Please print CHILD BEHAVIOR CHECKLIST FOR AGES 6-18 For office use only

ID #
CHILD’s First Middle Last PARENTS’ USUAL TYPE OF WORK, even if not working now.
FULL (Please be specific — for example, auto technician, high school teacher,
NAME
homemaker, laborer, lathe operator, shoe salesman, army sergeant.)
CHILD’S GENDER CHILD’S AGE CHILD’S ETHNIC GROUP
PARENT 1 (or FATHER)
OR RACE
TYPE OF WORK ____________________________________________
TODAY’S DATE CHILD’S BIRTHDATE PARENT 2 (or MOTHER)
Mo. ____ Day ____ Year _____ Mo. ____ Day ____ Year ______ TYPE OF WORK ____________________________________________
THIS FORM FILLED OUT BY: (print your full name)
GRADE IN Please fill out this form to reflect your
SCHOOL _____________ view of the child’s behavior even if other ___________________________________________________________________
people might not agree. Feel free to Your Gender: _____________________________________________
NOT ATTENDING print additional comments beside each
SCHOOL q item and in the space provided on page Your relation to the child (e.g., parent):
2. Be sure to answer all items.

I. Please list the sports your child most likes Compared to others of the same Compared to others of the
to take part in. For example: swimming, age, about how much time does same age, how well does
baseball, skating, skate boarding, bike child spend in each? child do each one?
riding, fishing, etc.

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Less Than More Than Don’t Below Above Don’t
q None Average Average Average Know Average Average Average Know

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a. ____________________________ q q q q q q q q
b. ____________________________ q q q q q q q q
c. ____________________________ q q q q q q q q

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II. Please list your child’s favorite hobbies, Compared to others of the same Compared to others of the
activities, and games, other than sports. For age, about how much time does same age, how well does
example: video games, dolls, reading, piano, child spend in each? child do each one?

q None
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crafts, cars, computers, singing, etc. (Do not
include listening to radio, TV, or other media.)

a. ____________________________
Less Than

q q
More Than Don’t
Average Average Average Know
q q
Below
Average
q
Average
q
Above Don’t
Average Know
q q
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q q q q q q q q
b. ____________________________
q q q q q q q q
c. ____________________________
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III. Please list any organizations, clubs, teams, Compared to others of the same
or groups your child belongs to. age, how active is child in each?
Less More Don’t
q None Active Average Active Know
a. ____________________________ q q q q
b. ____________________________ q q q q
c. ____________________________ q q q q

IV. Please list any jobs or chores your child has. Compared to others of the same
For example: doing dishes, babysitting, age, how well does child carry
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making bed, working in a store, etc. (Include them out?

both paid and unpaid jobs and chores.)
Below Above Don’t
q None Average Average Average Know
a. ____________________________ q q q q
b. ____________________________ q q q q Please be sure you answered
c. ____________________________ q q q q all items. Then see other side.
Copyright 2001 T. Achenbach UNAUTHORIZED COPYING IS ILLEGAL 09-21 Edition - 201
ASEBA, University of Vermont
www.ASEBA.org (09.28.21) PAGE 1
 Please print. Be sure to answer all items.

V. 1. About how many close friends does your child have? (Do not include brothers & sisters)
q None q1 q 2 or 3 q 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
q q q

VI. Compared to others of similar age, how well does your child:

Worse Average Better

a. Get along with brothers & sisters? q q q q Has no brothers or sisters
b. Get along with other kids? q q q
c. Behave with parents? q q q
d. Play and work alone? q q q

VII. 1. Performance in academic subjects. q Does not attend school because ______________________
__________________________________________________

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Check a box for each subject that child takes Below Above

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Failing Average Average Average
Other academic a. Reading, English, or Language Arts q q q q
subjects–for
example: com-
b. History or Social Studies q q q q
puter courses, c. Arithmetic or Math q q q q
foreign language,
d. Science q q q q

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business. Do not
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include gym, e. _______________________________ q q q q
shop, driver’s f. _______________________________
ed., or other q q q q
g. _______________________________ q q q q
nonacademic
subjects. C
2. Does your child receive special education or remedial services or attend a special class or special school?
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q No q Yes --- kind of services, class, or school:

3. Has your child repeated any grades? q No q Yes --- grades and reasons:
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4. Has your child had any academic or other problems in school? q No q Yes --- please describe:
When did these problems start?

Have these problems ended? q No q Yes --- when?

Does your child have any illness or disability (either physical or mental)? q No q Yes --- please describe:
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What concerns you most about your child?

Please describe the best things about your child.

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 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) 1 = Somewhat or Sometimes True 2 = Very True or Often True

0 1 2 1. Acts too young for age 0 1 2 32. Feels they have to be perfect
0 1 2 2. Drinks alcohol without parents’ approval 0 1 2 33. Feels or complains that no one loves them
(describe): _______________________
0 1 2 34. Feels others are out to get them
________________________________
0 1 2 35. Feels worthless or inferior
0 1 2 3. Argues a lot
0 1 2 36. Gets hurt a lot, accident-prone
0 1 2 4. Fails to finish things they start
0 1 2 37. Gets in many fights
0 1 2 5. There is very little they enjoy
0 1 2 38. Gets teased a lot
0 1 2 6. Bowel movements outside toilet
0 1 2 39. Hangs around with others who get in
0 1 2 7. Bragging, boasting trouble
0 1 2 8. Can’t concentrate, can’t pay attention for

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0 1 2 40. Hears sounds or voices that aren’t there
long

