Behavioral Checklist

If you have any trouble submitting this form, please download and print the pdf and fax it to us at (703) 530-9805. (Checklist following the Child/Adolescent Intake Form in pdf) Download

Please provide observations of your child's behavior by sharing if the behavior is:

PEERS

Shy Never
Sometimes
Often
Always

Feelings easily hurt Never
Sometimes
Often
Always

Has no close friends Never
Sometimes
Often
Always

SIBLING RELATIONS

Copies sibling(s) Never
Sometimes
Often
Always

Fights with sibling(s) Never
Sometimes
Often
Always

Physically or mentally cruel Never
Sometimes
Often
Always

Jealous Never
Sometimes
Often
Always

Tattles Never
Sometimes
Often
Always

RESTLESS

Restless or overactive Never
Sometimes
Often
Always

Excitable, impulsive Never
Sometimes
Often
Always

Short attention span Never
Sometimes
Often
Always

Doesn’t finish what he/she starts Never
Sometimes
Often
Always

TEMPER

Temper outburst, explosive, unpredictable Never
Sometimes
Often
Always

Throws, breaks, destroys things Never
Sometimes
Often
Always

Pouts or sulks Never
Sometimes
Often
Always

Hurts others physically Never
Sometimes
Often
Always

SCHOOL PROBLEMS

Is not learning up to potential Never
Sometimes
Often
Always

Does not like to go to school Never
Sometimes
Often
Always

Is afraid to go to school Never
Sometimes
Often
Always

Daydreams Never
Sometimes
Often
Always

Truancy Never
Sometimes
Often
Always

Will not obey school rules Never
Sometimes
Often
Always

LYING

Denies any wrong Never
Sometimes
Often
Always

Blames others for mistakes Never
Sometimes
Often
Always

Tells stories that did not happen Never
Sometimes
Often
Always

STEALING

From parents or family Never
Sometimes
Often
Always

At school Never
Sometimes
Often
Always

From stores and other places Never
Sometimes
Often
Always

FIRE SETTING

Plays with matches or candles Never
Sometimes
Often
Always

Sets fires Never
Sometimes
Often
Always

Please list any other information about your child that you feel is important for us to
know about:

Please list any other information about your child that you feel is important for us to know about:

TROUBLE WITH THE LAW

Please explain any trouble with the law:

Were you referred by the courts? Yes No

If so please explain:

What type of hearing did you have? Formal
Informal

Do you have a court date?

If so please explain.

Are you on probation? Yes No

Please explain:

Name*

Home Phone*

Cell Phone*

Email*

Digital Signature

Date

Verification

Thank you for filling out the Behavioral Checklist form.

Please return to the form page to fill out the next required form.

< Back to Form Page

(703) 530-9800

Our broad spectrum of services include, but are not limited to:

Treatment Services

Alcohol and Drug Services
Anger Management
Drug Court Treatment
DUI/DWI Evaluation/Assessments
Immigration Psychological Evaluations
Parent Education Groups (H.O.P.E.)
Shoplifting Intervention Services
Supervised Parent Visitation

Assessments

Chemical Dependency Evaluations
Alcohol and Drug Addiction Assessments
DWI/DUI Court-Ordered Chemical Use Assessments
Anger Management Assessments
Immigration Psychological Evaluations

Caring, Confidential, and Professional Counseling for Northern Virginia

Court Related DUI Evaluations and Drug and Alcohol Evaluations

HOPE, A State Approved Parent Education Class

Shoplifting Interventions for Adults and Juveniles

Behavioral Checklist

If you have any trouble submitting this form, please download and print the pdf and fax it to us at (703) 530-9805. (Checklist following the Child/Adolescent Intake Form in pdf) Download