SCHOOL VERSION RATING FORM PROFILE SHEET

SCHOOL VERSION RATING FORM
PROFILE
SHEET
Name:
School:
Class:
City:
Date of rating:
2002
Age at rating:
2. Interpersonal
Difficulties
3. Inappropriate
Behavior
4. Unhappiness/
Depression
5. Physical Symptoms/
Fears
(day)
5
11
(year)
(month)
(day)
10
2
15
Raw
Score
Subscales
1. Learning Problems
4
(month)
1990
Date of birth:
Grade:5
State:PA
10
(year)
SUMMARY OF SCORES
Gender:Female
Andrea Thomas
Midvale Elementary
all subjects
Midvale
Standard
Score
Age
Grade
APPX A
APPX D
(months)
(days)
Age
Standard
Scores
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
BES-3:L SV
Copyright © 2005
Learning
Problems
Age
APPX B
Grade
APPX E
A
G
Hawthorne Educational Servces, Inc.
G
A
G
A
G
G
Grade
APPX F
5
4
2.43
1.88
34
6
5
2.37
2.19
29
10
9
2.43
2.04
50
4
2
2.43
1.88
7
E
R
6
2.35
2.32
30
Age
Grade
APPX B APPX E
Interpersonal Inappropriate Unhappiness/
Physical
Depression Symptoms/Fears Quotients
Difficulties
Behavior
A
A
Grade
Age
APPX C
49
CO
S
K
Rated by (observer's name): M. Jackson
Total Score
C
I
N
Sum of
U
IO E %ile
Q
Comments:
Subscale SSR Quotient
G VE PL
N
O OL
M 77 10 6
L
:
32
26 A 81
3
O
S- CH LE S
E
B
S
I
Subscales
F
O
PR
(years)
Standard
Score SEM
150
145
140
135
130
125
120
115
110
105
100
95
90
85
80
75
70
65
60
55
50
Quotient
SEM
Quotient
A
G
Age
Grade
APPX C APPX F
2.53
Confidence
Interval
Age
Grade
5.47 99% 99%
Percentiles
Percentile
Rank
$ 99
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
#1
A
G
The Learning Problems subscale assesses behaviors conducive to learning, study habits, assignment and homework
completion, work habits, academic performance, memory and comprehension skills, and skill in following oral and
written directions. It represents the students who do not respond to traditional learning experiences and are not
successful in learning without special attention or assistance in the school environment. The understanding is that the
learning difficulty is behavioral, thus constituting its inclusion in the need to consider the failure to learn, without
other explanation, as a behavior disorder.
Andrea scored at two standard deviations below the mean on the Learning Problems subscale. The following are
primary behaviors of concern:
3.
Does not grasp basic concepts or information related to academic tasks
5.
Does not follow directions, written or verbal, related to academic tasks
7.
Has difficulty organizing or appropriately using necessary work materials (e.g., paper, pencil, books)
11.
Demonstrates difficulty or reluctance in beginning tasks
The Interpersonal Difficulties subscale assesses social skills conducive to the formation of positive relationships with
peers and teachers. Items within this subscale include such behaviors as fighting, inappropriate comments, agitation or
provocation of other students, withdrawn behavior, and lack of acceptance by the student's peers. It encompasses the
inclusion of behaviors ranging from the inability to make or keep friends to the acting out/aggressive behavior which
interferes with resolving conflict, etc. The range of behaviors runs from passivity to aggressiveness as exhibited in
varying forms by all age groups, 4.0 years through 19 years.
BE SSC H 3:L
H AV O
O I N
O O G
L R Q
V S U
ER O IC
SI F C K
O O SC
N N
SA CE OR
M RN E
PL
E
Andrea scored more than one standard deviation below the mean on the Interpersonal Difficulties subscale. The
following are primary behaviors of concern:
16.
Does not recognize or respond appropriately to nonverbal cues (e.g., gestures, facial expressions, body movements,
etc.) in social situations
18.
Seems unable or unwilling to communicate feelings or emotions to others
22.
