Learning Skills Rating Scale

Indicates problem areas that you see in your child.

Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent's Name(s)*
First Last
Phone*
Email*
Problem Areas
Indicate 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 utilized
Please list any past or current help, training or tutoring utilized for the above problems.
Learning Skills Rating Scale
Please read each of the following statements and rate this individual according to the following scale. 4=defining characteristic, THAT'S MY CHILD! 3=happens on and off, 2= sometimes, 1=rarely, 0= not at all.
1. Distracted from the task at hand*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
2. Reading is slow*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
3. Poor reading or comprehension*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
4. Often asks to have things repeated*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
5. Has difficulty maintaining attention*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
6. Slow, deliberate speech*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
7. Makes spelling errors in written assignments*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
8. Has difficulty remembering telephone numbers*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
9. Has difficulty organizing activities*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
10. Completes math assignments slowly*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
11. Has difficulty sounding out unknown words*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
12. Needs to look multiple times when copying*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
13. Has difficulty doing two things at once*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
14. Takes a long time to complete tasks*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
15. Oral reading is slow or choppy*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens onn & off
- 4 - defining characteristic
16. Has difficulty following verbal directions*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
17. Avoids prolonged mental effort*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
18. Generally does things slowly*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
19. Needs words repeated when taking spelling tests*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
20. Has difficulty recalling stories and jokes*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
21. Has difficulty remembering things just heard*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
22. Is often one of the last to complete tasks*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens onn & off
- 4 - defining characteristic
23. Avoids reading*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristics
24. Gets poor test results when being tested for facts*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
25. Is impulsive*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
26. Avoids or has difficulty with video games*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
27. Has difficulty finding words for verbal expression*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
28. Needs to restudy or reread materials*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
29. Has poor study or work habits*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
30. Writing assignments take too long*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
31. Has difficulty reading or spelling phonetically*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
32. Has problems remembering names*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
33. Poor sense of direction/map reading skills*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defiining characteristic
34. Poor math grades or test scores*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
35. Has poor handwriting*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
36. Swears or uses obscene language*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
37. Jigsaw puzzles are difficult or avoided*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
38. Has difficulty understanding stories or jokes*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
39. Squints, blinks, or rubs eyes when reading*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
40. Loses temper*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
41. Misreads similar words*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
42. Thoughts and materials are poorly organized*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
43. Has difficulty hearing*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
44. Argues with authority figures*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
45. Poor at or dislikes drawing*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
46. Poor at or avoids games like chess or checkers*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
47. Has poor coordination*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 -defining characteristic
48. Refuses requests or disobeys rules*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
49. Has difficulty with math word problems*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
50. Has problems seeing the "big picture"*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
51. Has speech difficulties*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
52. Deliberately does things that annoy others*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
53. Has difficulty creating pictures in the mind*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
54. Takes a while to catch on to new things*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
55. Complains about eye strain or fatigue*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
56. Blames others for mistakes*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
57. Lacks creativity or imagination in writing*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarerly
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
58. Doesn't like card games*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
59. Is bothered by loud sounds*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
60. Is angry and resentful*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
61. Poor at problem solving*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristivc
62. Has difficulty planning steps to solve problems*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
63. Skips words or lines when reading*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic
64. Holds grudges or seeks revenge*
Compared to others of the same age and gender, this behavior:
- 0 - not at all
- 1 - rarely
- 2 - sometimes
- 3 - happens on & off
- 4 - defining characteristic

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