me. If the child’s needs / functioning fall within a shaded box, explain why: I-12. Behavioral Regression Child’s behaviors are consistent and age appropriate or this information is unknown to me. Child has some regression in age-level behavior (e.g. thumb sucking, whining when age inappropriate). Child has moderate regression in age-level behavior including loss of ability to engage with peers, stopping play or exploration, or occasional bedwetting. Child has significant regression in behaviors as demonstrated by significant periods of changes in speech or loss of bowel or bladder control. If the child’s needs / functioning fall within a shaded box, explain why: A. EMOTIONAL CHARACTERISTICS (Ages 5 to 21) (Continued) I-13. Affect Dysregulation / Emotions Are Not Appropriate to the Situation (PAST 30 DAYS) No evidence of inappropriate emotional response, any concerns are age appropriate or this information is unknown to me. Child has mild to moderate problems demonstrating emotional responses that are appropriate to a given situation. Child has severe problems with appropriate emotional response but is able to control affect at times. Interferes with functioning in some areas of life. Child’s emotional response to situations are mostly inappropriate and interfere in several areas of life. If the child’s needs / functioning fall within a shaded box, explain why: I-14. Suicide Risk – Do Not Include Cutting Behaviors in This Category (PAST 30 DAYS) No evidence of suicidal thoughts or actions or this information is unknown to me. (Cutting behavior is not a suicidal action). History but no recent ideation or gesture. Recent ideation or gesture but not in the past 24 hours. Current ideation or intent OR command hallucinations that involve self-harm. If the child’s needs / functioning fall within a shaded box, explain why: I-15. Self-Injurious Behavior (PAST 30 DAYS) No evidence of self-injurious behavior or this information is History of self-mutilation. Engaging in self-mutilation that does not require medical Engaging in self mutilation that requires medical
unknown to me. attention. attention. If the child’s needs / functioning fall within a shaded box, explain why: A. EMOTIONAL CHARACTERISTICS (Ages 5 to 21) (Continued) I-16. Other Self Harm (PAST 30 DAYS) No evidence of behavior that places child at risk of physical harm. Any concerns are age appropriate or this information is unknown to me. History of engaging in reckless or risk-taking behaviors that put the child at risk of physical harm. Engages in reckless or behaviors that put the child at risk of serious physical harm. Engaged in reckless or risk-taking behavior that places child at immediate risk of death. If the child’s needs / functioning fall within a shaded box, explain why: I-17. Exploited This item is used to examine a history and pattern of abuse, and / or includes a level of current risk for re-victimization (parentification of children, being bullied, prostituted, or taken advantage of by others). There is no evidence of a history of exploitation or history of victimization over the past year or this information is unknown to me. Suspicion or history of exploitation, but person has not been exploited to any significant degree during the past year. Person is not presently at risk for This level indicates a person who has been recently exploited (within the past year) but is not at acute risk of re-exploitation. (Physical or sexual abuse, significant psychological abuse, extortion violent crime, etc.). This level indicates a person who has been recently exploited and has an acute risk of (Working as a prostitute, in an abusive relationship, etc.). If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) II-1. Child’s Functioning in His / Her Current Living Situation (PAST 30 DAYS) No evidence of problems functioning in current living situation. Concerns are age appropriate or this information is unknown to me. Mild problems functioning in current home. Caregiver has concerns about child’s behavior at home. Moderate to severe problems functioning at home. Child’s behavior is creating significant difficulties for others in the home. Profound problems with functioning at home. Child is in immediate risk of being removed due to his / her behavior. If the child’s needs / functioning fall within a shaded box, explain why: taking
B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) (Continued) II-2. Child’s Social Functioning – Peer (PAST 30 DAYS) Child has positive social relationships with peers. Any concerns are age appropriate or this information is unknown to me. Child is having some minor problems in social relationships with peers. Child is having some moderate problems with his / her social relationships with same age peers. Child is experiencing severe disruptions in his / her social relationships with same age peers. If the child’s needs / functioning fall within a shaded box, explain why: II-3. Child’s Social Functioning – Adult (PAST 30 DAYS) Child has positive social relationships with adults. Any concerns are age appropriate or this information is unknown to me. Child is having some minor problems in social relationships with adults. Child is having some moderate problems with his / her social relationships with adults. Child is experiencing severe disruptions in his / her social relationships with adults. If the child’s needs / functioning fall within a shaded box, explain why: II-4. Child’s Involvement with the Legal / Juvenile Justice System – Seriousness (PAST 30 DAYS) Youth has engaged in status offenses (curfew, tobacco possession, etc.) or this information is unknown to me. Youth has engaged in delinquent behavior equivalent to a misdemeanor. Youth has engaged in delinquent behavior equivalent to a felony. Youth has engaged in delinquent behavior that places other citizens at risk of significant physical harm. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) (Continued) II-5. Child’s Involvement with the Legal / Juvenile Justice System – History (PAST 30 DAYS) Current criminal / delinquent behavior is the first known occurrence or this information is unknown to me / not applicable. Youth has engaged in multiple criminal / delinquent acts in the past year. Youth has engaged in multiple criminal / delinquent acts for more than 1 year but has had 3+ month periods without. Youth has engaged in multiple criminal / delinquent acts for more than 1 year without any period without involvement.