Avoids interaction with other students or teachers
The Inappropriate Behavior subscale is an all encompassing one which represents behavior atypical in the context of
the educational environment. It is this area which represents attendance, stealing, predictability, sexual behavior,
cheating, rule-following, etc. Much of this characteristic deals with the inability to conform to expected patterns of
behavior necessary for social/employment success in society. Stability, responsibility, dependability, etc., are
behaviors measured by this characteristic.
Andrea scored at the mean on the Inappropriate Behavior subscale. The following are primary behaviors of concern:
28.
Fails to participate verbally or physically in group situations
39.
Exhibits off-task behaviors (e.g., stares away from task, does not make eye contact, remains on-task for only brief
periods of time)
BE
The Unhappiness/Depression subscale provides a measure of the more subtle indicators of emotional/behavioral
problems represented by a pervasive mood of dissatisfaction and negative feelings resulting from personal or schoolrelated experiences. This subscale includes behaviors such as avoidance of group activities, self-blame, difficulty
accepting suggestions or constructive criticism, suicidal comments, lack of affect (i.e., smiling or laughing), apparent
fatigue, apathy, frowning, scowling, and overly critical or pessimistic comments directed at oneself.
Andrea scored at two standard deviations below the mean on the Unhappiness/Depression subscale. The following are
primary behaviors of concern:
47.
Demonstrates facial expression of sadness or displeasure (e.g., frowning)
48.
Avoids or has difficulty discussing personal problems (school or non-school related)
49.
Exhibits overly pessimistic or negative attitude (e.g., interprets most situations in a negative manner, fails to
acknowledge positive circumstances, etc.)
54.
Fails to demonstrate a sense of humor when appropriate (e.g., smiling or laughing)
60.
Fails to participate in or demonstrate an interest in special events or interesting activities
The Physical Symptoms/Fears subscale provides a measure of behaviors representing a negative reaction to personal
or school experiences. In many cases the behaviors demonstrated under this characteristic constitute a phobic level of
response to environmental problems. Included in this subscale are behaviors such as complaints about physical
illnesses, self-injury, excessive concern related to family or school problems, temper tantrums, nervous habits, unusual
speech habits, tremors, stammering, shaking, or excessive fears.
Andrea scored more than one standard deviation below the mean on the Physical Symptoms/Fears subscale. The
following are primary behaviors of concern:
65.
Exhibits excessive fatigue (e.g., seems tired or listless)
71.
Seems to be upset by or afraid of new situations or changes in routine
BES-3:L SV
Page 2 of 4
HOME VERSION RATING FORM
PROFILE
SHEET
Date of rating:
2003
(year)
10
Age at rating:
(years)
16
(month)
(day)
2
15
(months)
Rated by (observer's name):
2. Interpersonal
Difficulties
3. Inappropriate
Behavior
4. Unhappiness/
Depression
5. Physical Symptoms/
Fears
(day)
11
(days)
M. Jackson
Sum of
Subscale SS
Comments:
Age
BES-3:L HV
Copyright © 2005
Grade
39
Quotient
Age
APPX B
83
A
G
Grade
APPX E
A
Hawthorne Educational Servces, Inc.
Standard
Score
Standard
Score SEM
Age
Grade
APPX A
APPX D
Age
Grade
APPX C
APPX F
20
9
10
2.37
2.45
25
10
10
2.32
2.45
87
7
7
2.48
1.55
22
5
4
2.32
3.10
19
8
8
2.32
2.45
Total Score
Age
84
Quotient
SEM
%ile
Grade
APPX B APPX E
13
Age
Grade
APPX C APPX F
15
2.53
Confidence
Interval
Age
Grade
5.47 99% 99%
Subscales
Interpersonal Inappropriate Unhappiness/
Physical
Depression Symptoms/Fears Quotients
Difficulties
Behavior
BE
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Learning
Problems
S-
39
Standard
Scores
Raw
Score
Subscales
1. Learning Problems
31
(month)
1992
Date of birth:
Grade:4
State:PA
1
(year)
SUMMARY OF SCORES
Gender:Female
Andrea Thomas
Midvale Elementary
all subjects
Midvale
3:
LO
H
PR O NG
O ME Q
FI V U
LE E IC
SA RSI K S
M ON CO
PL
R
E
E
Name:
School:
Class:
City:
G
A
A
G
A
G
G
150
145
140
135
130
125
120
115
110
105
100
95
90
85
80
75
70
65
60
55
50
Quotient
Percentiles
Percentile
Rank
$ 99
A
G
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
#1
A
G
The Inappropriate Behavior subscale is an all encompassing one which represents behavior atypical in the context of
the residential environment. It is this area which represents participation in family activities, stealing, sexually-related
behavior, cheating, etc. Much of this characteristic deals with the inability to conform to expected patterns of behavior
necessary for social/employment success in society. Stability, responsibility, dependability, etc., are behaviors
measured by this characteristic.
