0920-21CS CBCL School Age

First

CHILD’S GENDER
Boy

Middle

CHILD’S AGE

Girl

TODAY’S DATE
Mo.

Day

GRADE IN
SCHOOL
NOT ATTENDING
SCHOOL

CHILD’S BIRTHDATE
Year

Mo.

Day

c.

SA

III. Please list any organizations, clubs, teams,
or groups your child belongs to.
None

Man

Woman

Biological Parent

Step Parent

Grandparent

Adoptive Parent

Foster Parent

Other (specify):

Average

More Than
Average

Don’t
Know

Compared to others of the same
age, about how much time does
he/she spend in each?

Less Than
Average

Other (specify)

Your relation to the child:

M

II. Please list your child’s favorite hobbies,
activities, and games, other than sports. For
example: video games, dolls, reading, piano,
crafts, cars, computers, singing, etc. (Do not
include listening to radio, TV, or other media.)

Your gender:

Compared to others of the same
age, about how much time does
he/she spend in each?
Less Than
Average

b.

c.

THIS FORM FILLED OUT BY: (print your full name)

Year

Please fill out this form to reflect your
view of the child’s behavior even if other
people might not agree. Feel free to
print additional comments beside each
item and in the space provided on page
2. Be sure to answer all items.

a.

b.

For office use only
ID #

(Please be specific — for example, auto mechanic, high school teacher,
homemaker, laborer, lathe operator, shoe salesman, army sergeant.)
PARENT 1 (or FATHER)
CHILD’S ETHNIC GROUP
TYPE OF WORK
OR RACE
PARENT 2 (or MOTHER)
TYPE OF WORK

None

a.

AGES 6-18

PARENTS’ USUAL TYPE OF WORK, even if not working now.

Last

I. Please list the sports your child most likes
to take part in. For example: swimming,
baseball, skating, skate boarding, bike
riding, fishing, etc.

None

FOR

E

CHILD’S
FULL
NAME

CHILD BEHAVIOR CHECKLIST

Compared to others of the
same age, how well does
he/she do each one?

Below
Average

PL

Please print

Average

More Than
Average

Don’t
Know

Average

Above
Average

Don’t
Know

Compared to others of the same
age, how well does he/she do
each one?

Below
Average

Average

Above
Average

Don’t
Know

Compared to others of the same
age, how active is he/she in each?

Less
Active

Average

More
Active

Don’t
Know

a.
b.
c.

IV. Please list any jobs or chores your child has.
For example: doing dishes, babysitting,
making bed, working in store, etc. (Include
both paid and unpaid jobs and chores.)
None

Compared to others of the same
age, how well does he/she carry
them out?
Below
Average

Average

Above
Average

Don’t
Know

a.
b.

Be sure you answered all
items. Then see other side.

c.
Copyright 2001 T. Achenbach
UNAUTHORIZED COPYING
ASEBA, University of Vermont
1 South Prospect St., Burlington, VT 05401-3456
www.ASEBA.org
PAGE 1

IS ILLEGAL

07-02-18 Edition - 201

Please print. Be sure to answer all items.
V. 1. About how many close friends does your child have? (Do not include brothers & sisters)
None
1
2 or 3

4 or more

2. About how many times a week does your child do things with any friends outside of regular school hours?
(Do not include brothers & sisters)
Less than 1
1 or 2
3 or more
VI. Compared to others of his/her age, how well does your child:
Worse

Average

Better

a. Get along with his/her brothers & sisters?

Has no brothers or sisters

b. Get along with other kids?

d. Play and work alone?
VII. 1. Performance in academic subjects.

E

c. Behave with his/her parents?

Does not attend school because

Failing

Below
Average

Average

Above
Average

PL

Check a box for each subject that child takes
a. Reading, English, or Language Arts
b. History or Social Studies
c. Arithmetic or Math
d. Science
e.
f.
g.

M

Other academic
subjects–for example: computer
courses, foreign
language, business. Do not include gym, shop,
driver’s ed., or
other nonacademic
subjects.

2. Does your child receive special education or remedial services or attend a special class or special school?

SA

3. Has your child repeated any grades?

No

Yes—kind of services, class, or school:

No

Yes—grades and reasons:

4. Has your child had any academic or other problems in school?

No

Yes—please describe:

When did these problems start?
Have these problems ended?

No

Yes–when?

Does your child have any illness or disability (either physical or mental)?

No

Yes—please describe:

What concerns you most about your child?

Please describe the best things about your child.

PAGE 2

Be sure you answered all items.

Please print. Be sure to answer all items.
Below is a list of items that describe children and youths. For each item that describes your child now or within the past 6
months, please circle the 2 if the item is very true or often true of your child. Circle the 1 if the item is somewhat or sometimes
true of your child. If the item is not true of your child, circle the 0. Please answer all items as well as you can, even if some do not
seem to apply to your child.

