c3ÓU12

Your Name/lD S Gerider: M Birti Date: U9_

Ja07
(Circig One! Day Year

Grade: 1,? Today's Date:

S3COehiNf-oReEprtS
Age: . Yoars Mor:Js
Montr Day Year

true you think these things are about yc

lnstructions: Here are some things that children and teenagers might say.Tellus, in your opinion, hov happened to you in the past month.
often it
Think about yourself in the past mónth. Read each item carefully, then mark how true it is, or how
0= In the past month, this was not true at all about me. It never (or seldom) happened.
1=In the past month, this was just alitle true about me. It happened occasionally.
2= In the hast rmonth, thiswas pretty imuch true about me. It happened often (or quite a bit).
3= In the past month, this was very much true äbout me. It happened very often (very frequently).
Please circle only one answer for each item. It is important to respond to every item.
For items that you find difficult to answer, please give your best guess.

Ratina: o Not true at all (Never, Seldom) 2- Pretty much true (Often, Quite a bit)
n.the pas tmonth, this was.. 1Just a little true (Occasionally) 3-Very much true (Very often, Very frequentiy)

0 2 3
Iblürt out the first thing that Ithink of.
2. Istuggle to complete hard tasks.
3 It is hard for me to pay attention to details.
hard1for me to sit still.
5. can'tpay attention for long.
p. am good atsOnethings
7. Imake mistakes.
0
8.dothings to hurtpeople.
9. Ihave trouble understanding what I read.
10. Istártfights withotherpeople 3
11. Ilike it when people säy göod things about me.
12.Itell the truth; Ido not even telllitle white fes"
1
13. Ihave trouble with spelling.
14.lose track oi what l am supposed to do.
15. Ihave trouble playingor doing things quietly.
i6. Tget istracied by things that are going on around me.
17. I break things when Iam angry or upset.
timo
L8. Thave trouble inishine things. O23
19. Punishment in my housë is not fair. 3
20 am happy,,even when lam waiting in along line. 1
21. People like being around me.
22.My parents expect to0o much om_me
23. enjoy myself when Ido my favorite activities. 1

24.Tactlike an angel. 0

Iam happy and cheerful.

Ph.D. 25.
26.Myparents are too hatshwhen they punish me.
3

Coners, 27.
28.
29.
30.
Ihave trouble concentrating.
Iam perfect in every way.
Iam restless.
When I getmad atssomeone. Iget even with them.
0
3
31. Italk too much.

Keith 32.1destroystuff that belongsto other people

33. Ihave trouble with reading.
34. My parents'aretoo critical ot me. 3
C. 35. Ican't do things right,
36. Tlearn more slowlythan other kids my age
37. My parents are too strict with me.
38. Ihave trouble with math
39. 3
Ibully or treaten other people.

Additional Questions:
40. Do you have any other problems?.
41. What are your main strengths or skills?

AALC Copyrigla o2008 Mali-4ealdh Systems Inc. All righis rëserved in the United States, PO. Box 95u, Noath Tonnwanda, NY 141:0-09s0, )-s00-4$6-3003.
IoCanadz, 3770 Victoria Park Ave., Toronto, (ON M2I13M6, 1-800-268-6011, 1-416492-2627, Fas 1-4l6492-3343.
 ng hilc

Name/lD: 5S
Gender: M BirtiDate: Ytuar
(Circia Ong) 1Month Da

Age: Grade: I2 Administration Date: 7 | (2| 25

Morih Day Year

1Ogode-IsESAN
Scoring Grid
Instructions:
1. For each item, transíer the circled number into the unshaded box across each roW.
2. Sum the values in each column and write the totals in the Raw Score boxes at the botom of the grid.

IN HY LP AG FR PI NI 3
1
2. 0
3
4. 0 1
5.
6.
7
8.
9
10,
11
12.
13
"14.
15
16

-
17
18
19
20 0
21
22 2
23.
24
25
26 3
27.
2
28.
29.
30.
31.
32.
33.
34.

36.
37.
38.
39. 1
RAW SCoRÉS
IN HY LP AG FR P

40 Do you haveany other problems?.

41 What are your main strengths or skills?.

Copyigbt 2008 Multi-lJealth Systens Inc. All righis reserved. In the United States, P. Box 950, North Tonawanda, NY 14120-0950, 1-800-456-3003.
MHS In Canda, 3770 Victoria Park Ave., Toonto, ON M2H 3M6, 1-800-268-60|1, 1-4I6-492-2627, Fax 1-416-492-3343.
 415

C3O-ShSNelf-REoepSrt M
Birth Date.
Gender:
Name/lD:
7 12| 25
Grade: 2 Administration Date:
Age:
Yogrs Monhs

Female Profile: Ages 13-18

Instructions: scale and age COIUmn.
circle the raw score for each scale under the appropriate
1. USing the Raw Scores from the Scoring Grid.
2. Follow the row across to either outside column to find the T-score for each Scale.
3. Connect the circled scores with straight lines to obtain the profile.
Defiance/ Family
Hyperacttvity Learning Relations
Problems Aggression
Trnpuislvity
HY AG

