never Some- Often Very

Section 2 (Hyperactivity-Impulsivity) or rarely times often
10. Fidgeted with his/her hands or feet or squirmed in his/her 1 2 3 4
seat

11. Left his/her seat in classrooms or in other situations in 1 2 3 4

which remaining seated was expected
12. Shifted around excessively or felt restless or hemmed in 1 2 3 4

(continued)

BAARS-IV: Other-Report: Childhood Symptoms Rev. 05.04.16

 2

13. Had difficulty engaging in leisure activities quietly (felt 1 2 3 4

uncomfortable, or was loud or noisy)
14. Was “on the go” or acted as if “driven by a motor” 1 2 3 4

15. Talked excessively 1 2 3 4

16. Blurted out answers before questions had been completed, 1 2 3 4

completed others’ sentences, or jumped the gun
17. Had difficulty awaiting his/her turn 1 2 3 4

18. Interrupted or intruded on others (butted into conversations or 1 2 3 4

activities without permission or took over what others were
doing)
Office Use Only (Section 2)
Total Score __________ Symptom Count __________
Sum of Sections 1 – 2 for Total Scores __________
Sum of Sections 1 – 2 for Symptom Counts __________
Section 3

19. Did the person experience any of these 18 symptoms at least “Often” or more frequently (Did
you circle a 3 or a 4 above)? No Yes (Circle one)

20. If so, in which of these settings did those symptoms impair the person’s functioning? Place a
check mark () next to all of the areas that apply to the person.

_______ School
_______ Home
_______ Social Relationships

If you checked any of the domains in item # 20 indicating settings in which symptoms impaired the
person’s functioning, please provide examples of those childhood difficulties in the spaces below.

School: __________________________________________________________________________

_________________________________________________________________________________

Home:___________________________________________________________________________

_________________________________________________________________________________

Social Relationships:_______________________________________________________________

_________________________________________________________________________________

FEEL FREE TO ATTACH ADDITIONAL PAGES TO FULLY ANSWER THESE QUESTIONS IF NECESSARY.

BAARS-IV: Other-Report: Childhood Symptoms Rev. 05.04.16

 1

SCT: Other-Report: Childhood Symptoms

Name of person to be rated: ______________________________ Date: ____________________

Your name: ________________________________________________________________________

Your relationship to person being rated: (Circle one)

Mother Father Brother/sister Spouse/partner Friend Other (specify): _____________

Instructions

You are being asked to describe the behavior of someone whom you know well. How often did that
person experience each of these problems? For the first 9 items, please circle the number next to each
item below that best describes their behavior when they were a child BETWEEN 5 AND 12 YEARS
OF AGE. Then answer the remaining two questions. Please ignore the sections marked “Office Use
Only.”

Never Some- Often Very

Section 1 (Sluggish Cognitive Tempo) or rarely times often
1. Was prone to daydreaming when he/she should have been 1 2 3 4
concentrating on something or working
2. Had trouble staying alert or awake in boring situations 1 2 3 4

3. Was easily confused 1 2 3 4

4. Was easily bored 1 2 3 4

5. Was spacey or “in a fog” 1 2 3 4

6. Was lethargic, more tired than others 1 2 3 4

7. Was underactive or had less energy than others 1 2 3 4

8. Was slow moving 1 2 3 4

9. Didn’t seem to process information as quickly or as 1 2 3 4

accurately as others.
Office use only

Total Score: ______ Symptom Count: ______

(continued)

SCT: Other-Report: Childhood Symptoms 05.18.2016

 2

Section 2

10. Did the person experience any of these 9 symptoms at least “Often” or more frequently (Did
you circle a 3 or a 4 above)? No Yes (Circle one)

11. If so, in which of these settings did those symptoms impair the person’s functioning? Place a
check mark () next to all of the areas that apply to the person.

_______ School
_______ Home
_______ Social Relationships

If you checked any of the domains in item # 11 indicating settings in which symptoms impaired the
person’s functioning, please provide examples of those childhood difficulties in the spaces below.

School: __________________________________________________________________________

_________________________________________________________________________________

Home:___________________________________________________________________________

_________________________________________________________________________________

Social Relationships:_______________________________________________________________

_________________________________________________________________________________

FEEL FREE TO ATTACH ADDITIONAL PAGES TO FULLY ANSWER THESE QUESTIONS IF NECESSARY.

SCT: Other-Report: Childhood Symptoms 05.18.2016

 Regents’ Center for Learning Disorders Credit Card Agreement

Name on Card:______________________________________________________________________

Signature of Cardholder:____________________________________________________________

Amount to Charge:__________________________________________________________________

Card Type:__________________________________________________________________________

-----------------------------------------------------------------------------------------

Card Number:_______________________________________________________________________

Expiration Date:_____________________________________________________________________