Questionnaire For Teachers

Teacher SQ

Symptom Questionnaire Form

Instructions: Please answer the following questions to your best ability. If your student is currently taking any medications for emotional or behavioral concerns, please answer the following questions based on his/her behavior when he/she is NOT actively medicated. If you are unsure of your student’s medication status or have no knowledge of his/her behavior off medication, please check the appropriate box below. Thank you for taking the time to complete this form as it is very helpful in our efforts to provide this student with the best diagnostic and treatment services!

Please Note: You will not be able to save your progress, so please complete this questionnaire in one sitting. This form may take 30-45 minutes to complete.

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My responses are based upon:

Student's behavior ON medications

Student's behavior OFF medications

Unknown

Student's First Name

Student's Last Name

Student's Date of Birth

Completed By

Relationship to Student

If other, your relationship to Student

How well do you feel you know this student

DSA1

Does this student struggle with social interactions including any of the following:

= Currently

Approaches people in unusual ways (e.g. licks others, hugs strangers)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Does not initiate conversations with others?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Engages in one-sided conversations (e.g. talks excessively about own interests)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Does not understand social cues?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Does not share interests with others?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Fails to show excitement or pleasure when interacting with others?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Does not comfort or show affection to others?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Resists or lacks interest in affection from others?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Communicates with others primarily to get his/her needs met (e.g. food, toys) and not for social purposes?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

DSA2

Does this student have difficulties with different aspects of social communication including any of the following:

= Currently

Poor eye contact (e.g. looks away when speaking to someone or being spoken to)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Does not use gestures to communicate (e.g. nodding/shaking head, waving)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Speaks in an odd manner (e.g. pronounces words oddly, speaks like robot)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Shows limited range of facial expressions?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Does not appear to understand others' emotions?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

DSA3

Does this student have any of the following problems with developing and maintaining relationships appropriate for his/her age:

= Currently

Does not understand what a friendship really is?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Fails to understand when others are not interested in something that he/she is doing or talking about?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Asks questions or makes statements that are socially inappropriate?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Does not understand when or why others are upset with or tease him/her?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Shows limited interest in making friends?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Has trouble playing/talking with others if the focus of activity is not his/her interest?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Is overly rigid or passive in social interactions (e.g. always wants things his/her way, goes along with everything that others want)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

DSA4

Does this student exhibit odd behavior including any of the following:

= Currently

Very formal language (e.g. like an adult or "little professor ")?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Repeats words, phrases, or songs (immediately or after a delay)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Makes mistakes with pronouns (e.g. says "You" instead of "I")?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Makes repetitive sounds, squeals, or humming?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Makes odd motor movements (e.g. hand flapping, rocking, spinning)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Obsessively lines up toys or objects?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Plays with toys in odd way (e.g. not in the way that toy was intended and not imaginative)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Repeats behaviors (e.g. turning lights on/off, opening/closing doors)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

DSA5

Does this student exhibit rigid patterns of behavior including any of the following:

= Currently

Insists on following specific routines (e.g. puts clothes on same way, putting toys away)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Insists on odd routines (e.g. turning in circle before entering a room)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Has difficulty when routines are changed (e.g. becomes very upset or refuses to comply)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Follows rules rigidly and becomes upset if rules are not followed by others?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

DSA6

Does this student exhibit intense interests in specific objects or activities including any of the following:

= Currently

Is obsessed with particular objects, toys or topics?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Is a perfectionist (e.g. things must be perfectly organized)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Is overly interested in unusual objects (e.g. vacuum cleaners, batteries)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Has odd fears (e.g. people wearing earrings)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

DSA7

Does this student exhibit difficulties with sensory processing including any of the following:

= Currently

Has high pain tolerance?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Does not like to be touched?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Does not like certain textures (e.g. jeans, food)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Seems very interested in watching items spin or move repetitively?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Seems afraid of or very upset by sounds (e.g. vacuum)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

DMD

Does this student exhibit any of the following mood problems?

