Executive Functioning Checklist

Please check off all statements that apply to the potential client. These questions are to help the clinical and educational team of the S.S.G.C and College Life Skills Program (a subsidiary program of the S.S.G.C.) provide the best service possible. This information is considered private and confidential. (Parents answer with or for minor children)

Client Name *

Last

Client First *

First

Client Middle

Middle

Name of Parent or Guardian *

Last

Parent or Guardian First *

First

Birth Date *

Age *

Gender *

Male

Female

Executive Functioning Checklist (check all that apply)

Planning & Prioritizing

Can’t chunk larger assignments into smaller pieces

Doesn’t know where to start on a project or assignment

Gets ‘stuck’ easily

Often turns in assignments late because they underestimated complexity

Prefers multiple choice questions to open-ended responses

Struggles to take notes since everything seems equally important

Has difficulty making decisions

Struggles with strategizing and/or multi-step problem solving

Mental flexibility

Can become fixated on aspects of a routine (wants to eat the same food, wear same clothes, etc)

Struggles with transitions: between classes, activities, home/school, weekend/weekday, etc

Copes poorly when schedules or routines change

Can become ‘hyperfocused’ on one topic, idea, activity, etc

Struggles to switch gears

Working Memory

Really struggles to take notes from lectures (writing and listening at the same time)

Experiences ‘information overload’ easily when too much is presented too quickly

Finds mental math especially challenging

Struggles to remember multi-step directions and follow them out

May frequently forget what they were planning to say after raising hand or starting to speak

Might need to read text passages (especiall long ones) over and over to fully comprehend meaning

Struggles with tracking the flow of conversations and participating appropriately

Emotional Control (self-monitoring)

Can have angry outbursts at slight provocations

Quick to call things ‘unfair’

Struggle to persevere through difficulties in homework

Overreacts to negative situations (when disciplined, getting a bad grade, losing a game)

May unexpectedly laugh hysterically or burst into tears

Seems to have rapid mood changes

Appears not to care about others’ feelings

Task Initiation

Doesn’t know where to start on an assignment or project, even if directions were just given

Has trouble focusing again after a break

Procrastinates starting work until the last minute

Finds other things to do instead of work (frequently going to the bathroom, sharpening pencil, being on phone, etc)

Frequently seen with their head down or sneaking "phone time" during work time

Asks for help all the time, even when you know they understand the material and are capable of the work

Self-Monitoring

Unaware of how much effort they do or don’t put into their work

Think of grades somewhat magically, and confused/surprised by poor grades

Doesn’t recognize when their behavior negatively affects others

Talks too loudly or quickly

Might need to be told to sit down, stop touching that, put that down, etc, multiple times

Doesn’t think to check around them to gauge appropriate social behavior

Exhibits “annoying” repetitive behaviors like pencil tapping, knee-bouncing, even when others complain.

Organization

Frequently loses assignments, supplies, phone, water bottle, important messages, etc

Doesn’t change behaviors, even if they seem to want to/see consequences for disorganization

Doesn’t use planners, even if given one

Has a unrully backpack, bedroom, and/or work space and has trouble finding anything

Loses electronic files/emails because they can’t remember where they stored them, or under what file name

Shifting (Transitioning)

Frequently experiences dificulties with transitioning betwteen activities

Has a struggle with changing mental sets from thought to another thought

Does not tolerate changes well that may occur when problem solving or having to carry out a task

Experiences a feeling of being "stuck" when having to transition between thoughts or activities.

Signature

Select One

I am the parent/guardian

I am the adult

Signature

Clear

Executive Functioning Checklist (check all that apply)

Signature

Contact

Our Address

#MSDStrong

Proud Member