II-10. Child’s Involvement with the Legal / Juvenile Justice System – Peer Influences (PAST 30 DAYS) Youth’s primary peer social group does not engage in delinquent / criminal behavior or this information is unknown to me. Youth has peers in his / her peer group who do not engage in criminal / delinquent behavior, but some peers who do. Youth predominantly has peers who engage in delinquent behavior but youth is not a member of a gang. Youth is a member of a gang whose membership encourages or requires illegal behavior as an aspect of gang membership. If the child’s needs / functioning fall within a shaded box, explain why: II-11. Sexual Development (PAST 30 DAYS) No evidence of any problems with sexual development. Any concerns are age appropriate or this information is unknown to me. Mild to moderate problems with sexual development that may include concerns about sexual identity or anxiety about the reactions of others. Significant problems with sexual development that may include multiple and / or older partners or high-risk sexual behaviors. Profound problems with sexual development that may include prostitution, very frequent risky sexual behavior, or sexual aggression. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) (Continued) II-12. School – Attendance (PAST 30 DAYS) Child attends school regularly or this information is unknown to me. Child has some problems attending school, including a history of truancy, suspensions or expulsions but generally goes to school. Child is having problems with school attendance, including frequent truancy, suspensions or expulsions and is missing at least 2 days / week on average. Child is generally truant or refusing to go to school more than 3 days out of every week. If the child’s needs / functioning fall within a shaded box, explain why: II-13. School – Behavior (PAST 30 DAYS) Child is behaving well in school. Any concerns are age appropriate or this information is unknown to When child is in school, he / she behaves well although some behavior problems exist. When child is in school, he / she has moderate behavioral problems and is disruptive. Child may have received When child is in school, he / she is having severe problems with behavior and is frequently or
me. discipline including suspensions. severely disruptive. Child is in danger of expulsion. If the child’s needs / functioning fall within a shaded box, explain why: II-14. School – Achievement (PAST 30 DAYS) Child is doing well in school, any concerns are age appropriate or this information is unknown to me. Child is doing well in school achievement, although some problems exist, such as failing to turn in work, disorganization or refusal to do some assignments. Child is having moderate problems with school achievement. He / she may be failing some subjects. Child is having severe achievement problems and may be failing most subjects or has failed more than 1 year within the past two years. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) (Continued) II-15. School – Relationship with Teachers Child has good relations with teachers. Any concerns are age appropriate or this information is unknown to me. Child has occasional difficulties relating with at least 1 teacher or during at least one subject period. Child has difficult relations with teachers that notably interferes with his / her education. Child has very difficult relations with all teachers or with their only teacher which prevents the child from learning. If the child’s needs / functioning fall within a shaded box, explain why: II-16. Impulsivity / Hyperactivity (PAST 30 DAYS) No evidence of impulsivity / hyperactivity, any concerns are age appropriate or this information is unknown to me. Some problems with impulsive, distractible or hyperactive behavior. Clear evidence of problems with impulsive, distractible or hyperactive behavior that is interfering with the child’s ability to function. Clear evidence of a dangerous level of impulsive behavior that can place the child at risk of physical harm. If the child’s needs / functioning fall within a shaded box, explain why: II-17. Oppositional Behaviors (PAST 30 DAYS) No evidence of oppositional behaviors. Child displays age appropriate resistance History or recent onset of defiance towards authority figures. Clear evidence of oppositional and / or defiant behaviors which are Clear evidence of a dangerous level of oppositional behavior
towards adults or this information is unknown to me. interfering with the child’s functioning and/or causing emotional harm to others. involving the threat of physical harm to others. