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Please provide the following:
Please fill in all required fields so your form is properly processed.
Child's Name: * required
Completed By: * required
E-Mail: * required
Relationship Mother Father Teacher Other * required
Please indicate if this child presents any behavior problems for you in any of these situations? If so, indicate how severe they are:
Does this child present any behavior problems for you while arriving at school? Never!
Well, a bit
Yes, some
Oh! Yes!
ALL THE TIME !!
Does this child present any behavior problems for you during individual deskwork? Never!
Well, a bit
Yes, some
Oh! Yes!
ALL THE TIME !!
Does this child present any behavior problems for you during small-group activities? Never!
Well, a bit
Yes, some
Oh! Yes!
ALL THE TIME !!
Does this child present any behavior problems for you during free-play time in class? Never!
Well, a bit
Yes, some
Oh! Yes!
ALL THE TIME !!
Does this child present any behavior problems for you during lectures to the class? Never!
Well, a bit
Yes, some
Oh! Yes!
ALL THE TIME !!
Does this child present any behavior problems for you at recess? Never!
Well, a bit
Yes, some
Oh! Yes!
ALL THE TIME !!
Does this child present any behavior problems for you at lunch? Never!
Well, a bit
Yes, some
Oh! Yes!
ALL THE TIME !!
Does this child present any behavior problems for you in the hallways? Never!
Well, a bit
Yes, some
Oh! Yes!
ALL THE TIME !!
Does this child present any behavior problems for you in the bathroom? Never!
Well, a bit
Yes, some
Oh! Yes!
ALL THE TIME !!
Does this child present any behavior problems for you on field trips? Never!
Well, a bit
Yes, some
Oh! Yes!
ALL THE TIME !!
Does this child present any behavior problems for you during special assemblies? Never!
Well, a bit
Yes, some
Oh! Yes!
ALL THE TIME !!
Does this child present any behavior problems for you on the bus? Never!
Well, a bit
Yes, some
Oh! Yes!
ALL THE TIME !!

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