Application for FDU's Child and Parent ADHD Specialty Group Program
139 Temple Avenue Hackensack, NJ 07601
Office: 201-692-2645 Fax: 201-692-2164 

Child's name:
Age:    Date of Birth(mm/dd/yy)    Gender: m  f

Mother's name:
Father's name: 

Address:
City:    Zip:

Home phone:     Father's work phone:
Mother's work phone:     Fax number:
Best time(s) to be reached:

Referred by:

Child's school:
Grade:     Classification:

Does your child have problems paying attention or concentrating in any of these situations? If so, indicate how severe these attentional difficulties are. 
Situations  If no,
click
here		 If yes, how severe? (click one) 

<--Mild                                                              Severe-->
1 While playing alone N 1 2 3 4 5 6 7 8 9
2 While playing with other children N 1 2 3 4 5 6 7 8 9
3 Mealtimes N 1 2 3 4 5 6 7 8 9
4 Getting dressed N 1 2 3 4 5 6 7 8 9
5 While watching TV N 1 2 3 4 5 6 7 8 9
6 When visitors are in your home  N 1 2 3 4 5 6 7 8 9
7 When you are visiting someone else N 1 2 3 4 5 6 7 8 9
8 At church/temple N 1 2 3 4 5 6 7 8 9
9 In supermarkets, restaurants, or other public areas N 1 2 3 4 5 6 7 8 9
10 When asked to do chores at home  N 1 2 3 4 5 6 7 8 9
11 During conversations with others N 1 2 3 4 5 6 7 8 9
12 While in the car  N 1 2 3 4 5 6 7 8 9
13 When father is home N 1 2 3 4 5 6 7 8 9
14 When asked to do school homework N 1 2 3 4 5 6 7 8 9
For office use only: Number of problems =  Mean severity = 
Factor I =                  Factor II =