Attention Skills Assessment^©

shutterstock_83691799 Dear Parent,
The purpose of the Checklist is to help you make better decisions to help your child become a focused, happy, and skillful learner. This information is not intended to diagnose or treat any condition and is for educational purposes only.
Please enter all of the mandatory fields, which are marked with the *.

GENERAL INFORMATION

Name of Child: *

Age of Child: *

Name of Parent:

Phone Number:

Email Address: *

Parent’s Main Concerns:

How Did You Hear About Us?:

SENSITIVITY ANALYSIS

1. Easily Frustrated: *

2. Is excitable, impulsive: *

3. Has difficulty controlling emotions: *

4. Can't sustain attention in a routine situation: *

5. Makes careless mistakes: *

6. Is easily distracted: *

7. Misses important information: *

8. Is impulsive: *

9. Is easily frustrated: *

10. Has trouble listening: *

ATTENTION SKILLS ITEMS

11. Engages in nervous habits: *

12. Off task: *

13. Cannot adjust behavior to current situation : *

14. Calls out instructions: *

15. Fidgets: *

16. Hums: *

17. Cries: *

18. Has Outbursts: *

19. Does not want to complete task (verbal argument) : *

20. Needs instructions repeated: *

21. Fails to remember short instructions: *

22. Does not complete chores independently: *

23. Attempts to begin without parents: *

24. Makes unnecessary banter or noises: *

25. Attempts inappropriate behaviors: *

26. Is disorganized: *

27. Does not finish things: *

28. Is forgetful: *

29. Tends to lose and misplace things: *

SPARKS OF GENIUS

30. Spatial - How often does your child think in pictures, think in 3 dimensions or use imagination to create designs and build objects?: *

31. Verbal - How often does your child think in words and use language as in reading, writing, and speaking?: *

32. Spiritual - How often does you child think about spiritual matters like God, truth, prayer or the suffering of others?: *

33. Musical - How often does your child think musically in terms of listening, creating, or reproducing music with voice, rhythm, or instrument?: *

34. Interpersonal - How often does your child get along with and understand others and show empathy?: *

35. Intrapersonal - How often does your child think about understanding himself, both strengths & weaknesses and achieving personal goals?: *

36. Mathematical – How often does your like to think logically, work with numbers and understand cause and effect connections?: *

37. Kinesthetic – How often does your child use his body in skilled and complicated ways such as participating in sports, dance, the gym, or other physical activities?: *

38. Naturalist – How often does your child think about the natural world including plants, animals, and scientific studies?: *

Disclaimer:
Keep in mind that your child's chronological age, gender, previous learning experiences, and any medical condition may also affect first grade readiness. This checklist is not intended to diagnose any condition. Its purpose is to give information with regard to your child's education.

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