= Currently

Has severe and recurring temper outbursts (e.g. verbal or physical aggression)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Is typically in an irritable mood?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

AIA

Does this student struggle with any of the following areas of attention:

= Currently

Fails to give close attention to details or makes careless mistakes in schoolwork or during other activities (e.g. overlooks or misses details, word is inaccurate)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Has difficulty sustaining attention in tasks or play activities (e.g. has difficulty remaining focused during lectures, conversations, or lengthy reading)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g. starts tasks but quickly loses focus and is easily sidetracked)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Has difficulty organizing tasks and activities (e.g. difficulty managing sequential tasks, difficulty keeping materials and belongings in order, messy disorganized work, has poor time management, fails to meet deadlines)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g. schoolwork or homework)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Loses things necessary for tasks or activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Is easily distracted by extraneous stimuli?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Is forgetful in daily activities?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

AHI

Does this student struggle with any of the following areas of hyperactivity/impulsivity:

= Currently

Fidgets with or taps hands or feet or squirms in seat?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Leaves seat in situations when remaining seated is expected (e.g. leaves his/her place in the classroom or in other situations that require remaining in place)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Runs about or climbs in situations where it is inappropriate?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Unable to play or engage in leisure activities quietly?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Is “on the go”, acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, may be experienced by others as being restless or difficult to keep up with)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Talks excessively?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Blurts out an answer before a question has been completed (e.g. completes people’s sentences, cannot wait for turn in conversation)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Has difficulty waiting his/her turn (e.g. while waiting in line)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Interrupts or intrudes on others (e.g. butts into conversations, games, or activities, may start using other people’s things without asking or receiving permission)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

DC

Does this student exhibit any of the following areas of conduct problems?

= Currently

Bullies, threatens, or intimidates others?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Initiates physical fights?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Has been physically cruel to animals?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Has deliberately destroyed others' property (other than fire setting)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Lies?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Has stolen items from others?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Has run away from home?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

DDO

Does this student exhibit difficulty in any of the following areas of emotional and behavioral regulation?

= Currently

Loses his/her temper?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Is touchy or easily annoyed?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Is angry and resentful?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Argues with authority figures or with adults?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Actively defies or refuses to comply with requests from authority figures or with rules?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Deliberately annoys others?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Blames others for his/ her mistakes or misbehavior?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Has been spiteful or vindictive?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

EBQ

Does this student exhibit difficulty in any of the following areas of emotional and behavioral regulation?

= Currently

Touches things for no apparent reason?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Drags his/her fingers along walls or objects?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Excessively touches or hugs people?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Smells people or objects for no apparent reason?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Touches self inappropriately (e.g. private parts) in public?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Licks people or inedible objects?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Invades others’ personal space?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Spits on self or others for no apparent reason?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Excessively imitates the sounds of others?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Touches others inappropriately (e.g. breasts, buttocks)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Excessively puts objects (e.g. shirt, toys) in mouth (not for eating)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Blurts out socially inappropriate statements?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Rubs objects on his/her body?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Likes to be touched or caressed excessively?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Hugs others inappropriately tight?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Rams self into objects or people?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

XNA

Does this student exhibit any of the following problems with anxiety?

= Currently

Worries?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Is fearful in social situations?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Is afraid to try new things?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

PED

Does this student exhibit any of the following problems with depression?

= Currently

Talks about or has made threats to kill or harm him/her self?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Has mood swings?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Is sad?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Is tearful/crying?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

YSP

Does this student exhibit any of the following problems?

= Currently

Has thoughts that others would think are very strange?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Sees or hears things that others do not see or hear?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

CIT

Does this student exhibit any of the following motor problems?

= Currently

Makes repeated simple motor movements (e.g. eye blinking, shoulder shrugging, open eyes wide, scrunches face/mouth)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Makes repeated jerking or twitching movements (eg. twitching head to one side, touching shoulder to chin)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Makes repeated noises (e.g. throat clearing, grunting, animal noises)?

Never

Past (not now)

Rarely

Sometimes

Often

Unknown

Please provide some examples of any behaviors listed above that your student has experienced.

IMP

For each item, please select a rating from 0 to 7.

0 = No problem | 7 = Extreme problem.

How do your student’s problems affect his/her relationships with peers?

How do your student’s problems affect his/her self-esteem?

How do your student’s problems affect his/her academic progress?

How do your student's problems affect his/her relationship with teacher(s)?

For the question(s) below, please use the following scale:

0 = No Problem; No need for intervention | 7 = Definite Problem; Significant need for intervention