|
Positive Achievement Change Tool (PACT) 1.0
Full-Assessment
Assessments.com
|
DOMAIN 1: Record of
Referrals |
|
Referrals, rather than offenses, are used to assess the persistence of
re-offending by the youth. Include only referrals that resulted in
diversion, adjudication withheld, adjudication, deferred prosecution or
referral to adult court (regardless of whether successfully completed). |
|
1.
Age
at first offense:
The age at the time of the offense for which the youth was referred to
juvenile court for the first time on a non-traffic misdemeanor or felony
that resulted in diversion, adjudication withheld, adjudication,
deferred prosecution or referral to adult court.
|
O
Over 16
O
16
O
15
O
13 to 14
O
12 and Under |
|
Felony and misdemeanor referrals:
Items 2 and 3 are mutually exclusive and should add to the total number
of referrals that resulted in diversion, adjudication withheld,
adjudication, deferred prosecution or referral to adult court. |
|
2.
Misdemeanor referrals:
Total number of referrals for which the most serious offense was a
non-traffic misdemeanor that resulted in diversion, adjudication
withheld, adjudication, deferred prosecution or referral to adult court
(regardless of whether successfully completed).
|
O
None or one
O
Two
O
Three or four
O
Five or more |
|
3.
Felony referrals:
Total number of referrals for a felony offense that resulted in
diversion, adjudication withheld, adjudication, deferred prosecution or
referral to adult court (regardless of whether successfully completed). |
O
None
O
One
O
Two
O
Three or more |
|
Against-person or weapon referrals:
Items 4, 5, and 6 are mutually exclusive and should add to the total
number of referrals that involve an against-person or weapon offense,
including sex offenses that resulted in diversion, adjudication
withheld, adjudication, deferred prosecution or referral to adult court
(regardless of whether successfully completed). |
|
4.
Weapon referrals:
Total referrals for which the most serious offense was a
firearm/weapon charge or a weapon enhancement finding. |
O
None
O
One or more |
|
5.
Against-person misdemeanor referrals:
Total number of referrals for which the most serious offense was an
against-person misdemeanor – a misdemeanor involving threats, force, or
physical harm to another person or sexual misconduct (assault, coercion,
harassment, intimidation, etc.). |
O
None
O
One
O
Two or more |
|
6.
Against-person felony referrals:
Number of referrals involving force or physical harm to another
person including sexual misconduct as defined by FDLE as violent
felonies. |
O
None
O
One or two
O
Three or more |
|
Sex offense referrals:
Items 7 and 8 are mutually exclusive and should add to the total number
of referrals that involve a sex offense or sexual misconduct that
resulted in diversion, adjudication withheld, adjudication, deferred
prosecution or referral to adult court. |
|
7.
Sexual misconduct misdemeanor referrals:
Number of referrals for which the most serious offense was a sexual
misconduct misdemeanor including obscene phone calls, indecent exposure,
obscenity, pornography, or public indecency, or misdemeanors with sexual
motivation. |
O
None
O
One
O
Two or more |
|
8.
Felony sex offense referrals:
Referrals for a felony sex offense or involving sexual motivation
including carnal knowledge, child molestation, communication with minor
for immoral purpose, incest, indecent exposure, indecent liberties,
promoting pornography, rape, sexual misconduct, or voyeurism. |
O
None
O
One
O
Two or more |
|
9.
Confinements in secure detention where youth was held for at least 48
hours:
Number of times the youth was held for at least 48 hours physically
confined in a detention facility. |
O
None
O
One
O
Two
O
Three or more |
|
10.
Commitment orders where youth served at least one day confined under
residential commitment:
Total number of commitment orders and modification orders for which the
youth served at least one day confined under residential commitment. A
day served includes credit for time served. |
O
None
O
One
O
Two or more |
|
11.
Escapes:
Total number of attempted or actual escapes that resulted in
adjudication. |
O
None
O
One
O
Two or more |
|
12.
