STAND Application Packet

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STAND Application Packet To be completed by parent and teacher of adolescent seeking help with academic, organization, or behavior problems in school.

1 STAND Application Packet To be completed by parent and teacher of adolescent seeking help with academic, organization, or behavior problems in school. Supporting Teens Academic Needs Daily: A Family Approach to Improving Academics *I would like my application packet to be destroyed if the adolescent does not enroll in STAND (Circle One): YES NO

2 Part 1: To be completed by Parent- Please rate your son/daughter during the past month. DSM-5 Rating Scale 1. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). 2. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy readings). 3. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). 4. Often does not follow through on instructions and fails to finish schoolwork, chores, or other responsibilities or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). 5. Often 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). 6. Often avoids, seems to dislike, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, or reviewing lengthy papers). 7. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). 8. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts.). 9. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). 10. Often fidgets with or taps hands or feet or squirms in seat. 11. Often leaves seat in situations when remaining seated is expected (e.g., leaving his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). 12. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless). 13. Often unable to play or engage in leisure activities quietly. 14. Is often on the go, acting as if driven by a motor (e.g., is unable to be or is uncomfortable being still for an extended time, as in restaurants, meetings; may be experienced by others as being restless and difficult to keep up with). 15. Often talks excessively. 16. Often blurts out an answer before a question has been completed (e.g., completes people s sentences; cannot wait turn in conversations). 17. Often has difficulty waiting his or her turn (e.g., while waiting in line). 18. Often 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; for adolescents or adults may intrude into or take over what others are doing). Not at All Just a Little Pretty Very Impairment Rating On a scale from 0 (no problem) to 6 (extreme problem) please rate your child s academic problems:

3 Part 1: To be completed by Parent- Please rate your son/daughter during the past month. Adolescent Academic Problems Checklist 1) Fails to take class notes 2) Receives poor grades on tests/quizzes 3) Does not follow through on homework instructions 4) Is disruptive in class 5) Does not follow through on instructions given during class 6) Arrives late for class 7) Does not study for tests/quizzes 8) Turns in work that was not completed thoroughly 9) Has poorly organized folders or binders 10) Forgets to bring appropriate materials to class 11) Fails to turn in homework that he/she has already completed 12) Fails to turn in assignments on time 13) Actively refuses to complete work. 14) Has difficulty organizing writing assignments 15) Is noncompliant with adult requests 16) Makes careless errors on work 17) Fails to record homework assignments in a daily planner 18) Fails to participate in class discussions 19) Is off-task during school work 20) Fails to raise hand before speaking in class 21) Leaves longer-term projects until the last minute 22) Skips class for unexcused reasons 23) Poor time management 24) Has difficulty getting started on assignments Not at all Just a little Pretty Very Conflict Behavior Questionnaire Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree 1. My son or daughter is easy to get along with My son or daughter is receptive to criticism My son or daughter is well behaved in our discussions For the most part, my son or daughter likes to talk to me We almost never seem to agree My son or daughter usually listens to what I tell him/her At least three times a week, we get angry at each other My son or daughter says that I have no consideration of his/her feelings. 9. My son or daughter and I compromise during arguments My son or daughter often doesn t do what I ask The talks we have are frustrating My son or daughter often seems angry at me My son or daughter acts impatient when I talk In general, I don t think we get along very well

4 Part 1: To be completed by Parent- Please rate your son/daughter during the past month. Conflict Behavior Questionnaire Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree 15. My son or daughter almost never understands my side of an argument. 16. My son or daughter and I have big arguments about little things. 17. My son or daughter is defensive when I talk to him/her My son or daughter thinks my opinions don t count We argue a lot about rules My son or daughter tells me he/she thinks I am unfair Parents- please answer the next set of questions about yourself during the past month. In a typical week, how often did you 0 days 1. Use an academic contract or daily rewards program to reward academic habits 2. Communicate with the child s teachers 3. Help your child organize school materials 4. Check to see if your child wrote in a daily planner 5. Check the grade portal 6. Help your child plan out what to do during homework time 7. Help your child do his/her homework 8. Help your child study for an upcoming test 9. Check to see if your child had taken notes in class 10. Monitor whether your child was studying or doing homework when he/she was supposed to be 11. Use a calendar to help your child plan for an upcoming project 12. Check your child s homework for errors 13. Make a checklist or to-do list with your child 14. Provide a reward for completing school work, homework, or other academic tasks 15. Restrict privileges for failing to do school work, homework, or other academic tasks 16. Do some of your child s homework for him/her 1 day 2 days 3 days 4 days 5 days Time Spent 1. In an average week (7 days), I usually spend about hours in activities related to my son/daughter s academics (please give an exact estimate, not a range). Example responses: six hours; ½ hour; zero hours; 20 hours. 3

