Learning Behavior Rating Scale Learning Behavior Rating Scale Indicates problem areas that you see in your child. Name* First Last Date of Birth* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Parent's Name(s)* First Last Phone*Email* Problem AreasIndicate any problems in the following areas. Check all that apply. Reading Writing Math Spelling Comprehension Avoidance of school work Works too hard Slow work Reversals of letters or words Loses place/skips lines Poor memory Attention/Concentration Motivation/behavior Low self-esteem Overly Active Other Other:Help utilizedPlease list any past or current help, training or tutoring utilized for the above problems. Learning & Behavior Rating ScalePlease read each of the following statements and rate this individual according to the following scale. Select your rating number using the given scale: 1. Is careless*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more2. Fidgets or squirms*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more3. Swears or uses obscene language*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more4. Often asks to have things repeated*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more5. Has difficulty maintaining attention*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more6. Overreacts*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more7. Loses temper*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more8. Has poor study and work habits*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more9. Has difficulty organizing activities*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more10. Leaves seat in class*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more11. Argues with adults*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more12. Reverses letters or words*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more13. Fails to follow through on tasks*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more14. Runs or climbs excessively*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more15. Refuses adults' requests or rules*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more16. Feels schoolwork is too hard*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more17. Takes a long time to complete tasks*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more18. Has difficulty playing quietly*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more19. Deliberately does things that annoy others*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more20. Does not complete school assignments*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more21. Avoids prolonged mental effort*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more22. Answers questions before they are completed*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more23. Blames others for mistakes*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more24. Has difficulty remembering*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more25. Is distracted by other activities*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more26. Has difficulty waiting for turn*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more27. Is angry and resentful*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more28. Has difficulty learning math facts*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more29. Does not listen*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more30. Is touchy or easily annoyed by others*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more31. Holds grudges and seeks revenge*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more32. Has difficulty with abstract concepts and reasoning*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more33. Poor spelling grades or test scores*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more34. Worries about future events*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more35. Poor reading comprehension*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more36. Has poor handwriting*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more37. Poor math grades or test scores*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more38. Worries about past behaviors*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more39. Makes spelling errors in written assignments*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more40. Squints, blinks or rubs eyes when reading*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more41. Dislikes school*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more42. Is concerned about what others will think*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more43. Has difficulty sounding out unknown words*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more44. Has difficulty hearing*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more45. Makes grammatical errors*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more46. Is overly concerned about himself/herself*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more47. Had ear infections or speech problems in the past*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more48. Has poor coordination*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more49. Poor reading grades or test scores*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more50. Needs reassurance in many areas of life*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more51. Needs words repeated when taking spelling tests*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more52. Has speech difficulties*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more53. Receives low test scores*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more54. Complains about physical discomforts*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more55. Avoids reading*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more56. Complains about eye strain or fatigue*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more57. Has difficulty writing a paper*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more58. Appears tense or unable to relax*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more59. Reading is slow or choppy*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more60. Is bothered by loud sounds*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more61. Has poor vocabulary*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more62. Fears taking tests*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more63. Has difficulty reading or spelling phonetically*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more64. Skips words or lines when reading*Compared to others of the same age and gender, this behavior:0 - occurs less often OR the question doesn't apply to the age of this person1 - Occurs at about the same frequency2 - Occurs slightly more3 - Occurs considerably more4 - Occurs significantly more Individual Child Profile Family Profile Enrollment Form