010*

1816
13

1715
12.12
2

43.13

11:11:11: 11
101012 12
91010 10 10

1010 10: 10
9
1010

3
810
10 8 8 7 7
3
9
7 9 7 4 6
7 7
8 6 6

Ph.D. 6 8
5 6
6
6 6
6 5

5 6

Coners, 7

5
6

4 4
5 5
4

3
5

2
4

3 3
4 4

5 3 4 4

Keith 4 3
3 3

3 1
2 2

2 3 3 2
C. 3 2 1 1 1
2 2 2 2
2 2 " 1 1
1 0 0 0
1 1
2 1 0
0 0 0-1 0-1 0-1 0 0 0-1 0-1

Respose Style Analysis

Instructions:
Positive Possible positive response style
1. Transfer the Raw Scores fur both the Positive impression (Pl) and Impression (P)
Negative Impression (NI) scales from the Scoring Grid. indicated if Raw Score 4.
2. Insert a checkmark in the Ihterpretative Guideline box if the response Negative n Possible negative response style
style is indicated. Impression (NI) indicaled if Raw Score 5.
Copyright 92008 Multi-Healtih vstens Inc. All rights reserved. Jn the United States, P.O. Box 950, North Ionawanda, NY 14120-0950, 1-s00-456-3003.
IMHS InCanadn, 3770 Victoria Park,. Ave.. Toronto, ON M2|| 3M6, 1-800-268-6011.
1-416-492-2627, Fas |-416--492-3343.
 (473
Child's Name/D: Gender: M Birth Date06 L3
Parent's Name/D KS Age. SO
MortuA
Grade Today's Date.O
ont t
12Q02s
Uay

nstructions: Here are sonme things parents might say about thelr children. Please tel us about your child and what he/she has been like in the
p2st month Read each itenm carefully, then mark how well it describes your child or how frequently it has happened in the past month.
0=In the past month, this was not true at all about my child. lt never (or seldom) happened
1= n the past month, this was justa litle true about ny child. lt happened occasionally.
2=In the past month,this was pretty much true about iy chld It happened often (or quite a bit).

S1AuH•LN0d4-OEg 3= In the past month,this was very much true about my child. It happened very often (very frequently)
Please circle only one answer for each item It is important to respond to every item.
For items that you find difficuit to answer, please give your best guess.
Rating: 0=Not true at all.(Never, Seldom) 2Pretty: múch true (Often, Quite a bit)
In the past month, this was. 1Just alitle true (0ccasionally) 3 Very muchtrue(Very often, Very frequently)
Forgets to tum in completed work.
2. Is perfectin every way. 3
3
3 Fidgets or squirms in seat. 01 2 3
4 Is one of the last to be picked for teams or games.
2 3
5 Restless oroveractive.
Does not khowhow to make friends.
7 Runs or climbs when he/she is not suppösed to.
01 3
8. Cannot grasp arithmetic. 2 3
9. Is difficult to please or amuse. 0
10. Needs oxtra explanation of instructions,
11 Is hard to Motivate. (evn with rewards like candy Ùr moiey).
12 Makes mistakes. 1 3
13.
2 3
Acts as if driven by a motor.
I4. Starts fights with others on purpose, 3
15 Hastrouble getting started on tasks or projects. 0 23
16. Is happy, cheerful, and has a positive attitude. 3
2
17 Doesn't pay attention todetails; makes careless mistakes.
18.. Has trouble keeping friends.sa
19. Bullies, threatens, or scares others. 0)
20. Loses things (for oxanmple, schoolwork, pencils, books, tools, or toys) 3
21. Tells lies to hurt other people.
22., I cannot figure out what nmakes him/her happy. 23
23 Threatens to hurt öthèrs. 3
24. Is constantly noving. 2 3
25. Has trouble with reading.
26. Is angry and resentful.
27 Hasa short attention span.
28. Excitable, impulsive. 03
29. Cannot dothinigs right. 3
30. Has trouble concentrating. 0
31. Tells the truth: doesn't even tell little white lies," 2 3
32 Has tröuble organizing tasks or activities. 023
33 Is fun to be around.
34. Inattentive, casily distracted.
35. 0s messy or disorganized. 2 3
36. Speling is poos.
37. Is patient and conteit, even when waiting ina long line.
38, Has no friens.
39 Does not understand what he/she reads. 2 3
3
40. Behayes like an angel.
41. Has troubje keeping his/her mind on work or onplay for long. 2 3
42. Has to sruggle io complete hard tasks.
43. Does not get invited to play or go out with others. 2 3