5 Part 1: To be completed by Parent- Please rate yourself during the past month. Parent ASRS 1. How often do you have trouble wrapping up the final details of a project once the challenging parts have been done? 2. How often do you have difficulty getting things in order when you have to do a task that requires organization? 3. How often do you have problems remembering appointments or obligations? 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? 6. How often do you feel overly active and compelled to do things, like you were driven by a motor? 7. How often do you make careless mistakes when you have to work on a boring or difficult project? 8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? 9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? 10. How often do you misplace or have difficulty finding things at home or work? 11. How often are you distracted by activity or noise around you? 12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? 13. How often do you feel restless or fidgety? 14. How often do you have difficulty unwinding and relaxing when you have time to yourself? 15. How often do you find yourself talking too much when you are in a social situation? 16. When you re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves? 17. How often do you have difficulty waiting your turn in situations when turn taking is required? 18. How often do you interrupt others when they are busy? Never Rarely Sometimes Often Very Often Parent PHQ-9: In the past month, how often were you bothered by these problems? Not at all Sometimes Often Very Often 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much Parent PHQ-9 Not at Some- Often Very 4

6 Part 1: To be completed by Parent- Please rate yourself during the past month. 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself- or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite- being so fidgety or restless that you move around a lot more than usual. 9. Thoughts that you would be better off dead or of hurting yourself in some way. Please answer the following questions about your family members: all times Often Adolescent Name: Date of Birth: Age: Adolescent Sex: Male Female Current Grade in School: Adolescent Ethnicity: Hispanic Not Hispanic Adolescent Race: White Black Asian Mixed Other Your Name: Your Age: Your Relationship to the Child: Biological Mother Biological Father Other: Your Ethnicity: Hispanic Not Hispanic Your Race: White Black Asian Native American Mixed Other Your Highest Level of Education: Your Occupation: Do you have legal custody of the adolescent? Yes No Marital Status: Single/Never Married Married Living with Partner Divorced Separated Widowed Do you live with the adolescent? Yes No; If No, how often do you see adolescent: Parent 2 Name: Parent 2 Age: Parent 2 Relationship to the Child: Biological Mother Biological Father Other: Parent 2 Ethnicity: Hispanic Not Hispanic 5

7 Part 1: To be completed by Parent- Please answer the following questions about your family members. Parent 2 Race: White Black Asian Native American Mixed Other Parent 2 Highest Level of Education: Parent 2 Occupation: Does Parent 2 have legal custody of the adolescent? Yes No Marital Status: Single/Never Married Married Living with Partner Divorced Separated Widowed Does Parent 2 live with the adolescent? Yes No; If No, how often does he/she see adolescent: How many siblings does adolescent have? (List ages: ) Adolescent s School: Ever held back? Y N: if Yes what grade? Does Adolescent have an: IEP 504 Plan Neither Not Sure Class Placement: Regular ESE Inclusion Gifted/Advanced Other: Has the adolescent been diagnosed with: (ADHD: Y / N) (ADD: Y / N) (Learning Disability: Y / N) (Autism: Y / N) (Pervasive Developmental Disorder: Y / N) (Asperger s Syndrome: Y/ N) Does adolescent currently take medication to help with attention, behavior, mood, or emotions? Y / N If Yes: Please write the name of the medication(s) and the dose: Is adolescent receiving any therapy, tutoring, or treatment for academics, behavior, or attention? Y/ N If Yes: Please describe services: Your cell phone: Your Your work phone: Alternative Your Address: Parent 2 cell phone: Parent 2 Parent 2 work phone: Alternative If we cannot get in touch with you at the information above, who is someone we can call who can help us get in touch with you? Name: Phone: 6