Pick Up Orders for failure-to-appear in court or absconding supervision:
Total number of failures-to-appear in court or absconding supervision
that resulted in a pick up order being issued. Exclude failure-to-appear
warrants for non-criminal matters. |
O
None
O
One
O
Two or more |
|
DOMAIN
3A: School History |
|
1.
Youth
is a special education student or has a formal diagnosis of a special
education need:
(Check all that apply.) |
¨
No special
education need
¨
Learning
¨
Mental retardation
¨
Behavioral
¨
ADHD/ADD |
|
2.
History
of expulsions and out of school suspensions since the first grade: |
O
No expel/suspend
O
1 expel/suspend
O
2 or 3 |
O
4 or 5
O
6 or 7
O
More than 7 |
|
3.
Age at
first expulsion or suspension:
|
O
No expulsions
O
5 to 9 years
old
O
10 to 13 years
old |
O
14 to 15 years
old
O
16 to 18 years
old |
|
4.
Youth
has been enrolled in a community school during the last 6 months,
regardless of attendance:
|
O
No, graduated/GED
and not attending school, do not complete Domain 3B
O
No, dropped-out
or expelled for more than six months, do not complete Domain 3B
O
Yes, must
complete Domain 3B |
|
DOMAIN 3B: Current School
Status |
|
O
For Initial
Assessments, current is the
most recent term in last 6 months.
O
For
Re-assessments and Final Assessments,
current is the last 4 weeks in the
most recent term. |
|
1.
Youth’s
current school enrollment status, regardless of attendance:
If the youth is in home school as a result of being expelled or
dropping out, check expelled or dropped out; otherwise check enrolled,
if in home school. |
O
Graduated/GED
O
Enrolled
full-time
O
Enrolled
part-time |
O
Suspended
O
Dropped out
O
Expelled |
|
2.
Type of
school in which youth is enrolled:
Name of School
|
O
Public academic
O
Vocational
O
Alternative
O
GED program |
O
Private
academic
O
Home school
O
College
O
Other
__________ |
|
3.
Youth
believes there is value in getting an education: |
O
Believes
getting an education is of value
O
Somewhat
believes education is of value
O
Does not
believe education is of value |
|
4.
Youth
believes school provides an encouraging environment for him or her: |
O
Believes school
is encouraging
O
Somewhat
believes school is encouraging
O
Does not
believe school is encouraging |
|
5.
Teachers, staff, or coaches the youth likes or feels comfortable talking
with: |
O
Not close to
any teachers, staff, or coaches |
|
O
Close to 1
O
Close to 2 |
O
Close to 3
O
Close to 4 or
more |
|
6.
Youth’s
involvement in school activities during most recent term:
School leadership; social service clubs; music, dance, drama, art;
athletics; other extracurricular activities. |
O
Involved in 2
or more activities
O
Involved in 1
activity
O
Interested but
not involved in any activities
O
Not interested
in school activities |
|
7.
Youth’s
conduct in the most recent term:
Fighting or threatening students; threatening teachers/staff; overly
disruptive behavior; drug/alcohol use; crimes (e.g., theft, vandalism);
lying, cheating, dishonesty. |
O
Recognition for
good behavior
O
No problems
with school conduct
O
Problems
reported by teachers
O
Problem calls
to parents
O
Calls to police |
|
8.
Number
of expulsions and suspensions in the most recent term: |
O
No expel/suspend
O
1 expel/suspend |
O
2 or 3
O
More than 3 |
|
9.
Youth’s
attendance in the most recent term:
Partial-day absence means attending majority of classes and missing
minority. Full-day absence means missing majority of classes. Habitual
truancy as defined in FS includes 15 unexcused absences in a 90 day
period. |
O
Good
attendance; few excused absences
O
No unexcused
absences
O
Some
partial-day unexcused absences
O
Some full-day
unexcused absences
O
Habitual truant |
|
10.
