SNAP-IV 26 – Teacher and Parent Rating Scale

Source: James M. Swanson, Ph.D., University of California, Irvine, CA 92715

PRIVATE & CONFIDENTIAL

Completed by one or both guardians of a patient - Each person must complete their own form
Please complete all required fields and submit your form at least 72 hours prior to the patient's appointment. This form will be provided to the patient's specialist doctor.

PARENT Details

Your full name *

Relationship to the Patient *

Other *

CHILD (Patient) Details

Patient's First Name *

Patient's Last Name *

Date of Birth *

Questionnaire

Please select the most appropriate option that best describes the patient's behaviour

0 = Never or Rarely: This is not a problem or concern. Any challenges are/were age-appropriate

1 = Sometimes: Some difficulty (somewhat)

2 = Often: This is a problem (pretty much)

3 = Very Often: This is a serious problem (very much)

Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks *

0123

Often has difficulty sustaining attention in tasks or play activities *

0123

Often does not seem to listen when spoken to directly *

0123

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties *

0123

Often has difficulty organizing tasks and activities *

0123

Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort *

0123

Often loses things necessary for activities (e.g., toys, school assignments, pencils, or books) *

0123

Often is distracted by extraneous stimuli *

0123

Often is forgetful in daily activities *

0123

Often fidgets with hands or feet or squirms in seat *

0123

Often leaves seat in classroom or in other situations in which remaining seated is expected *

0123

Often runs about or climbs excessively in situations in which it is inappropriate *

0123

Often has difficulty playing or engaging in leisure activities quietly *

0123

Often is “on the go” or often acts as if “driven by a motor” *

0123

Often talks excessively *

0123

Often blurts out answers before questions have been completed *

0123

Often has difficulty awaiting turn *

0123

Often interrupts or intrudes on others (e.g. butts into conversations/ games) *

0123

Often loses temper *

0123

Often argues with adults *

0123

Often actively defies or refuses adult requests or rules *

0123

Often deliberately does things that annoy other people *

0123

Often blames others for his or her mistakes or misbehavior *

0123

Often touchy or easily annoyed by others *

0123

Often is angry and resentful *

0123

Often is spiteful or vindictive *

0123

Areas

Treatment Plan

Specialist: Please confirm if your child is booked to see this type of practitioner *

I understand that psychologists cannot diagnose and they cannot prescribe medications; Appointments are for therapy sessions. I understand I may therefore need to seek additional services for diagnosis/treatment plan, including specialist care from a psychiatrist or paediatrician where separate fees apply.

*

I confirm that I understand: Due to the limitation of telehealth services, most of our Psychiatrists and paediatricians are providing assessment and diagnostic services to hand over the ongoing care to your referring GPs.

The management of patients with attention deficit hyperactivity disorder (ADHD) may involve the prescription of restricted (S8) psychostimulant medications (e.g. Lisdexamfetamine/Vyvanse or Ritalin/Methylphenidate). Please be aware that while Telecare’s specialists may recommend treatment with such medications, but they will not provide the prescription for these medications (unless exceptional circumstances apply). Our psychiatrists/paediatricians are able to provide a supporting letter to your GP, detailing their recommendation for the medication. Your GP may then be able to use that recommendation to apply for a permit to prescribe these recommended medications.

I understand I must confirm with my referring GP that this is acknowledged and understood, prior to any telehealth appointment. We suggest that you confirm your GP can prescribe and has capacity to provide ongoing prescribing (which generally includes regular appointments for vitals measurements). Any queries, your GP/clinic can contact Telecare

*

I understand that if I am a NSW or WA patient, there are higher restrictions with restricted (S8) medications. This is due to complexities surrounding the regulations for interstate prescribing and GP co-initiation of psychostimulants. The team at Telecare has worked tirelessly to try to ensure a guaranteed route to obtain this authority but the current regulations have made it unpredictable.

I understand the appointment will only be an assessment and diagnosis only. I understand I may therefore need to seek local services including specialist care from a psychiatrist or paediatrician where separate fees apply.

*

I understand that if I am a WA patient, there are higher restrictions with restricted (S8) medications. This is due to complexities surrounding the regulations for interstate prescribing and GP co-initiation of psychostimulants. The team at Telecare has worked tirelessly to try to ensure a guaranteed route to obtain this authority but the current regulations have made it unpredictable.

I understand the appointment will only be an assessment and diagnosis only. I understand I may therefore need to seek local services including specialist care from a psychiatrist or paediatrician where separate fees apply.

*

SIGNATURE

I confirm the above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature *

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Today's Date *

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