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Rating Scale Spouse/Teacher
Supervisor/Teacher/Spouse Name_____________________
Email or phone number__________________________
Client_____________________________Age________
Date______________________
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.
Not at all=0 A little=1 Often=2 Very Often=3
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)