Learning Behavior Rating Scale 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 Skills 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. Distracted from the task at hand*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. Reading is slow*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. Poor reading or 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 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. Slow, deliberate speech*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. 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 more8. Has difficulty remembering telephone numbers*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. Completes math assignments slowly*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. 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 more12. Needs to look multiple times when copying*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. Has difficulty doing two things at once*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. 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 more15. Oral 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 more16. Has difficulty following verbal directions*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. 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 more18. Generally does things slowly*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. 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 more20. Has difficulty recalling stories and jokes*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. Has difficulty remembering things just heard*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. Is often one of the last 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 more23. 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 more24. Gets poor test results when being tested for 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 more25. Is impulsive*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. Avoids or has difficulty with video games*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. Has difficulty finding words for verbal expression*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. Needs to restudy or reread materials*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. Has poor study or 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 more30. Writing assignments take too long*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. 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 more32. Has problems remembering names*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 sense of direction/map reading skills*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. 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 more35. 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 more36. 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 more37. Jigsaw puzzles are difficult or avoided*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. Has difficulty understanding stories or jokes*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. 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 more40. 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 more41. Misreads similar 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 more42. Thoughts and materials are poorly organized*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 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 more44. Argues with authority figures*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. Poor at or dislikes drawing*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. Poor at or avoids games like chess or checkers*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. 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 more48. Refuses requests or disobeys 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 more49. Has difficulty with math word problems*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. Has problems seeing the "big picture"*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. 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 more52. 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 more53. Has difficulty creating pictures in the mind*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. Takes a while to catch on to new things*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. 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 more56. 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 more57. Lacks creativity or imagination in writing*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. Doesn't like card games*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. 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 more60. 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 more61. Poor at problem solving*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. Has difficulty planning steps to solve problems*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. 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 more64. Holds grudges or 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 more Individual Child Profile Family Profile Enrollment Form