Sanction Seeking Behavior High Risk Sexual Activity Sexual Exploitation CULTURAL FACTORS 0 = No evidence of problems; no reason to believe item requires action. 1 = Watchful waiting; monitoring or possibly preventive action. 2 = Need for action. Some strategy needed to address problem/need. 3 = Need for Immediate action. Safety concern; priority for intervention. 0 1 2 3 Language Cultural Identity Ritual Discrimination/Bias Cultural Differences within the Family DEVELOPMENTAL FACTORS/MILESTONES 0 = No evidence of problems; no reason to believe item requires action. 1 = Watchful waiting; monitoring or possibly preventive action. 2 = Need for action. Some strategy needed to address problem/need. 3 = Need for Immediate action. Safety concern; priority for intervention. 0 1 2 3 Sensory Communication Autism Spectrum Failure to Thrive Regulatory Problems Birth Weight Prenatal Care Substance Exposure Labor and Delivery Maternal Availability Curiosity Playfulness Temperament Feeding/Elimination Daycare/Preschool EXTENSION MODULES 1 - School 2 - Developmental Needs 3 - Substance Abuse 4 – Trauma/ 4a – Sexual Abuse 5- Suicide Risk 6 - Violence 7 - Sexually Aggressive Behavior 8- Runaway 9- Juvenile Justice 10- Fire Setting SCHOOL 0 1 2 3 Educational Attributes Academic Persistence School Achievement Tardiness Class Avoidance School Attendance Classroom Behavior Non Classroom Behavior School Discipline Students Needs
Self Management Decision-Making Skills Ability to Pay Attention Bullying Bullied by Others Student Life Domain Needs Parenting Responsibilities Gang Involvement Student Strengths Clubs/ Athletics Leadership Peer Relationships Relationship with Teachers DEVELOPMENTAL NEEDS 0 1 2 3 Cognitive Developmental Communication Self Care/ Daily Living Skills SUBSTANCE ABUSE 0 1 2 3 Severity of Use Duration of Use Stage of Recovery Peer Influences Parental Influences Environmental Influences TRAUMA 0 1 2 3 Traumatic Stress Symptoms Affective/Physical Dysregulation Intrusions Traumatic Re-experiencing Hyper arousal Avoidance Numbing Dissociation Time Before Treatment Sexual Abuse (4a) Emotional Closeness of Perpetrator Frequency of Abuse Duration Physical Force Reaction to Disclosure SUICIDE RISK MODULE 0 1 2 3 History of Attempts Suicide Ideation Suicide Intent Suicide Planning Substance Use (#35) Depression (# 30) SUICIDE RISK MODULE continued 0 1 2 3 Conduct (#33) Caregiver Mental Health (#194) Accessible Firearm/Medication DANGEROUSNESS/VIOLENCE 0 1 2 3 Historical Risk Factors History of Physical Abuse History of Violence Witness to Community Violence (#45) Witness to Family Violence (#44) Emotional/Behavioral Risks Frustration Management Hostility Paranoid Thinking Secondary Gains from Anger Violent Thinking Resiliency Factors Aware of Violence Potential Response to Consequences Commitment to Self Control Treatment Involvement SEXUALLY AGGRESSIVE BEHAVIOR 0 1 2 3 Relationship Physical Force/Threat Planning Age Differential Type of Sex Act Response to Accusation Temporal Consistency History of Sexually Abusive Behavior Severity of Sexual Abuse Prior Treatment RUNAWAY 0 1 2 3 Frequency of Running Consistency of Destination Safety of Destination Involvement of Illegal Acts Likelihood of Return on Own Involvement of Others Realistic Expectations Planning JUVENILE JUSTICE 0 1 2 3 Seriousness History Arrests Planning Community Safety Legal Compliance Peer Criminal Behavior (Influences) Parental Criminal Behavior (#50) Environmental Influences FIRE SETTING 0 1 2 3 Seriousness History Arrests Planning Use of Accelerants Intention to harm Community Safety Response to Accusation Remorse Likelihood of Future Fire setting CAREGIVER NEEDS (Optional) Not applicable; no caregiver identified. 0 = No evidence of need; potential resource for the 1 = Watchful waiting; monitoring or possibly preventive action. 2 = Need for action. Some strategy needed to address problem/need. 3 = Need for Immediate action. Safety concern; priority for intervention. Caregiver Information First name: Last name: Caregiver type Adoptive parent Aunt Biological parent Foster parent Godparent Grandparent Legal guardian Stepparent Uncle Other 0 1 2 3
Supervision Involvement with Care Knowledge Organization Resources Residential Stability Physical Mental Health Substance Use Developmental Safety Family Stress Legal Additional Caregiver name: Last name: Caregiver type Adoptive parent Aunt Biological parent Foster parent Godparent Grandparent Legal guardian Stepparent Uncle 0 1 2 3 Supervision Involvement with Care Knowledge Organization Resources Residential Stability Physical Mental Health Substance Use Developmental Safety Family Stress Legal Additional Caregiver name: Last name: Caregiver type Adoptive parent Aunt Biological parent Foster parent Godparent Grandparent Legal guardian Stepparent Uncle Other 0 1 2 3 Supervision Involvement with Care Knowledge Organization Resources Residential Stability Physical Mental Health Substance Use Developmental Safety Family Stress Additional Caregiver First name: Last name: Caregiver type Adoptive parent Aunt Biological parent Foster parent Godparent Grandparent Legal guardian Stepparent Uncle Other 0 1 2 3 Supervision Involvement with Care Knowledge Organization Resources Residential Stability Physical Mental Health Substance Use Developmental Safety Family Stress Legal