Additional Questions:
44. Do you have any other concerns about your child?
45. What strengths or skills does your child bave?
Copyright O2008 Muti-Healh Systetns Inc. Arights röserved: lh tieUaied Siates, Q. Box 950, NarthTanáw'anda, NY 14124-0950, -80.-4$6-3003.
MHS n Canada, 3770 Victoria Pak Ave., Toronto, ON M2H3Mó, 1-800-268-601, 1-416-492-2627, Fax -416-492-3343.
THIS FOBM CcONTANSA COPY PROTECTION FEATÜRË TO PREVENI UNAUTHORIZED REPRODUcTION,TO OBTAIN PERMISSsION TO COPY EMAL Iegaldept@mhs.conm
 Child's Name/lD: 6 7.5
Gender: M ) Birth Date:
(Circle he)
Month Day

Parent's Name1D: Admin Date:

Age:$o 0 Grade: tMonth Day Vaa
Years Wionths

SHAOUNsureDtE
Scoring Grid
Instructions:
1. For each item, transfer the circled number into the unshaded box across each row.
2. Sum the values in each column and write the totals in the Raw Score boxes at the bottom of the gria.

IN HY LP AG PR PI NI
EF 1. 2
0
3
2.
3.
2
4 0
5.
6.
7
8.
9.
3
10.
6 11.
12.
13. 3
3
14.
15. 3
16. 1
17.
18.
19.
20.
21. 3
22.
23.
24.

-o
25.
26.
27. 0
2 28.
2 29.
30. 3
31. 1
32 0 3
33.
34. 3
2 3
35.
36. 2 3
37. ) 1

-
38. 2 3
39 2
40. 1
41. 2 3
42.
43. 2 3
RAW SCORES

LP AG PR PI N
IN HY
44 Do you have any other concerns about your child?
45 What strengths or skills does your child have?
States, P.O. Box 950, North Tonawanda, NY 14120-0950, 1-800-456-3003.
Copyright O 2008 Multi-Health Systems Inc. Allrights reserved. In the United 1-416-492-2627, Fax 1-416-492-3343.
MHS Jn Canada, 3770 Victoria Park Ave.. Toronto. ON M2H 3M6. 1-800-268-6011,
 Child's Name/lD: Birth Date:

C3SO"N-hPaoErRenSt
Gender: M

Parent's Name/D. Grade: Admin Date: 7 / 22s

Age:
Rdonis

Female Profile: Ages 12-18

Instructions:
1. Usingthe Raw Scores from the Scoring Grid, circle the raw score for each scale under
2. Follow the rowacross to either outside column the appropriate scale and age column.
to find the T-score for each scale.
3. Connect the circled scores with
straight lines to obtain the profile.

Inattenton LGarning Execuive Deflancel Pesr

pust
Problems Functiontng Aggrosslon Relatlons
HY LP AG PR
213 19 1s 16 7A8 2 18 445 16 7323 14
2901 134124 1& 134 5 6-F/13 2163 5 16 T//8213 14 6 16 17/k8 12 8 145 16 768
12412+114111+11t 114 124 12+13+11 12
13 12+13r f: 13+
7 7 71 290
88 13 12 16
15 12
37 8:
86 12 72 13
11 10 10 87
"j0 11
14 12 86
84 12 1 11
10 85
83 32 15
84
82 11 11 14
10 9 83
11 10"
80 " 14
79 10 11 13
12
80
5 5 79
10 13
78
11 12 5 5
10
76
9
75
9 8 10 74
10 6 7 3
73
8 1

8 8 8 10
7 71
69
6 6 70
68 10 4
69
67 9
7 6 68
66 7 67
6 6
65 66
5 5 7
64 7 65
2
6 5 6 5 64
62 2 3
5 5 63
5 6
6 4 4 4 62
60 6

Ph.D. 59 5 5
4 5
5
6
60
59

Coners,
5
58
4 4 3 3 5
57
4 56
4 4 4
3 3 3 3 $5
54
3 2 2 53
2 52
3 3 3 3

Keith 2
2

1 1 1 1
2 2 2 2
1"

5
51

49
48
2 2 2 2 2
C. 11 1 1 1 2 0
1
46
45
0 0 0 0 1 0
43 0 0 0 11 1
42 43
0 0 0 00
42
41
41
S40 0
0 0 0 0 0 s40

Response Style Analysis Scale Raw

Score Interpretive Guideline
Instructions:
Positive Possible positive response style
1 Transfer the Raw Scores for both the Positive Impression (Pl) and
Impression (Pl) indicated if Raw Score > 5.
Negative Impression (NI) scales from the Scoring Grid.
2 Insert a checkmark in the Interpretive Guideline box if the response Negative Possible negative response style
style is indicated. Impression (NI) indicated if Raw Score >5.

MHS Copyright o 2008 Multi-Health Systems Inc. Al rights reserved. In the United States, P.O, Box 950, North Tonawanda, NY 14120-0950, 1-800-456-3003.
In Canada, 3770 Victoria Park Ave. Toronto. ON M2H 3M6. 1-800-268-60||, 1-416-492-2627, Fax
1-416-492-3343.