Instructions: Read each item below. Rate the degree you observed the client in the behaviors in the past month. Write the number in the box to the left of each item.

Engages in nervous habits (e.g., twists hair, bites nails, chews objects, etc.)

Off task (e.g., eyes moving, off target)

Can not adjust behavior to expectations of situation

Calls out

Fidgets

Hums

Easily frustrated

Cries

Outbursts

Excitable, impulsive

Does not want to complete tasks (Verbal argument)

Does not follow verbal instructions

Needs instructions repeated

Fails to remember short instructions

Does not complete chores/tasks independently

Makes unnecessary Banter or noises (e.g. burping, chatting to self)

Attempts inappropriate behavior (e.g., kicks things, throws things)