Risk Factors Hearing or vision impaired History of seizures Medical diagnosis requiring life sustaining measure Medical diagnosis requiring ongoing care Medical issues (asthma, broken arm, severe allergy) Mental health diagnosis ongoing medications Physical disability Requires psychotropic meds to function No Risk Factors Protective Factors No physical/mental health issues Received care for identified mental health issues Receives care for identified medical issues Up to date on immunizations Child Development/Education (check all that apply) Risk Factors Developmentally delayed Difficulty communicating needs Educationally delayed/IEP not utilized Is not potty trained or unable to use toilet Lack of muscle control, motor skills Limited verbal ability or non-verbal Non-mobile or limited mobility Not attached to adult caregiver Poor social skills/peer relations Requires assistance for dressing/bathing No risk factors Protective Factors Able to dress/bath self Child receiving services for delay Developmentally on track Educationally on track Good social skills/peer relations Secure attachment to adult caregiver Child Behaviors (check all that apply)
Risk Factors Alcohol use/abuse AWOL history/risk Bullying Can’t focus/hyperactive Destruction of property Doesn’t follow rules/oppositional Drug use/abuse Encopresis/enuresis not due to age Escalating negative behaviors Expulsion/suspensions from school Fire setting Gang involvement Has harmed self or others Past victim of abuse/neglect Previous juvenile court involvement Rages/tantrums Requires extensive supervision Sexually reactive/Sexually acting out Sexually active Threatens to harm self or others Torturing/killing small animals Truancy/ skipping school No Risk Factors Protective Factors Behavioral issues within normal range for child’s age Child is responding to services provided Receives services for identified behavioral indicators Describe child and any factors that need further explanation:
Neglect (Check all that apply) Hygiene/clothing Clothing does not protect from elements Illness or exposure due to clothes Regularly wears soiled clothes Repeated infestations of lice/bedbugs No issues Food Dehydration Dietary needs not met Feeding children non-human food items Food poisoning Malnourished Symptoms of failure to thrive No issues Educational (Check all that apply) Numerous unexcused absences No issues Exploitation Engages child in criminal activities Uses child’s financial resources for personal gain Victim of Human Trafficking No issues Medical (Check all that apply) Failure to seek medical attention Life threatening unmet health needs Unmet health needs may have long term effects No issues Risk of Harm (Check all that apply) Risk of Physical Abuse Child has fear of caretaker Caretaker has caused death/serious injury to a child Child exposed to bizarre forms of punishment No issues Risk of Sexual Abuse Caretaker has previous sex abuse finding or conviction Child exhibiting physical/ behavioral indicators of sexual abuse Child unsupervised with person listed on the sex offender registry No issues
Adult Health and Functioning Risk Factors Alcohol abuse Attention seeking Dishonest and/or manipulative Disregard for others’ safety or wellbeing Drug abuse Hostile to authority figures or service providers Impulsive or unpredictable Intellectual or cognitive disability Irrational or disconnected from reality Lacks insight into their own behavior Mental health issue that affects functioning Paranoid Physical disability or debilitating illness Selfish, self-centered decision-making Unable to apply logic to solve problems Unable to assess (due to inability to interview) Victim of domestic violence No Risk Factors Protective Factors Accepts assistance that enhances functioning Candid and/or cooperative Copes or functions despite a disability Demonstrates logic/reasoning ability No mental health issues No physical health issues Primary relationships are stable Realistic awareness of self and reality Respects the rights and feeling or others Seeks and give affection to loved ones Ability to Manage Daily Life and Stress (High Risk Behaviors) Risk Factors Abuses substances (drugs/alcohol to escape or deal with stress Blames others for problems Displays of frustration/anger cause injury or likelihood of harm Displays of frustration/anger out of proportion to situation Escalating frustration/anger Lack of realistic long term goals Overwhelmed/discouraged by responsibilities Parasitic lifestyle: relies on others to provide food, housing, etc. Poor self-control Rapidly changing affect or emotional displays Serial relationships Unable or unwilling to plan ahead Unable to assess (due to inability to interview) Unstable/chaotic relationships No Risk Factors Protective Factors College or career training Healthy support network High school education or GED Realistic coping strategies Realistic understanding of barriers Realistic view of daily needs/obligations Self-sufficient, able to meet own needs
CPS/APS/Criminal History Risk Factors Adult is registered sex offender Parental rights on a child involuntarily terminated Prior convictions involving drugs/alcohol Criminal “versatility”: variety of types of convictions Prior felony convictions involving weapon/violence Prior reports of domestic violence Prior revocation of parole/probation Prior substantiated reports Prior substantiation death/near death of another child Action or lack of action contributed to death/serious harm of a child Multiple prior reports not accepted for investigation Prior unsubstantiated reports No Risk Factors Protective Factors Acknowledges responsibility for prior charges Acknowledges responsibility for child welfare allegations No criminal charges No felony convictions No prior CPS/APS history Non-violent/traffic offenses Other rehabilitative services Received treatment/rehabilitative services related to prior sexual abuse Notes Family Functioning