Youth’s
academic performance in the most recent school term:
|
O
Honor student
(mostly As)
O
Above 3.0 (mostly As
and Bs)
O
2.0 to 3.0 (mostly Bs
and Cs, no Fs)
O
1.0 to 2.0 (mostly Cs
and Ds, some Fs)
O
Below 1.0 (some Ds and
mostly Fs) |
|
11.
Interviewer’s assessment of likelihood the youth will stay in and
graduate from high school or an equivalent vocational school: |
O
Very likely to
stay in school and graduate
O
Uncertain if
youth will stay and graduate
O
Not very likely
to stay and graduate |
| |
|
|
|
|
DOMAIN 4A: Historic Use
of Free Time |
|
1.
History
of structured recreational activities within the past 5 years:
Youth has participated in structured and supervised pro-social community
activities, such as religious group/church, community group, cultural
group, club, athletics, or other community activities. |
O
Involved in 2
or more structured activities
O
Involved in 1
structured activity
O
Never involved
in structured activities |
|
2.
History
of unstructured pro-social recreational activities within the past 5
years:
Youth has engaged in activities that positively occupy the youth's time,
such as reading, hobbies, etc. |
O
Involved in 2
or more pro-social unstructured activities
O
Involved in 1
pro-social unstructured activity
O
Never involved
in pro-social unstructured activities |
|
DOMAIN 4B: Current Use of
Free Time |
|
O
For Initial
Assessments, current means
behaviors during the last 6 months.
O
For
Re-assessments and Final Assessments,
current means behaviors during the last
4 weeks. |
|
1.
Current
interest and involvement in structured recreational activities:
Youth participates in structured and supervised pro-social community
activities, such as religious group/church, community group, cultural
group, club, athletics, or other community activity. |
O
Currently involved
in 2 or more structured activities
O
Currently
involved in 1 structured activity
O
Currently
interested but not involved
O
Currently not
interested in any structured activities |
|
2.
Types
of structured recreational activities in which youth currently
participates: (Check all
that apply.)
|
¨
None
¨
Community/cultural group
¨
Hobby group or
club
¨
Athletics
¨
Religious
group/church
¨
Volunteer
organization |
|
3.
Current
interest and involvement in pro-social unstructured recreational
activities:
Youth engages in activities that positively occupy his or her time, such
as reading, hobbies, etc. |
O
Currently involved
in 2 or more pro-social unstructured activities
O
Currently
involved in 1 pro-social unstructured activity
O
Currently
interested but not involved
O
Not interested
in any pro-social unstructured activities |
|
DOMAIN 5A: Employment
History |
|
1.
History of employment: |
O
Too young for
employment consideration
O
Never been
employed
O
Has been
employed |
|
2.
History of successful employment: |
O
Never
successfully employed
O
Has been
successfully employed |
|
3.
History of problems while employed: |
O
Never fired or
quit because of problems
O
Fired or quit
because of poor performance
O
Fired or quit
because he or she could not get along with employer or coworkers |
|
4.
History of positive personal relationship(s) with past employer(s) or
adult coworker(s):
|
O
Never had any
positive relationships
O
Had 1 positive
relationship
O
Had 2 or more
positive relationships |
|
DOMAIN 5B: Current
Employment |
|
O
For Initial
Assessments, current means
behaviors during the last 6 months.
O
For
Re-assessments and Final Assessments,
current means behaviors during the last
4 weeks. |
|
1.
Understanding of what is required to maintain a job:
|
O
Lacks knowledge
of what it takes to maintain a job
O
Has knowledge
of abilities to maintain a job
O
Has
demonstrated ability to maintain a job |
|
2.
Current interest in employment:
|
O
Currently
employed
O
Not employed
but highly interested in employment
O
Not employed
but somewhat interested
O
Not employed
and not interested in employment
O
Too young for
employment consideration |
|
3.
