Internal &amp;#8211; Pre Course Behavioural Assessment

Primary Email Address - (This is the email address we will use for all Maxi Mind communications.)*

This email address should match the primary email on all your Maxi Mind forms
Child's Name:*
First Last
Your Name:*
First Last
Relationship to Child:*
Purpose of Assessment*
This Behavioural Assessment should be filled by the same parent or guardian who filled the previous Behavioural Assessment.
Attention-Related LD

Evaluate the following statements.*

	Almost Never	A Little	Very Often	Nearly Always
Fidgets with hands or feet or squirms in seat.
Difficulty remaining seated.
Difficulty waiting turn.
Talks excessively.
Interrupts others.
Always “on the go”.
Easily distracted.
Fails to complete assigned tasks.
Trouble paying attention.
Careless/messy work.
Does not seem to listen when spoken to.
Difficulty following directions.

Note: For the following three items, higher scores indicate better functioning by the child.*
Almost Never A Little Very Often Nearly Always
Follows rules.
Gets along socially.
Seems happy and in good mood.

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Sensory & Sensory Motor

Note: For the following three items, higher scores indicate better functioning by the child.*

	Almost Never	A Little	Very Often	Nearly Always
Bothered by textures on body, face or hands, having nails cut, hair combed
Bothered by background noise, loud, unexpected sounds
Avoids movement activities (swings, climbing, playground activities)
Doesn’t feel pain, doesn’t notice when touched
Avoids eye contact
Unaware of body sensations such as hunger, hot or cold or need to use toilet
Doesn’t seem to notice sensory stimuli (smells, noisy crowded places)
Constantly on the move, seeks intense crashing or rough play
Has difficulty sitting still, wiggles a lot, especially if trying to pay attention
Makes disruptive noises or sounds
Has poor balance and falls easily, avoids balance-related activities (bike riding)
Has poor endurance, is weak and gets tired easily, avoids physical activity
Slumps when sits in a chair or on the floor, uses arms/hands to support self
Difficulty learning new motor activities or those that require more than one step
Clumsy, awkward, or accident prone, tripping or bumping into people or objects
Difficulty organizing personal spaces or takes a long time to perform daily life tasks
Struggles with fine motor skills, like handwriting
Dislikes or avoids group sports
Difficulty with visual pursuits: often loses place, eyes skip one or more lines
Cannot follow directions in a noisy environment
Has difficulty completing puzzles
Has difficulty identifying and distinguishing between different sounds or letters
Has difficulty judging force required for a task
Cannot find pictures hidden in background
Difficulty finding number or words on page especially during math or reading tasks

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Auditory / Language

Evaluate the following statements.*

	Almost Never	A Little	Very Often	Nearly Always
Difficulty following what others are saying
Misuses or confuses words and sounds
Says “What?” or “Huh?” needs instructions repeated, needs visual cues
Is difficult to understand due to poor enunciation
Difficulty with spelling
Unable to recognize or repeat rhymes or songs
Does not like to sing or hum
Difficulty interpreting tone of voice – e.g. angry vs. joking
Tendency to ramble, can’t “get to the point”
Poor grammar, doesn’t speak in complete sentences
Mumble, has monotone voice
Slow to react to speech
Needs to be given directions repeatedly before responding
Seems to not understand what is said, i.e. poor comprehension, needs explanations

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Social / Emotional

Evaluate the following statements.*

	Almost Never	A Little	Very Often	Nearly Always
Irritable, short-tempered
Easily overwhelmed, frustrated by daily life activities
Does not transition smoothly from one activity to another
Has difficulty making and keeping friends
Does not sleep well, can’t get enough rest
Lacks confidence with new environments and new tasks
Has frequent mood fluctuations
Is not affectionate, not touching or hugging
“Needy” – lacks independence, low self reliance, low self-esteem
Lacks of tactfulness, acts impulsively
Response to situations appears immature for age
Anxious, bites nails, face and body not relaxed

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Organizational / Attention / Cognitive

Evaluate the following statements.*

	Almost Never	A Little	Very Often	Nearly Always
Is distracted easily, not able to stay on task
Has poor short term memory
Must re-read schoolwork several times to comprehend
Has difficulty getting/finding clothes, getting dressed in the morning
Planning ahead is difficult, prefers to avoid planning at all
Disorganized with school assignments, belongings, schedule
Can’t remember sequential tasks – e.g. do A, then B, then C
Often fails to begin or to complete tasks or projects unless helped