attachment and bonding center of ohio

gregory c. keck phd

Attachment Symptom Checklist for Children Over 5

 

CHILD'S NAME:_______________________________

DATE OF BIRTH:______________________________      

Symptoms

None

Moderate

Severe

1. Superficially engaging and "charming"

 ______ ______ ______

2. Lack of eye contact on parental terms

 ______ ______ ______

3. Indiscriminately affectionate with strangers

 ______ ______ ______

4. Not affectionate on parents' terms (not cuddly)

 ______ ______ ______

5. Destructive to self, others, and material things
(accident prone)

 ______ ______ ______

6. Cruel to animals

 ______ ______ ______

7.Stealing

 ______ ______ ______

8. Lying about the obvious (crazy lying)

 ______ ______ ______

9. No impulse controls (frequently acts hyperactive)

 ______ ______ ______

10. Learning lags

 ______ ______ ______

11. Lack of cause and effect thinking

 ______ ______ ______

12. Lack of conscience

 ______ ______ ______

13. Abnormal eating patterns

 ______ ______ ______

14. Poor peer relationships

 ______ ______ ______

15. Preoccupation with fire

 ______ ______ ______

16. Persistent nonsense questions and incessant chatter

 ______ ______ ______

17. Inappropriately demanding and clingy

 ______ ______ ______

18. Abnormal speech patterns

 ______ ______ ______

Completed by:________________________________    		Relationship to child:_________________________________
 

Address: __________________________   

___________________________________

 Phone:(day)

______________________________________


Date completed:____________________		 Phone:(evening)

______________________________________

Gregory Keck, Ph.D.

Attachment and Bonding Center of Ohio
12608 State Road
Suite 1
Cleveland, Ohio  44133
Cleveland Office  440-230-1960
Columbus Office  614-261-8800

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