Current employment status:
|
O
Not currently
employed
O
Employment is
currently going well
O
Having problems
with current employment |
|
4.
Current positive personal relationship(s) with employer(s) or adult
coworker(s):
|
O
Not currently
employed
O
Employed but no
positive relationships
O
At least 1
positive relationship |
|
DOMAIN 6A: History of
Relationships |
|
|
1.
History
of positive adult non-family relationships not connected to school or
employment:
Adults, who are not teachers and not part of the youth’s family, who
can provide support and model pro-social behavior, such as religious
leader, club member, community person, etc. |
O
No positive
adult relationships
O
1 positive
adult relationship
O
2 positive
adult relationships
O
3 or more
positive adults relationships |
|
|
2.
History
of anti-social friends/companions:
Anti-social peers are youths hostile to or disruptive of the legal
social order; youths who violate the law and the rights of others and
other delinquent youth. (Check all that apply.) |
¨
Never had
consistent friends or companions
¨
Had pro-social
friends
¨
Had anti-social
friends
¨
Been a gang
member/associate |
|
|
DOMAIN 6B: Current
Relationships |
|
|
O
For Initial
Assessments, current means
behaviors during the last 6 months.
O
For
Re-assessments and Final Assessments,
current means behaviors during the last
4 weeks. |
|
1.
Current
positive adult non-family relationships not connected to school or
employment:
Adults, who are not teachers and not part of the youth’s family, who can
provide support and model pro-social behavior, such as religious leader,
club member, community person, etc. |
O
No positive
adult relationships
O
1 positive
adult relationship
O
2 positive
adult relationships
O
3 or more
positive adults relationships |
|
|
2.
Current
pro-social community ties:
Youth feels there are people in his or her community who discourage him
or her from getting into trouble or are willing to help the youth. |
O
No pro-social
community ties
O
Some pro-social
community ties
O
Has strong
pro-social community ties |
|
|
3.
Current
friends/companions youth actually spends time with:
(Check all that apply.) |
¨
No consistent
friends or companions
¨
Pro-social
friends
¨
Anti-social
friends
¨
Gang
member/associate |
|
|
4.
Currently in a “romantic,” intimate, or sexual relationship: |
O
Not
romantically involved with anyone
O
Romantically
involved with a pro-social person
O
Romantically
involved with an anti-social person/criminal |
|
|
5.
Currently admires/emulates anti-social peers: |
O
Does not
admire, emulate anti-social peers
O
Somewhat
admires, emulates anti-social peers
O
Admires,
emulates anti-social peers |
|
|
6.
Current
resistance to anti-social peer influence: |
O
Does not
associate with anti-social peers
O
Usually resists
going along with anti-social peers
O
Rarely resists
goes along with anti-social peers
O
Leads
anti-social peers |
|
|
DOMAIN 7A: Family History |
|
1.
History
of court-ordered or DCF voluntary out-of-home and shelter care
placements exceeding 30 days:
Exclude DJJ residential commitments. |
O
No out-of-home
placements exceeding 30 days
O
1 out-of-home
placement
O
2 out-of-home
placements
O
3 or more
out-of-home placements |
|
2.
History
of running away or getting kicked out of home:
Include times the youth did not voluntarily return within 24 hours, and
include incidents not reported by or to law enforcement. |
O
No history of
running away or being kicked out
O
1 instance of
running away/kicked out
O
2 to 3
instances of running away/kicked out
O
4 to 5
instances of running away/kicked out
O
Over 5
instances of running away/kicked out |
|
3.
History
of petitions filed:
Include all petitions regardless of whether the petition was granted.
(Check all that apply.) |
¨
No petitions
filed
¨
CINS/FINS
¨
Dependency |
|
4.
History of jail/imprisonment of persons who were ever involved in the
household for at least 3 months:
(Check all that apply.)
|
¨
No
jail/imprisonment history in family
¨
Mother/female
caretaker
¨
Father/male
caretaker
¨
Older sibling
¨
Younger sibling
¨
Other member |
|
5.
