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ADHD Preliminary Screener – Self Report

Directions: Of the following symptoms, select the ones you find you have been struggling with most in the past six (6) months to a degree that is inconsistent with your developmental level and that negatively impacts directly on your social, academic, and/or occupational activities.

Directions: In the next section, please answer “Yes” or “No” to the best of your recollection in order to better understand how the endorsed symptoms above have affected you throughout your life.

1. Do, and/or, have the above-mentioned symptoms occurred in two or more settings throughout the course of your life?
2. Were several of the inattentive or hyperactive-impulsive symptoms present prior to age 12 years
3. Throughout the course of childhood, were any of the inattentive behaviors endorsed above due to defiance or lack of comprehension?
4. Throughout the course of childhood, would you find yourself constantly daydreaming, or finding your mind drifting off somewhere else completely while focus was meant to be placed on the task at hand?
5. Throughout the course of your childhood, would you find yourself constantly feeling as though you had to outperform those around you, and/or maybe instead finding yourself giving up in academics all together?
6. Throughout the course of childhood, did you find yourself committing to hasty actions without forethought that could have had high potential for harm (e.g., darting into the street without looking)?
7. Throughout the course of your childhood, would you describe family relationships or peer interactions to have been characterized by discord and negative interactions?
8. Would you say there are many in your life, past and current, that would say that symptoms endorsed above were/are problematic at home, school, work, etc?
9. Would, or do the symptoms endorsed above often become minimal or absent when engaged in receiving frequent rewards for appropriate behavior, under close supervision, in novel settings, engaged in especially interesting activities, consistent external stimulation (e.g., via electronic screens), or when interacting in one-on-one situations?
10. Throughout the course of your life, did you experience any of the following: reduced school performance and academic attainment, social rejection, poorer occupational performance, attainment, attendance, and higher probability of unemployment as well as elevated interpersonal conflict?
11. Do you find that your inadequate or variable self-application to tasks that require sustained effort is often interpreted by others as laziness, irresponsibility, or failure to cooperate?
12. Throughout the course of your life, have you constantly found yourself seeking for immediate reward or having difficulty delaying gratification?
13. Would you say you have a history of emotional dysregulation which may include: low frustration tolerance, irritability, or mood lability (rapid or exaggerated changes in mood)?
14. Do you find yourself constantly resorting to the use of caffeinated beverages, energy drinks, cigarettes, alcohol, or stimulants and find that it helps you feel more calm, alert, and/or focused?
15. Throughout the course of your life, have there been times in which you have ignored or ‘tuned out’ other important aspects of life, like forgetting to eat or neglecting family and loved ones, primarily due to focusing intensely on one thing to the exclusion of everything else?
16. Throughout the course of your life, have you found yourself in an intense state of concentration and focus, usually when it comes to things that you find enjoyable or fascinating, in which your task performance improves, and you are unaware of the passage of time?

Directions: In this last section, please answer the following questions in order to better understand how the endorsed symptoms above have affected you throughout your life.

By clicking "submit" below, I express understanding that this information will be utilized by a licensed mental health professional as a way to better understand my experience as it relates to the symptoms endorsed above, along with further information that will be gathered during my evaluation. All of the information I have supplied is true to the best of my understanding, and I understand that any false information I provide may lead to a misdiagnosis which may hinder services for myself. I understand that the licensed mental health professional will consider this information, along with other pertinent information collected, when formulating a diagnosis, and that there may be a possibility that my symptoms may be better explained by a differential diagnosis. I understand that the information contained in this screener should not be used as a substitute for the medical care and advice of a doctor, psychiatrist, or mental health provider. There may be variations in treatment that my provider may recommend based on individual facts and circumstances. I also understand that the information contained in this screener is anonymous, as I am not supplying personal identifiers, and that this information will be destroyed after its use.

This instrument was created by Bryant Prieto, MS, LPC, owner of New Leaf Counseling of the River Valley, Inc. for use by its provider, as well as Dr. Monty Atchley who is affiliated with Stonehaven Behavioral Health & Wellness. 


Thanks for submitting! We look forward to meeting you for your scheduled appointment!

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