Appendix F: Groves Bonding Checklist (GBC)

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