Youth
living under any “adult supervision.”
Adult supervision must be someone who is responsible for the youth’s
welfare, either legally or with parental consent. |
O
No, living with
peers without adult supervision, do not complete Domain 7B
O
No, living
alone without adult supervision, do not complete Domain 7B
O
No, transient
without adult supervision, do not complete Domain 7B
O
Yes, living
under adult supervision, must complete Domain 7B |
DOMAIN 7B: Current Living
Arrangements |
|
O
For Initial
Assessments, current means
behaviors during the last 6 months.
O
For
Re-assessments and Final Assessments,
current means behaviors during the last
4 weeks. |
|
1.
All
persons with whom youth is currently living:
(Check all that apply.)
|
¨
Living
alone
¨
Transient (street)
¨
Biological
mother
¨
Biological father
¨
Non-biological
mother
¨
Non-biological father
¨
Older
sibling(s)
¨
Younger sibling(s)
¨
Grandparent(s)
¨
Other relative(s)
¨
Long-term
parental partner(s)
¨
Short-term parental partner(s)
¨
Youth’s
romantic partner
¨
Youth’s child
¨
Foster/group
home
¨
Youth’s friends |
|
2.
Annual
combined income of youth and family: |
O
Under $15,000
O
$15,000 to
$34,999
O
$35,000 to
$49,999
O
$50,000 and
over |
|
3.
Jail/imprisonment history of persons who are currently involved with the
household:
(Check all that apply.) |
¨
No
jail/imprisonment history in family
¨
Mother/female
caretaker
¨
Father/male
caretaker
¨
Older sibling
¨
Younger sibling
¨
Other member |
|
4.
Problem
history of parents who are currently involved with the household:
(Check all that apply.) |
¨
No problem
history of parents in household
¨
Parental
alcohol problem history
¨
Parental drug
problem history
¨
Parental
physical health problem history
¨
Parental mental
health problem history
¨
Parental
employment problem history |
| |
|
|
|
5.
Problem
history of siblings who are currently involved with the household:
(Check all that apply.) |
¨
No siblings
currently in household
¨
No problem
history of siblings in household
¨
Sibling alcohol
problem history
¨
Sibling drug
problem history
¨
Sibling
physical health problem history
¨
Sibling mental
health problem history
¨
Sibling
employment problem history |
|
6.
Support
network for family:
Extended family and/or family friends who can provide additional support
to the family. |
O
No support
network
O
Some support
network
O
Strong support
network |
|
7.
Family
willingness to help support youth: |
O
Consistently
willing to support youth
O
Inconsistently
willing to support youth
O
Little or no
willingness to support youth
O
Hostile,
berating, and/or belittling of youth |
|
8.
Family
provides opportunities for youth to participate in family activities and
decisions affecting the youth: |
O
No
opportunities for involvement provided
O
Some
opportunities for involvement provided
O
Opportunities
for involvement provided |
|
9.
Youth
has run away or been kicked out of home:
Include times youth did not voluntarily return within 24 hours, and
include incidents not reported by or to law enforcement. |
O
Has not run
away/kicked out of home
O
Has run
away/kicked out of home
O
Is currently
kicked out of home or is a runaway |
|
10.
Family
member(s) youth feels close to or has good relationship with:
(Check all that apply.) |
¨
Does not feel
close to any family member
¨
Feels close to
mother/female caretaker
¨
Feels close to
father/male caretaker
¨
Feels close to
male sibling
¨
Feels close to
female sibling
¨
Feels close to
extended family |
|
11.
Level
of conflict between parents, between youth and parents, among siblings:
|
O
Some conflict
that is well managed
O
Verbal
intimidation, yelling, heated arguments
O
Threats of
physical abuse
O
Domestic
violence: physical/sexual abuse |
|
12.