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(describe): ___________________________
0 1 2 9. Can’t get mind off certain thoughts; ____________________________________
obsessions (describe): _______________ 0 1 2 41. Impulsive or acts without thinking
_________________________________
0 1 2 42. Would rather be alone than with others
0 1 2 10. Can’t sit still, restless, or hyperactive
0 1 2 43. Lying or cheating

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0 1 2 11. Clings to adults or too dependent
0 1 2 44. Bites fingernails
0 1 2 12. Complains of loneliness
0 1 2 45. Nervous, highstrung, or tense
0 1 2 13. Confused or seems to be in a fog
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0 1 2 14. Cries a lot
0 1 2 15. Cruel to animals
0 1 2 16. Cruelty, bullying, or meanness to others
0 1 2 46. Nervous movements or twitching (describe):
____________________________________
____________________________________
0 1 2 47. Nightmares
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0 1 2 17. Daydreams or gets lost in thoughts 0 1 2 48. Not liked by other kids
0 1 2 18. Deliberately harms self or attempts suicide 0 1 2 49. Constipated, doesn’t move bowels
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0 1 2 19. Demands a lot of attention 0 1 2 50. Too fearful or anxious

0 1 2 20. Destroys own things 0 1 2 51. Feels dizzy or lightheaded
0 1 2 21. Destroys things belonging to family or 0 1 2 52. Feels too guilty
others 0 1 2 53. Overeating
0 1 2 22. Disobedient at home
0 1 2 54. Overtired without good reason
0 1 2 23. Disobedient at school 0 1 2 55. Overweight
0 1 2 24. Doesn’t eat well
56. Physical problems without known medical
0 1 2 25. Doesn’t get along with other kids cause:
0 1 2 26. Doesn’t seem to feel guilty after 0 1 2 a. Aches or pains (not stomach or headaches)
misbehaving 0 1 2 b. Headaches
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0 1 2 c. Nausea, feels sick

0 1 2 27. Easily jealous
0 1 2 d. Problems with eyes (not if corrected by glasses)
0 1 2 28. Breaks rules at home, school, or elsewhere
(describe): ___________________________
0 1 2 29. Fears certain animals, situations, or places, 0 1 2 e. Rashes or other skin problems
other than school (describe): __________ 0 1 2 f. Stomachaches
_________________________________ 0 1 2 g. Vomiting, throwing up
0 1 2 30. Fears going to school 0 1 2 h. Other (describe): ______________________
0 1 2 31. Fears they might think or do something bad ____________________________________

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Then see other side.
 Please print. Be sure to answer all items.
0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True

0 1 2 57. Physically attacks people 0 1 2 84. Strange behavior (describe): ___________

0 1 2 58. Picks nose, skin, or other parts of body __________________________________
(describe): _________________________ 0 1 2 85. Strange ideas (describe): ______________
__________________________________ __________________________________

0 1 2 59. Plays with own sex parts in public 0 1 2 86. Stubborn, sullen, or irritable
0 1 2 60. Plays with own sex parts too much 0 1 2 87. Sudden changes in mood or feelings

0 1 2 61. Poor school work 0 1 2 88. Sulks a lot

0 1 2 62. Poorly coordinated or clumsy 0 1 2 89. Suspicious

0 1 2 63. Prefers being with older kids 0 1 2 90. Swearing or obscene language
0 1 2 64. Prefers being with younger kids 0 1 2 91. Talks about killing self

0 1 2 65. Refuses to talk 0 1 2 92. Talks or walks in sleep (describe): ______

0 1 2 66. Repeats certain acts over and over; __________________________________
compulsions (describe): _____________ 0 1 2 93. Talks too much

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0 1 2 94. Teases a lot
0 1 2 67. Runs away from home 0 1 2 95. Temper tantrums or hot temper
0 1 2 68. Screams a lot
0 1 2 96. Thinks about sex too much
0 1 2 69. Secretive, keep things to self 0 1 2 97. Threatens people

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0 1 2 70. Sees things that aren’t there (describe):
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0 1 2 98. Thumb-sucking
_________________________________
0 1 2 99. Smokes, chews, sniffs tobacco or uses e-cigs
_________________________________

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0 1 2 71. Self-conscious or easily embarrassed
0 1 2 72. Sets fires

0 1 2 73. Sexual problems (describe): __________

0 1 2 100. Trouble sleeping (describe): ___________
__________________________________
0 1 2 101. Truancy, skips school
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0 1 2 102. Underactive, slow moving, or lacks energy

_________________________________ 0 1 2 103. Unhappy, sad, or depressed
_________________________________
0 1 2 74. Showing off or clowning 0 1 2 104. Unusually loud
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0 1 2 105. Uses drugs for nonmedical purposes (don’t

0 1 2 75. Too shy or timid include alcohol or tobacco) (describe):
0 1 2 76. Sleeps less than most kids __________________________________
0 1 2 77. Sleeps more than most kids during day __________________________________
and/or night (describe): ______________ 0 1 2 106. Vandalism
_________________________________ 0 1 2 107. Wets self during the day
0 1 2 78. Inattentive or easily distracted
0 1 2 108. Wets the bed
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 a different gender
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0 1 2 111. Withdrawn, doesn’t get involved with others

0 1 2 81. Steals at home
0 1 2 82. Steals outside the home 0 1 2 112. Worries
113. Please write in any problems your child has
0 1 2 83. Stores up too many things they don’t need that were not listed above:
(describe): ________________________ 0 1 2 ___________________________________
_________________________________ 0 1 2 ___________________________________
_________________________________ 0 1 2 ___________________________________

PAGE 4 Please be sure you answered all items.