Parent Report: Executive Functioning School Age Intake

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Parent Report: Executive Functioning School Age Intake

Student's Name:
*

Student's Age *

Student's Grade *

Name of School: *

Parent's name filling out in-take

Parent's email

Planning/Prioritizing: The ability to determine what is important and what to ignore; to develop a “road map for an activity or event.”

Underestimates assignment time and effort
*

Never

Rarely

Sometimes

Often

Procrastinates on homework, reading, and studying
*

Never

Rarely

Sometimes

Often

Easily distracted
*

Never

Rarely

Sometimes

Often

Demonstrates difficulty planning *

Never

Rarely

Sometimes

Often

Spends time on unimportant details
*

Never

Rarely

Sometimes

Often

Challenges with prioritizing important information (main ideas, note-taking)

Never

Rarely

Sometimes

Often

Organization: Figuring out the best way to get tasks done effectively and efficiently.

Room is untidy and disorganized
*

Never

Rarely

Sometimes

Often

Favorite places to study and do homework *

Frequently loses personal belongings and school materials
*

Never

Rarely

Sometimes

Often

Struggles to stay on top of assignments and projects
*

Never

Rarely

Sometimes

Often

Difficulty following multi-step directions
*

Never

Rarely

Sometimes

Often

Has trouble explaining tasks in a logical sequence
*

Never

Rarely

Sometimes

Often

Encounters issues with writing

Never

Rarely

Sometimes

Often

Initiation: The skill to initiate a task promptly and effectively.

Delays getting started assignments or chores
*

Never

Rarely

Sometimes

Often

Consistently feels pressured by deadlines
*

Never

Rarely

Sometimes

Often

Relies on prompts and cues to initiate tasks
*

Never

Rarely

Sometimes

Often

Utilizes rebellious, confrontational, or evasive approaches
*

Never

Rarely

Sometimes

Often

Seems "inactive," lacking motivation, or uncooperative
*

Never

Rarely

Sometimes

Often

Encounters challenges in seeking assistance or clarification

Never

Rarely

Sometimes

Often

Working Memory: The skill to remember information long enough to use it.

Shows trouble with note-taking at school *

Never

Rarely

Sometimes

Often

Needs instructions repeated or clarified before finishing
*

Never

Rarely

Sometimes

Often

Understands something initially but forgets it quickly
*

Never

Rarely

Sometimes

Often

Leaves tasks incomplete due to forgetfulness
*

Never

Rarely

Sometimes

Often

Strays off course, repeats, or skips steps
*

Never

Rarely

Sometimes

Often

Adaptability: The skill to adjust or change direction when needed.

Fails to learn from previous errors
*

Never

Rarely

Sometimes

Often

Persists with the same actions even after bad results
*

Never

Rarely

Sometimes

Often

Becomes discouraged rapidly
*

Never

Rarely

Sometimes

Often

Displays a pessimistic demeanor
*

Never

Rarely

Sometimes

Often

Becomes excessively anxious with unforeseen situations
*

Never

Rarely

Sometimes

Often

Struggles to adapt and change thinking patterns

Never

Rarely

Sometimes

Often

Self-Monitoring: The skill to evaluate your own performance and how effectively it helps achieve goals or complete tasks.

Persists with a task despite unclear directions
*

Never

Rarely

Sometimes

Often

Frequently veers off-topic
*

Never

Rarely

Sometimes

Often

Commits "careless" errors
*

Never

Rarely

Sometimes

Often

Skips the editing process
*

Never

Rarely

Sometimes

Often

Struggles with interpreting social cues and adapting behavior
*

Never

Rarely

Sometimes

Often

Jumps from one task to another without finishing the first

Never

Rarely

Sometimes

Often

Inhibition/Emotional Control: The capacity to regulate emotions to achieve a goal or task completion.

Highly sensitive (strong reaction to minor issues)
*

Never

Rarely

Sometimes

Often

Misinterprets the intentions of others
*

Never

Rarely

Sometimes

Often

Exhibits poor sportsmanship and struggles with losing
*

Never

Rarely

Sometimes

Often

Becomes easily agitated in response to situations
*

Never

Rarely

Sometimes

Often

Becomes quickly agitated, especially in group settings or special occasions
*

Never

Rarely

Sometimes

Often

Takes constructive criticism as a personal attack or sign of failure.

Never

Rarely

Sometimes

Often

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