Parental supervision:
Parents know whom youth is with, when youth will return, where youth is
going, and what youth is doing. |
O
Consistent good
supervision
O
Sporadic
supervision
O
Inadequate
supervision |
|
13.
Parental authority and control:
|
O
Youth usually
obeys and follows rules
O
Youth sometimes
obeys or obeys some rules
O
Youth
consistently disobeys and/or is hostile |
|
14.
Consistent appropriate punishment for bad behavior:
Appropriate means clear communication, timely response, and response
proportionate to conduct. |
O
Consistently
appropriate punishment
O
Consistently
overly severe punishment
O
Consistently
insufficient punishment
O
Inconsistent or
erratic punishment |
|
15.
Consistent appropriate rewards for good behavior:
Appropriate means clear communication, timely response, and response
proportionate to conduct; rewards mean affection, praise, etc. |
O
Consistently
appropriate rewards
O
Consistently
overly indulgent/overly protective
O
Consistently
insufficient rewards
O
Inconsistent or
erratic rewards |
|
16.
Parental characterization of youth's anti-social behavior: |
O
Disapproves of
youth's anti-social behavior
O
Minimizes,
denies, justifies, excuses behavior, or blames others/circumstances
O
Accepts youth's
anti-social behavior as okay
O
Proud of
youth's anti-social behavior |
|
DOMAIN 8A: Alcohol and
Drug History |
|
Disrupted
functioning involves having a problem in any of these five life areas:
education, family conflict, peer relationships, crime, or health, and
usually indicates treatment is warranted. Use that contributes to
criminal behavior typically precipitates the commission of a crime;
there is evidence or reason to believe the youth’s criminal activity is
related to alcohol/drug use. |
|
1.
History
of alcohol use:
(Check all that apply.)
|
¨
No past alcohol
use
¨
Past alcohol use
¨
Alcohol caused
family conflict
¨
Alcohol
disrupted education
¨
Alcohol caused
health problems
¨
Alcohol interfered
with keeping pro-social friends
¨
Alcohol
contributed to criminal behavior
¨
Youth needed
increasing amounts of alcohol to achieve same level of intoxication or
high
¨
Youth
experienced withdrawal problems |
|
2.
Youth’s
history of drug use:
(Check all that apply.)
|
¨
No past drug
use
¨
Past drug use
¨
Drugs caused
family conflict
¨
Drugs disrupted
education
¨
Drugs caused
health problems
¨
Drugs interfered
with keeping pro-social friends
¨
Drugs
contributed to criminal behavior
¨
Youth needed
increasing amounts of drugs to achieve same level of intoxication or
high
¨
Youth
experienced withdrawal problems |
|
3.
Youth’s
history of referrals for alcohol/drug assessment: |
O
Never referred
for drug/alcohol assessment
O
Diagnosed as no
problem
O
Referred but
never assessed
O
Diagnosed as
abuse
O
Diagnosed as
dependent/addicted |
|
4.
History
of attending alcohol/drug education classes for an alcohol/drug
problem:
|
O
Never attended
drug/alcohol education classes
O
Voluntarily
attended drug/alcohol education classes
O
Attended
classes by parent, school, or other agency request
O
Attended
classes at court direction |
|
5.
History
of participating in alcohol/drug treatment program: |
O
Never
participated in treatment program
O
Participated
once in treatment program
O
Participated
several times in treatment programs |
|
6.
Youth
currently using alcohol or drugs: |
O
No, do not
complete Domain 8B
O
Yes, must
complete domain 8B |
|
DOMAIN 8B: Current
Alcohol and Drugs |
|
O
For Initial
Assessments, current means
behaviors during the last 6 months.
O
For
Re-assessments and Final Assessments,
current means behaviors during the last
4 weeks.
|
|
1.