8 Part 1: To be completed by Parent I authorize (circle one) Authorization for Release of Information To Be Completed by the Parent Miami-Dade County Public Schools Broward County Public Schools Other: to release information from the record of: Adolescent s Name Birth Date To: Center for Children and Families, Florida International University SW 8 th Street AHC1 Room 140 Miami, FL Phone: (305) ; Fax: (305) For the purpose of screening eligibility and participation in research activities conducted at the Center for Children and Families. Specific information to be released: Teacher and school reports (including completion of rating scales, general performance impressions, observation of student s behavior) School records (including report cards, disciplinary records) I understand that this authorization is effective for a period of 18 months from the date of this signature. Date of Signature Signature of Parent, Legal Guardian Or Authorized Representative Date of Signature Witness Signature Printed Name of Parent*: Best Phone Number to Reach Parent: Best Time to Reach Parent: 7

9 Part 1: To be completed by Teacher The following questions should be completed by one of the adolescent s core academic teachers (Math, Language Arts/English, Science, or Social Studies/History). Dear Teacher, One of your student s is applying to the Supporting Teens Academic Needs Daily Program (STAND) at FIU. This program helps middle and high school students improve their academics, organization skills, and/or behavior. In order to help us assess whether STAND is appropriate for this student, we ask that you please take a few minutes to complete a very brief set of questions about your observations of this student. If you have any questions, please contact our staff: (305) or stand@fiu.edu. Your Name: Your School: Your Student s Name: In which class/subject do you teach this student: Please rate the student during the past month: Adolescent Academic Problems Checklist 1) Fails to take class notes 2) Receives poor grades on tests/quizzes 3) Does not follow through on homework instructions 4) Is disruptive in class 5) Does not follow through on instructions given during class 6) Arrives late for class 7) Does not study for tests/quizzes 8) Turns in work that was not completed thoroughly 9) Has poorly organized folders or binders 10) Forgets to bring appropriate materials to class 11) Fails to turn in homework that he/she has already completed 12) Fails to turn in assignments on time 13) Actively refuses to complete work. 14) Has difficulty organizing writing assignments 15) Is noncompliant with adult requests 16) Makes careless errors on work 17) Fails to record homework assignments in a daily planner 18) Fails to participate in class discussions 19) Is off-task during school work 20) Fails to raise hand before speaking in class 21) Leaves longer-term projects until the last minute 22) Skips class for unexcused reasons 23) Poor time management 24) Has difficulty getting started on assignments Not at all Just a little Pretty Very 8

10 Part 1: To be completed by Teacher DSM-5 Rating Scale 1. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). 2. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy readings). 3. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). 4. Often does not follow through on instructions and fails to finish schoolwork, chores, or other responsibilities or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). 5. Often 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). 6. Often avoids, seems to dislike, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, or reviewing lengthy papers). 7. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). 8. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts.). 9. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). 10. Often fidgets with or taps hands or feet or squirms in seat. 11. Often leaves seat in situations when remaining seated is expected (e.g., leaving his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). 12. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless). 13. Often unable to play or engage in leisure activities quietly. 14. Is often on the go, acting as if driven by a motor (e.g., is unable to be or is uncomfortable being still for an extended time, as in restaurants, meetings; may be experienced by others as being restless and difficult to keep up with). 15. Often talks excessively. 16. Often blurts out an answer before a question has been completed (e.g., completes people s sentences; cannot wait turn in conversations). 17. Often has difficulty waiting his or her turn (e.g., while waiting in line). 18. Often 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; for adolescents or adults may intrude into or take over what others are doing). Not at All Just a Little Pretty Very Impairment Rating On a scale from 0 (no problem) to 6 (extreme problem) please rate the student s academic problems:

SUPPORT INFORMATION ADVOCACY

SUPPORT INFORMATION ADVOCACY THE ASSESSMENT OF ADHD ADHD: Assessment and Diagnosis in Psychology ADHD in children is characterised by developmentally inappropriate overactivity, distractibility, inattention, and impulsive behaviour.