0 = Not True (as far as you know)

0

1

1 = Somewhat or Sometimes True

2 = Very True or Often True

2

1. Acts too young for his/her age

0

1

2

32. Feels he/she has to be perfect

0

1

2

33. Feels or complains that no one loves
him/her

1

2

2. Drinks alcohol without parents’ approval
(describe):

0

1

2

34. Feels others are out to get him/her

0

1

2

3. Argues a lot

0

1

2

35. Feels worthless or inferior

0

1

2

4. Fails to finish things he/she starts

0

1

2

0

1

2

5. There is very little he/she enjoys

0

1

2

0

1

2

6. Bowel movements outside toilet

0

1

2

0

1

2

7. Bragging, boasting

0

1

2

0

1

2

8. Can’t concentrate, can’t pay attention for
long

0

1

2

9. Can’t get his/her mind off certain thoughts;
obsessions (describe):

E

0

36. Gets hurt a lot, accident-prone
37. Gets in many fights
38. Gets teased a lot

PL

39. Hangs around with others who get in
trouble

0

1

2

40. Hears sound or voices that aren’t there
(describe):

0

1

2

41. Impulsive or acts without thinking

1

2 10. Can’t sit still, restless, or hyperactive

0

1

2

42. Would rather be alone than with others

0

1

2 11. Clings to adults or too dependent

0

1

2

43. Lying or cheating

0

1

2 12. Complains of loneliness

0

1

2

44. Bites fingernails

0

1

2 13. Confused or seems to be in a fog

0

1

2

45. Nervous, highstrung, or tense

0

1

2 14. Cries a lot

0

1

2

0

1

2 15. Cruel to animals

46. Nervous movements or twitching
(describe):

0

1

2 16. Cruelty, bullying, or meanness to others

0

1

2 17. Daydreams or gets lost in his/her thoughts

0

1

2

47. Nightmares

0

1

2 18. Deliberately harms self or attempts suicide

0

1

2

48. Not liked by other kids

0

1

2 19. Demands a lot of attention

0

1

2

49. Constipated, doesn’t move bowels

0

1

2 20. Destroys his/her own things

0

1

2

50. Too fearful or anxious

0

1

2 21. Destroys things belonging to his/her family
or others

0

1

2

51. Feels dizzy or lightheaded

0

1

2

52. Feels too guilty

2 22. Disobedient at home

0

1

2

53. Overeating

1

2

54. Overtired without good reason

1

2

55. Overweight

SA

M

0

0

1

0

1

2 23. Disobedient at school

0

0

1

2 24. Doesn’t eat well

0

0

1

2 25. Doesn’t get along with other kids

0

1

2 26. Doesn’t seem to feel guilty after
misbehaving

0

1

2 27. Easily jealous

0

1

2 28. Breaks rules at home, school, or elsewhere

0

1

2 29. Fears certain animals, situations, or places,
other than school (describe):

0

1

0

1

56. Physical problems without know medical
cause:
0

1

2

a. Aches or pains (not stomach or
headaches)

0

1

2

b. Headaches

0

1

2

c. Nausea, feels sick

0

1

2

d. Problems with eyes (not if corrected by
glasses) (describe):

2 30. Fears going to school

0

1

2

e. Rashes or other skin problems

2 31. Fears he/she might think or do something
bad

0

1

2

f. Stomachaches

0

1

2

g. Vomiting, throwing up

0

1

2

h. Other (describe):
__________________________________

PAGE 3

Be sure you answered all items Then see other side.

0 = Not True (as far as you know)

Please print. Be sure to answer all items.
1 = Somewhat or Sometimes True

0

1

2 57. Physically attacks people

0

1

2 58. Picks nose, skin, or other parts of body
(describe):

2 = Very True or Often True

0

1

2

84. Strange behavior (describe):

0

1

2

85. Strange ideas (describe):

1

2 59. Plays with own sex parts in public

0

1

2 60. Plays with own sex parts too much

0

1

2

86. Stubborn, sullen, or irritable

0

1

2 61. Poor school work

0

1

2

87. Sudden changes in mood or feelings

1

2

88. Sulks a lot
89. Suspicious

0

1

2 62. Poorly coordinated or clumsy

0

0

1

2 63. Prefers being with older kids

0

1

2

1

2

1

2 64. Prefers being with younger kids

0

1

2 65. Refuses to talk

0

1

2

2 66. Repeats certain acts over and over;
compulsions (describe):

0

1

2

0

1

2

0

1

90. Swearing or obscene language
91. Talks about killing self

92. Talks or walks in sleep (describe):
93. Talks too much

PL

0

0

E

0

0

1

2 67. Runs away from home

0

1

2 68. Screams a lot

0

1

2 69. Secretive, keeps things to self

0

1

2 70. Sees things that aren’t there (describe):

0

1

2 71. Self-conscious or easily embarrassed

0

1

2

94. Teases a lot

0

1

2

95. Temper tantrums or hot temper

0

1

2

96. Thinks about sex too much

0

1

2

97. Threatens people

0

1

2

98. Thumb-sucking

0

1

2

0

1

2

100. Trouble sleeping (describe):

0

1

2

101. Truancy, skips school

0

1

2

102. Underactive, slow moving, or lacks energy

99. Smokes, chews, or sniffs tobacco

1

2 72. Sets fires

0

1

2 73. Sexual problems (describe):

0

1

2 74. Showing off or clowning

0

1

2 75. Too shy or timid

0

1

2

103. Unhappy, sad, or depressed

0

1

2 76. Sleeps less than most kids

0

1

2

104. Unusually loud

0

1

2 77. Sleeps more than most kids during day
and/or night (describe):):

0

1

2

105. Uses drugs for nonmedical purposes (don’t
include alcohol or tobacco) (describe):

0

1

2

106. Vandalism

0

1

2

107. Wets self during the day

0

1

2

108. Wets the bed

SA

M

0

0

1

2 78. Inattentive or easily distracted

0

1

2 79. Speech problem (describe):

0

1

2

109. Whining

0

1

2 80. Stares blankly

0

1

2

110. Wishes to be of opposite sex

0

1

2 81. Steals at home

0

1

2

111. Withdrawn, doesn’t get involved with others

0

1

2 82. Steals outside the home

0

1

2

112. Worries

0

1

2 83. Stores up too many things he/she doesn’t
need (describe):

113. Please write in any problems your child has
that were not listed above:

___________________________________

PAGE 4

0

1

2

0

1

2

0

1

2

Please be sure you answered all items.