Client and other details

Client first name *

Client last name *

Client date of birth *

Please enter the client's legal name so our system can match them correctly...

Your first name *

Your last name *

Relationship to the client *

Your mobile number *

Your email address

You are being asked to describe the behaviour of someone you know well. How often does that person experience each of these problems? Please select the answer next to each item below that best describes the person’s behaviour during the past 6 months.

Section 1 (Inattention)

1. Fails to give close attention to details or makes careless mistakes in work or other activities *

Never or rarelySometimesOftenVery often

2. Difficulty sustaining attention in tasks or fun activities *

Never or rarelySometimesOftenVery often

3. Doesn’t listen when spoken to directly *

Never or rarelySometimesOftenVery often

4. Doesn’t follow through on instructions and fails to finish work or chores *

Never or rarelySometimesOftenVery often

5. Has difficulty organising tasks and activities *

Never or rarelySometimesOftenVery often

6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort *

Never or rarelySometimesOftenVery often

7. Loses things necessary for tasks or activities *

Never or rarelySometimesOftenVery often

8. Easily distracted by extraneous stimuli or irrelevant thoughts *

Never or rarelySometimesOftenVery often

9. Forgetful in daily activities *

Never or rarelySometimesOftenVery often

Inattention score

Inattention symptom count

Section 2 (Hyperactivity)

10. Fidgets with hands or feet or squirms in seat *

Never or rarelySometimesOftenVery often

11. Leaves seat in classrooms or in other situations in which remaining seated is expected *

Never or rarelySometimesOftenVery often

12. Shifts around excessively or feels restless or hemmed in *

Never or rarelySometimesOftenVery often

13. Has difficulty engaging in leisure activities quietly (feels uncomfortable, or is loud or noisy) *

Never or rarelySometimesOftenVery often

14. Is “on the go” or acts as if “driven by a motor” (or feels like they have to be busy or always doing something) *

Never or rarelySometimesOftenVery often

Hyperactivity score

Hyperactivity symptom count

Section 3 (Impulsivity)

15. Talks excessively (in social situations) *

Never or rarelySometimesOftenVery often

16. Blurts out answers before questions have been completed, completes others’ sentences, or jumps the gun *

Never or rarelySometimesOftenVery often

17. Has difficulty awaiting their turn *

Never or rarelySometimesOftenVery often

18. Interrupts or intrudes on others (butts into conversations or activities without permission or takes over what others are doing) *

Never or rarelySometimesOftenVery often

Impulsivity score

Impulsivity symptom count

Section 4 (Cognitive tempo)

19. Prone to daydreaming when they should have been concentrating on something or working *

Never or rarelySometimesOftenVery often

20. Has trouble staying alert or awake in boring situations *

Never or rarelySometimesOftenVery often

21. Easily confused *

Never or rarelySometimesOftenVery often

22. Easily bored *

Never or rarelySometimesOftenVery often

23. Spacey or “in a fog” *

Never or rarelySometimesOftenVery often

24. Lethargic, more tired than others *

Never or rarelySometimesOftenVery often

25. Underactive or have less energy than others *

Never or rarelySometimesOftenVery often

26. Slow moving *

Never or rarelySometimesOftenVery often

27. Doesn't seem to process information as quickly or as accurately as others *

Never or rarelySometimesOftenVery often

SCT score

SCT symptom count

Total ADHD Score

Section 1 Symptom Count

Sum of Sections 2 and 3 Symptom Counts

Total ADHD Symptom Count

SCT Symptom Count

28. How old was the client when these symptoms began?

29. In which of these settings did those symptoms impair the client's functioning?

School Home Work Social relationships

School difficulties

Home difficulties

Work difficulties

Social relationship difficulties

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