Questionnaire for teachers

Child's name Required

Date of birth Required

Teacher's name Required

Teacher's position (for example class teacher, form tutor, head of year)

Email address Required

Contact number Required

Considerate of other people's feelings Required

Restless, overactive, cannot stay still for long Required

Often complains of headaches, stomach-aches or sickness Required

Shares readily with other children (treats, toys, pencils etc.) Required

Often has temper tantrums or hot tempers Required

Rather solitary, tends to play alone Required

Generally obedient, usually does what adults request Required

Many worries, often seems worried Required

Helpful if someone is hurt, upset or feeling ill Required

Constantly fidgeting or squirming Required

Has at least one good friend Required

Often fights with other children or bullies them Required

Often unhappy, down-hearted or tearful Required

Generally liked by other children Required

Easily distracted, concentration wanders Required

Nervous or clingy in new situations, easily loses confidence Required

Kind to younger children Required

Often lies or cheats Required

Picked on or bullied by other children Required

Often volunteers to help others (parents, teachers, other children) Required

Thinks things out before acting Required

Steals from home, school or elsewhere Required

Gets on better with adults than with other children Required

Many fears, easily scared Required

Sees tasks through to the end, good attention span Required

Do you have any other comments or concerns? Required

Overall, do you think that this child has difficulties in one or more of the following areas: emotions, concentration, behaviour or being able to get on with other people?

How long have these difficulties been present?

If yes, please identify which areas they are having difficulties (please select all that apply)

Emotions

Concentration

Behaviour

Getting on with other people

Do the difficulties upset or distress this child?

Do the difficulties interfere with the child's everyday life in terms of peer relationships?

Do the difficulties interfere with the child's everyday life in terms of classroom teaching?

Do the difficulties put a burden on you or the class as a whole?

Does the child access/receive any specific emotional support during school hours? Please provide details

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