Appendix F: Groves Bonding Checklist (GBC)

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Name	Birthdate _______________
Caregiver’s Name	         Date ___________
Place the appropriate number before each listed behavior in the space provided.  This data is for clinical consideration only.  No cumulative score is intended.
None = 0	Some = 1	A Lot = 2
Positive Infant Behaviors (6 to 18 months)
___ Alert Appearance
___ Responds to caregiver’s voice
___ Vocalizes frequently
___ Shows age-appropriate motor skills
___ Likes to be cuddled
___ Can be easily comforted by caregiver
___ Sleeps well
___ Eats well
___ Prefers primary caregiver over others
Negative Infant Behaviors
___ Cries or is fussy most of the time
___ Resistant to comforting
___ Overly demanding
___ Delayed developmental milestones
___ Stiffens or is rigid when held
___ Flat or empty emotion
___ Lacks age-appropriate motor skills

Positive Pre-School Checklist (18-60 months)
___ Explores surroundings
___ Enjoys hugs and physical contact with main caregivers
___ Copies mannerisms of main caregivers
___ Physical development at age-appropriate levels
___ Makes eye contact
___ Shows responses to separation from caregivers
___ Able to set limits on own behavior (age 3+)
___ Shows some understanding of how others feel
___ Comfortable enough to get in and out of caregiver’s lap

Negative Pre-School Checklist
___ Resistant to comforting and nurturing
___ Fails to imitate behavior
___ Overly affectionate to strangers.
___ Does not appear relaxed or happy
___ Fails to show normal fears.

Positive School-Age Checklist (5-12)
___ Makes eye contact appropriately
___ Comfortable around primary caregivers
___ Gets along with friends
___ Shows appropriate responses to situations
___ Avoids self-harm and dangerous situations
___ Accepts comfort when in pain
___ Plays with peers without hurting them
___ Understands consequences of bad behavior
___ Sees self as a member of the family
___ Perceived by friends, school, and neighbors as a member of the caregiver’s family

Negative School-Age Checklist
___ Fails to make eye contact
___ Cruel to animals
___ Destroys property
___ Steals
___ Poor relationships with peers
___ Lies about things that are obvious
___ Makes inappropriate demands
___ Overly dependent or clingy
___ Few or no friends