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) (Continued) II-18. Conduct (PAST 30 DAYS) No evidence of intentional misconduct. Any concerns are age appropriate or this information is unknown to me. History / suspicion of problems associated with behavior including lying, stealing, manipulating others, sexual aggression, violence towards property people or animals. Clear evidence of behavior which includes lying, stealing, manipulating others, sexual aggression, violence towards property people or animals. Evidence of a severe level of behavior that places the child or community at significant risk of physical harm due to these behaviors. If the child’s needs / functioning fall within a shaded box, explain why: 11-19. Anger Control (PAST 30 DAYS) No evidence of any significant anger control problems. Any concerns are age appropriate or this information is unknown to me. Some problems with controlling anger. Child may become verbally aggressive when frustrated. Moderate anger control problems. Child’s temper can become violent and has gotten him / her in significant trouble with peers, family and / or school. Severe anger control problems. Child’s temper is likely associated with frequent fighting that is often physical. Others likely fear him / her. If the child’s needs / functioning fall within a shaded box, explain why: 11-20. Substance Use (PAST 30 DAYS) No evidence of substance use or this information is unknown to me. History or suspicion of substance use. Clear evidence of substance abuse that interferes with functioning in any area of life. Child requires detoxification OR is addicted to alcohol / drugs. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) (Continued)
11-21. Danger to Others (PAST 30 DAYS) No evidence that the child presents a danger to others. Any concerns are age appropriate or this information is unknown to me. History of homicidal ideation, physically harmful aggression or fire setting that has put self or others in danger of harm. Recent homicidal ideation, physically harmful aggression or dangerous fire setting but not in the past 24 hours. Homicidal ideation with a plan or physically harmful aggression within the past 24 hours. If the child’s needs / functioning fall within a shaded box, explain why: II-22. Sexual Aggression (PAST 30 DAYS) No evidence of any history of sexually aggressive behavior. Any sexual contact has been age appropriate and consenting. No sexual contact with younger children, or this information is unknown to me. History of sexually aggressive behavior (but not in the past year) OR sexually inappropriate behavior in the past year (e.g. harassing talk or excessive masturbation). Child is engaged in sexually aggressive behavior in the past year but not in the past 30 days (use of force, coercion, unconsenting contact). Child has engaged in sexually aggressive behavior in the past 30 days (use of force, coercion, unconsenting contact). If the child’s needs / functioning fall within a shaded box, explain why: II-23. Delinquent Behavior No evidence of any delinquent behavior or this information is unknown to me. History of criminal / delinquent behavior but no acts in the past 30 days. Recent acts of criminal / delinquent behavior but no acts in the past 30 days. Severe acts of criminal / delinquent behaviors that placed others at risk of significant loss or injury or place the child at risk of adult sanctions. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) (Continued) II-24. Runaway (PAST 30 DAYS) No evidence that the child runs away. Any concerns are age appropriate or this information is unknown to me. History of runaway from home or other settings involving at least 1 overnight absence, at least 30 days ago. Recent runaway behavior or ideation but not in the past 7 days. Serious threat to runaway as shown by either recent attempts OR child is currently a runaway. If the child’s needs / functioning fall within a shaded box, explain why:
II-25. Running Away – Frequency Youth has only run once in the past year or this information is unknown to me / not applicable. Youth has run on multiple occasions in the past year. Youth runs often (two or more times per month) but not always. Youth runs at every opportunity. If the child’s needs / functioning fall within a shaded box, explain why: II-26. Running Away – Consistency of Destination Youth always runs to the same location or this information is unknown to me / not applicable. Youth generally runs to the same location or neighborhood. Youth runs to the same community but the specific locations change. Youth runs to no planned destination. If the child’s needs / functioning fall within a shaded box, explain why: II-27. Running Away – Safety of Destination Youth runs to a safe environment that meets his / her basic needs (e.g. food, shelter) or this information is unknown to me / not applicable. Youth runs to generally safe environments; however, they might be somewhat unstable or variable. Youth runs to generally unsafe environments that cannot meet his / her basic needs. Youth runs to very unsafe environments where the likelihood that he / she will be victimized is high. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) (Continued) II-28. Running Away – Involvement in Illegal Activities Youth does not engage in illegal activities while on the run or this information is unknown to me / not applicable. Youth engages in status offenses beyond those involved with the running itself (e.g. curfew violations, underage drinking). Youth engages in delinquent activities while on the run. Youth engages in dangerous delinquent activities while on the run (e.g. prostitution, selling / buying drugs). If the child’s needs / functioning fall within a shaded box, explain why:
II-29. Running Away – Likelihood of Return on Own Youth will return from run on his / her own without prompting or this information is unknown to me / not applicable. Youth will return from run when found, but not without being found. Youth will make him / herself difficult to find and / or might passively resist return once found. Youth makes repeated and concerted efforts to hide so as to not be found and / or resists return. If the child’s needs / functioning fall within a shaded box, explain why: 11-30. Running Away – Involvement With Others Youth runs by self with no involvement of others or this information is unknown to me / not applicable. Others enable youth to run by not discouraging youth’s behavior. Others are involved in youth’s running by actively helping or encouraging youth. Youth actively is encouraged to run by others. Others actively help running behavior. If the child’s needs / functioning fall within a shaded box, explain why: II-31. Running Away – Realistic Expectations Youth has realistic expectations about the consequences of his / her running behavior or this information is unknown to me / not applicable. Youth has reasonable expectations about the consequences of his / her running, but may be hoping for a somewhat ‘optimistic’ outcome. Youth has unrealistic expectations about the consequences of his / her running behavior. Youth has obviously false or delusional expectations about the consequences of his / her running behavior. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) (Continued) II-32. Intentional Misbehavior (PAST 30 DAYS) No evidence of problematic social behavior. Any concerns are age appropriate or this information is unknown to me. Mild level of problematic social behavior (e.g. behavior that results in consequences by adults, inappropriate comments, unusual behavior in social settings). Moderate level of problematic social behavior which is intentional and causing problems in the child’s life. Child is getting into trouble in school, at home and in the community. Severe level of problematic social behavior that might result in significant consequences such as expulsion, removal from the home or community. If the child’s needs / functioning fall within a shaded box, explain why:
information is unknown to me / does not apply. medical condition, but these are not affecting other areas of life. interfering with treatment and other areas of life. her condition that is interfering with treatment and functioning. If the child’s needs / functioning fall within a shaded box, explain why: III-11. Medical Needs – Impairment in Functioning (PAST 30 DAYS) Child’s medical condition is not interfering with his / her functioning in other areas of life or this information is unknown to me / does not apply. Child’s medical condition is having a limited impact on functioning in one area of life (self care, social interaction, communication, etc). Child’s medical condition is interfering with functioning in more than one area of life or is disabling in at least one domain. Child’s medical condition has disabled him / her in all other areas of life. If the child’s needs / functioning fall within a shaded box, explain why: C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages 5 to 21) (Continued) III-12. Medical Needs – Treatment Involvement (PAST 30 DAYS) Child is actively involved in treatment or this is not applicable or this information is unknown to me. Child is generally involved in treatment but may struggle to stay consistent. Child is generally uninvolved although they are sometimes compliant with recommendations. Child is currently resistant to all efforts to provide medical treatment. If the child’s needs / functioning fall within a shaded box, explain why: III-13. Medical Needs – Intensity of Treatment (PAST 30 DAYS) Child’s medical treatment involves taking daily medications or visiting a medical professional no more than weekly, or this information is unknown to me / does not apply. Child’s medical treatment involves multiple medications or visiting a medical professional multiple times per week. Child’s treatment is daily but non-invasive. Treatment can be administered by a caregiver. Child’s medical treatment is daily and invasive and requires either a medical professional or trained caregiver to administer. If the child’s needs / functioning fall within a shaded box, explain why: III-14. Medical Needs – Organizational Complexity (PAST 30 DAYS) All medical care is provided by a single medical professional or this Child’s medical care is generally provided by a coordinated team of medical Child’s medical care requires collaboration of multiple professionals who work for Child’s medical care requires the collaboration of multiple professionals
III-18. Life Skills (PAST 30 DAYS) Child has age appropriate independent living skills. No indication of problems or this information is unknown to me. Child has minor indications of problems in independent living skills compared to same age children (cleanliness, diet, organization). Child has notable problems with completing tasks necessary for independent living compared to same age children (self management, cleaning). Child has profound problems of independent living skills compared to same age children. If not addressed, child will be unable to live independently in the future. If the child’s needs / functioning fall within a shaded box, explain why: D. ADDITIONAL DETAILS OF CHILD’S LEVEL OF NEED (OPTIONAL) Attach school, medical, psychological or other evaluations that document the child’s current special care needs and / or attach signed ‘Confirmation of Needs’ forms. SECTION III. AUTHORIZATION