Family Matters Psychological Services
P.O. Box 490
107 South Streetcar Way
Lost Creek, WV 26385
(304) 745-5065
FAX (304) 745-5067
Amy Wilson Strange, Ph.D.
Jennifer Adams, Ph.D.
Emotional Behavioral Assessment
Child name: _______________________________________________________________
Date: _________________
DOB: ___________________ Age: _____________ Social Security Number: _______________________________
Address: _________________________________ City: _______________________ State: ______ Zip: __________
Respondent’s name: ____________________________________________ Relationship: _________________________
Please use the back of any sheet of more space if needed.
1. Check the following behaviors or skills that describe positive characteristics of the child.
Accepts praise
Friendly
Polite
Affectionate
Gregarious
Reading/writing
Apologizes
Grooming/hygiene
Respects others
Assertive
Helpful
Responsible
Clean/neat
Hobbies/crafts
Safety skills
Community skills
Honesty
Sense of humor
Cooperative
Independent
Shares
Courteous
Insightful
Survival skills
Daily living skills
Listening skills
Verbal expression
Dependable
Money management skills
Works hard
Emotional
Motivated
____ ________________
Eye contact
Organize
___ ______________
Comments: ________________________________________________________________________________________
___________________________________________________________________________________________________
2. Which of the following normal emotions or responses do you recognize as at least sometimes
taking place with the client?
Anger
Embarrassment
Grief
Anxiety
Envy
Happiness
Boredom
Fear
Loneliness
Depression
Frustration
Stress
3. List any concerns you have regarding any of the above emotions or responses. _______________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
4. How does s/he express (verbally and nonverbally) the following emotions?
Happiness: ________________________________________________________________________________________
___________________________________________________________________________________________________
Sadness: __________________________________________________________________________________________
___________________________________________________________________________________________________
Anger: ____________________________________________________________________________________________
___________________________________________________________________________________________________
Frustration: ________________________________________________________________________________________
___________________________________________________________________________________________________
5. Briefly describe any self-injurious behaviors (SIBs) and/or inappropriate self-stimulation behaviors.
Behavior: (describe the problem behavior)
Antecedents: (describe what usually takes place before the behavior occurs)
Consequences: (describe what actions are taken after the behavior occurs)
Frequency/duration: (describe how often and for how long it occurs)
Behavior: __________________________________________________________________________________________
Antecedents: _______________________________________________________________________________________
Consequences: _____________________________________________________________________________________
Frequency/duration: ________________________________________________________________________________
6. Briefly describe aggressive acts (to people or property).
Behavior: __________________________________________________________________________________________
Antecedents: _______________________________________________________________________________________
Consequences: _____________________________________________________________________________________
Frequency/duration: ________________________________________________________________________________
Behavior: __________________________________________________________________________________________
Antecedents: _______________________________________________________________________________________
Consequences: _____________________________________________________________________________________
Frequency/duration: ________________________________________________________________________________
7. Describe any inappropriate sexual behavior.
________None known
____________________________________________________________________________________________________
____________________________________________________________________________________________________
8. Describe any inappropriate social behaviors. __________None known
____________________________________________________________________________________________________
____________________________________________________________________________________________________
9. How would you rate his/her listening skills?
Low
Average
1
2
3
Comments:
4
High
5
10. How would you rate his/her ability to cope with problems?
Low
Average
1
2
3
4
Comments:
High
5
11. How would you rate his/her respect for other people?
Low
Average
1
2
3
4
Comments:
High
5
12. How would you rate his/her ability to manage anger?
Low
Average
1
2
3
4
Comments:
High
5
13. How would you rate his/her motivation to change negative behaviors?
Low
Average
High
1
2
3
4
5
Comments:
14. How would you rate his/her ability to accept constructive criticism?
Low
Average
High
1
2
3
4
5
Comments:
15. How would you rate his/her potential for increased independent living?
Low
Average
High
1
2
3
4
5
Comments:
16. Please list any significant stressful events or major changes in his/her life in the past six months (e.g.,
loss of loved one, significant others moving, change in residence, new housemate, new sibling, major
illness, etc.). ______None known
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If applicable, what behavioral/emotional effects may this have had? ________None known
____________________________________________________________________________________________________
____________________________________________________________________________________________________
17. Check any of the following which apply to him/her. (Add others that apply.)
Anxiety
Explosive behaviors
Schizophrenia
Auditory hallucinations
Impulse control concerns
Sexual concerns
Chemical dependency
Mood shifts
Social withdrawal
Conduct problems
Obsessive/compulsive
Suicidal threats
Depression
Paranoid
Thought disorder
Eating disorder
Phobias/fears
Visual hallucinations
Describe behavioral effects or incidents of each of the above items.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
18. Briefly describe any past events that may significantly impact his/her behavior. (e.g., abuse, injuries).
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
19. Briefly describe any past events that were particularly encouraging or led to positive life changes for
him/her.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
20. Please list any other information about him/her (e.g., important background information, special
strengths/weaknesses, concerns with other people, problems at school).
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________