Please answer based on your child’s behavior over the last six months.

Child Information
 

For each item, mark one option: Not True, Somewhat True, or Certainly True.

1. Considerate of other people's feelings

2. Restless, overactive, cannot stay still for long

3. Often complains of headaches, stomach-aches or sickness

4. Shares readily with other children, for example toys, treats, pencils

5. Often loses temper

6. Rather solitary, prefers to play alone

7. Generally well behaved, usually does what adults request

8. Many worries or often seems worried

9. Helpful if someone is hurt, upset or feeling ill

10. Constantly fidgeting or squirming

11. Has at least one good friend

12. Often fights with other children or bullies them

13. Often unhappy, depressed or tearful

14. Generally liked by other children

15. Easily distracted, concentration wanders

16. Nervous or clingy in new situations, easily loses confidence

17. Kind to younger children

18. Often lies or cheats

19. Picked on or bullied by other children

20. Often offers to help others (parents, teachers, other children)

21. Thinks things out before acting

22. Steals from home, school or elsewhere

23. Gets along better with adults than with other children

24. Many fears, easily scared

25. Good attention span, sees chores or homework through to the end

 

Comments
Overall Difficulties & Impact
26. Overall, do you think your child has difficulties in emotions, concentration, behavior, or getting along with other people?
 

If you answered “Yes,” please complete the following:

27. How long have these difficulties been present?
 
28. Do the difficulties upset or distress your child?
 
Do the difficulties interfere with your child's everyday life?
 
30. Home Life
 
31. Friendships
 
32. Classroom Learning
 
33. Leisure Activities
 
34. Do the difficulties put a burden on you or the family as a whole?
 
Relationship:

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Signature Certificate
PTC Survey
Lock icon Unique Document ID: fb16a3084c268b36255d36a2137b31c81bb09525
Timestamp Audit
September 22, 2025 11:07 am PDTPTC Survey Uploaded by Caley Rea - caleyr@oregoncp.org IP 10.0.10.81
September 22, 2025 11:49 am PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 11:49 am PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 11:51 am PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 11:51 am PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 11:56 am PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 11:56 am PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 12:27 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 12:27 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 12:41 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 12:41 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 12:42 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 12:42 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 1:20 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 1:20 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 1:22 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 1:22 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 1:24 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 1:24 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 1:34 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 22, 2025 1:34 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 3:39 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 3:39 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 3:52 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 3:52 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 3:57 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 3:57 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 3:58 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 3:58 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 4:01 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 4:01 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 4:38 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 4:38 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 4:39 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 4:39 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 4:41 pm PDTDani Emrick - danie@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 24, 2025 4:41 pm PDTAlexis Kingston - intakecoordinator@oregoncp.org added by OCP Documents - ocpdocs@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 29, 2025 12:22 pm PDT Document owner ocpdocs@oregoncp.org has handed over this document to caleyr@oregoncp.org 2025-09-29 12:22:34 - 10.0.10.128
September 29, 2025 12:22 pm PDTDani Emrick - danie@oregoncp.org added by Caley Rea - caleyr@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 29, 2025 12:22 pm PDTAlexis Kingston - alexisk@oregoncp.org added by Caley Rea - caleyr@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 30, 2025 2:30 pm PDTDani Emrick - danie@oregoncp.org added by Caley Rea - caleyr@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 30, 2025 2:30 pm PDTAlexis Kingston - alexisk@oregoncp.org added by Caley Rea - caleyr@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 30, 2025 2:34 pm PDTDani Emrick - danie@oregoncp.org added by Caley Rea - caleyr@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
September 30, 2025 2:34 pm PDTAlexis Kingston - alexisk@oregoncp.org added by Caley Rea - caleyr@oregoncp.org as a CC'd Recipient Ip: 10.0.10.128
October 29, 2025 12:18 pm PDTDani Emrick - danie@oregoncp.org added by Caley Rea - caleyr@oregoncp.org as a CC'd Recipient Ip: 10.0.10.81
October 29, 2025 12:18 pm PDTAlexis Kingston - alexisk@oregoncp.org added by Caley Rea - caleyr@oregoncp.org as a CC'd Recipient Ip: 10.0.10.81
October 29, 2025 3:45 pm PDTDani Emrick - danie@oregoncp.org added by Caley Rea - caleyr@oregoncp.org as a CC'd Recipient Ip: 10.0.10.81
October 29, 2025 3:45 pm PDTAlexis Kingston - alexisk@oregoncp.org added by Caley Rea - caleyr@oregoncp.org as a CC'd Recipient Ip: 10.0.10.81
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