Andrea scored at one standard deviation below the mean on the Inappropriate Behavior subscale. The following are
primary behaviors of concern:
38.
Refuses to accept decisions made by parents (e.g., does not take “no” for an answer)
39.
Is easily frustrated (e.g., gives up easily, does not put forth his/her best effort, etc.)
41.
Does not go to bed on time, does not go to sleep, etc.
52.
Has extreme mood changes (e.g., from calm to angry, happy to sad, etc.)
55.
Fails to accept failure, losing, or being unsuccessful
56.
Does not independently perform chores or responsibilities (e.g., has to be reminded, does not begin or complete
responsibilities without assistance, etc.)
BE SH H 3:L
O AV O
M I N
E OR G
Q
V
S
ER O U
SI F ICK
O CO S
N
SA NC CO
M ER RE
PL N
E
The Learning Problems subscale assesses behaviors conducive to learning, study habits, assignment and homework
completion, work habits, academic performance, memory and comprehension skills, and skill in following oral and
written directions. It represents the children and youth who do not respond to traditional learning experiences and are
not successful in learning without special attention or assistance in the home environment from parents or guardians.
The understanding is that the learning difficulty is behavioral, thus constituting its inclusion in the need to consider
the failure to learn, without other explanation, as a behavior disorder.
Andrea scored within one standard deviation below the mean on the Learning Problems subscale. The following are
primary behaviors of concern:
1.
Has difficulty with short-term or long-term memory (e.g., does not remember directions, does not recall information
previously learned, etc.)
BE
The Interpersonal Difficulties subscale assesses social skills conducive to the formation of positive relationships with
other persons in the home or residential setting. Items within this subscale include such behaviors as fighting,
inappropriate comments, agitation or provocation of others, difficulties at meal times, difficulties within the
community, and refusal to follow directions. It encompasses the inclusion of behaviors ranging from the inability to
make or keep friends to the acting out/aggressive behavior which interferes with resolving conflict, etc. The range of
behaviors runs from passivity to aggressiveness as exhibited in varying forms by all age groups, 4.0 years through 19
years.
Andrea scored at the mean on the Interpersonal Difficulties subscale. The following are primary behaviors of concern:
9.
Fights with brothers, sisters, or friends
The Unhappiness/Depression subscale provides a measure of the more subtle indicators of emotional/behavioral
problems represented by a pervasive mood of dissatisfaction and negative feelings resulting from personal, home, or
school-related experiences. This subscale includes behaviors such as avoidance of group activities, self-blame,
difficulty accepting suggestions or constructive criticism, lack of affect (e.g., smiling or laughing), apparent fatigue,
apathy, frowning, scowling, and overly critical or pessimistic comments directed at oneself.
Andrea scored more than one standard deviation below the mean on the Unhappiness/Depression subscale. The
following are primary behaviors of concern:
The Physical Symptoms/Fears subscale provides a measure of behaviors representing a negative reaction to personal,
school, or home experiences. In many cases the behaviors demonstrated under this characteristic constitute a phobic
level of response to environmental problems. Included in this subscale are behaviors such as complaints about physical
illnesses, self-injury, excessive concern related to family or school problems, temper tantrums, nervous habits, unusual
speech habits, tremors, stammering, shaking, or excessive fears.
Andrea scored within one standard deviation below the mean on the Physical Symptoms/Fears subscale. The
following are primary behaviors of concern:
67.
Reacts physically in response to excitement, disappointment, surprise, happiness, fear, etc. (e.g., flaps hands, shudders,
stutters, stammers, trembles, etc.)
BES-3:L HV
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