DLA20 — Growth In Healing Therapy

Daily Living Activity Screen

Instructions: Using the pop up boxes below, rate how often or how well you (or your child) independently performed or managed each of the 20 Activities of Daily Living (ADL's) in the community during the last 30 days. If your (or your child’s) level of functioning is varied, rate a lower score. Consider impairments in functioning due to physical limitations as well as those due to mental impairments. Do not consider environmental limitations (eg, "no jobs available"). Scoring a 1, 2, or 3 indicates that there is a concern. Scoring a 6 or 7 indicates you have no concerns.

Today's Date

YYYY

Name

First Name

Last Name

Date of Birth

YYYY

1. Health Practices

Assist or manage adequate weight, moods, outdoor exercise, aches, pains. Take medications or over the counter drugs with adult supervision only.

2. Housing Stability

Housing is stable and youth contributes to stability in the home (age-appropriate). Respect others and property. Share in chores, involve caretakers in school related projects, grades.

3. Communication

Greets adults. Listens. Expresses feeling, anger, opinions effectively.

4. Safety

Play it safe? Avoid guns, knives, matches, danger people or places where there is likely trouble or an abuse potential. If driving, has a safe record.

5. Managing Time

Assist or manage time for promptness. Regularly attends school and work (age appropriate). Routinely completes tasks. Sleep, wake, meals on regular basis?

6. Managing Money

Reliably handles or manages monetary allowance. Abstains from overspending personal limits. Betting, stealing, borrowing?

7. Nutrition

Eats at least 2 basically nutritious meals with caretakers. Eat healthy snacks that reasonably limit sugar and caffeine?

8. Problem Solving

Understand presenting problems, reasons for seeking services. Focus on possible solutions for age-appropriate time periods. Assist or manage difficult situations?

9. Family Relationships

Feel close to at least one other person at home. Get along with family or caretakers. Feel loved?

10. Alcohol/Drug Use

Abstain from smoking cigarettes, drinking alcohol, doing drugs or inhalants of any kind including Vapes. Avoid high risk drinking situations and people who do drugs?

11. Leisure

Enjoy two or more fun and relaxing activities: musical instruments, music, watching/playing sports, reading, computer or board games, cards, art, hobbies, movies, TV?

12. Community Resources

Use community activities, resources such as after-school sponsored tutoring, clubs, sports, scouts, Boys/Girls Clubs, library, church, dances?

13. Social Network

Make and keep same-age friends. Avoid bullying, gangs, cults, anti-social groups.

14. Sexuality

Reports age-appropriate sexually responsible behaviors with girls/boys. Educated and avoids sexual activities, infections, pregnancy?

15. Productivity

Feel good about performance at school. Consider grades to be good. Complete school projects without undue difficulty. Have vocational goals?

16. Coping Skills

Accept adult correction without undue arguing, temper outburst. Tolerates frustration.

17. Behavior Norms

Control threatening or physical expression of anger, violent behavior - either to self or others or property. Law abiding, responsible with school, community rules, driving car.

18. Personal Hygiene

Help or manage general cleanliness - daily shower/bath, brush teeth.

19. Grooming

Assist or manage general appearance: hair, shave, comply with school rules

20. Dress

Assist or responsibly care for clean clothes, comply with school dress code. Does not sleep in clothes and then go to school in them.

Comments and concerns

This area is for information that would help explain or justify your choices.

Goals

What goals or needs would you like to work on to help support your (your child's) development and growth?