Behaviour Questionnaire: Tell me about your child

The child's name and date of birth

Does the child identify as male, female or another gender?

Is considerate of other people’s feelings

Shares readily with other children, eg: toys, treats, pencils

Is generally well behaved, usually does what adults request

Has at least one good friend

Can work well in a group

Is kind to younger children

Often offers to help others (parents, teachers, other children)

Is helpful if someone is hurt, upset or feeling ill

Readily approaches children he/she does not know

Can describe the difference between right and wrong

Would like to improve his/her behaviour

Is restless, overactive and often says he/she is bored

Often loses his/her temper

Is constantly fidgeting, squirming or scratching

Is often unhappy or tearful

Often tells lies or cheats

Has no energy, often feels tired

Is very impulsive, can’t wait when asked to

Is shy with children he/she does not know

Clings to adults or is very dependent

Gets very upset when separated from parents

Has trouble relaxing and enjoying him/herself

Reacts aggressively when contradicted or teased

Often fights with other children or bullies them

Scares other children to get what he/she wants

Has difficulty making simple decisions

Has difficulties accepting sanctions

Have these difficulties have been present for more than a year?

Do these issues intefere with his/her eating, sleeping, etc?

Thinks things out before acting

Has a good attention span, sees work through to the end

Gets along better with adults than children

Is aware of his/her behavioural issues

Has stolen from home, school or elsewhere

Often complains of headaches, stomach aches or sickness

Is usually solitary,and prefers to play alone

Is easily distracted, concentration wanders

Is overly nervous or clingy in new situations

Has many fears, is easily worried or scared

Doesn’t want to sleep alone

Is often nervous or tense

Appears to be not as happy as other children

Is picked on or bullied by other children

Takes a long time getting used to being in unfamiliar places

Repeatedly seeks reassurance

When angry with someone, says bad things behind their back

Hits, bites or pinches other children or adults

Does not seem to feel badly after misbehaving

Has difficulties with managing emotions

Doesn't cope with losing a game or getting something wrong

Do these difficulties upset or distress your child?

Do these issues put pressure on you/your family as a whole

Your answers and my responses will not constitute a diagnosis of any kind or guarantee any assurances. They help to understand what areas to explore when supporting your child. They may help you to consider how your child's current behaviour is impacting on them at school as well as at home. You may also recognise some positive qualities in your child that have gone unnoticed for a while. The information you provide may start a dialogue with other sources of support, but will not be shared without your consent.

Adult's name

Adult's email address

Thank you for completing the questionnaire