Youth’s
current alcohol use:
(Check all that apply.)
|
¨
No current
alcohol use
¨
Current alcohol use
¨
Alcohol causing
family conflict
¨
Alcohol
disrupting education
¨
Alcohol causing
health problems
¨
Alcohol
interfering with keeping pro-social friends
¨
Alcohol
contributing to criminal behavior
¨
Youth needs
increasing amounts of alcohol to achieve same level of intoxication or
high
¨
Youth
experiences withdrawal problems |
|
2.
Youth’s
current drug use:
(Check all that apply.)
|
¨
No current drug
use
¨
Current drug use
¨
Drugs causing
family conflict
¨
Drugs
disrupting education
¨
Drugs causing
health problems
¨
Drugs interfering
with keeping pro-social friends
¨
Drugs
contributing to criminal behavior
¨
Youth needs
increasing amounts of drugs to achieve same level of intoxication or
high
¨
Youth
experiences withdrawal problems |
|
3.
Type of
drugs currently used:
(Check all that apply.)
|
¨
No current drug
use
¨
Marijuana/hashish
¨
Inhalants
(glue/gasoline)
¨
Cocaine
(crack/rock)
¨
Cocaine (coke)
¨
Amphetamines
(Meth/uppers/speed/ecstacy)
¨
Barbiturates
(Tuinal/Seconal/downers)
¨
Tranquilizers/sedatives (Valium/Libnum/Dalmane/ Ketamine)
¨
Hallucinogens
(LSD/acid/mushrooms/GHB)
¨
Phencyclidine
(PCP/angel dust)
¨
Heroin
¨
Other opiates (Dilaudid/Demerol/Percodan/Codeine/
Oxycontin) |
|
4.
Current
alcohol/drug treatment program participation: |
O
Alcohol/drug
treatment not warranted
O
Not currently
attending needed alcohol/drug treatment program
O
Currently
attending alcohol/drug treatment program
O
Successfully
completed alcohol/drug treatment program |
|
DOMAIN 9A: Mental Health
History |
|
History of suicidal
ideation:
Include any previous thoughts, threats, plans and attempts even if youth
indicates they were manipulative or there was no intent. (Check all
that apply.) |
¨
Has never had
serious thoughts about suicide
¨
Has had serious
thoughts about suicide
¨
Has made a plan
to commit suicide. If yes, describe ____________________________
¨
Has attempted
to commit suicide. If yes, describe attempts and dates
_________________________________
¨
Feels life is
not worth living—no hope for future
¨
Knows someone
well who has committed suicide, If yes, who, when and how
_____________________________
¨
Engages in
self-mutilating behavior |
|
For abuse and neglect, include suspected
incidents of abuse, including those disclosed by youth, whether or not
reported or substantiated, but exclude reports of abuse/neglect
investigated but proven to be false. |
|
History of
violence/physical abuse:
Include suspected incidents of abuse, whether or not substantiated, but
exclude reports proven to be false. (Check all that apply.) |
¨
Not a victim of
violence/physical abuse
¨
Victim of
violence/physical abuse at home
¨
Victim of
violence/physical abuse in a foster/group home
¨
Victimized or
physically abused by family member
¨
Victimized or
physically abused by someone outside the family
¨
Attacked with a
weapon |
|
History of witnessing
violence:
(Check all that apply.)
Include perpetrators and victims of violence as having witnessed
violence. |
¨
Has not
witnessed violence
¨
Has witnessed
violence at home
¨
Has witnessed
violence in a foster/group home
¨
Has witnessed
violence in the community
¨
Family member
killed as a result of violence |
|
History of sexual
abuse/rape:
Include suspected incidents of abuse if disclosed by youth, whether or
not reported or substantiated, but exclude reports investigated but
proven to be false. (Check all that apply.) |
¨
Not a victim of
sexual abuse/rape
¨
Sexually
abused/raped by family member
¨
Sexually
abused/raped by someone outside the family |
|
History of being a
victim of neglect: |
O
Not a victim of
neglect
O
Victim of
neglect |
|
History of ADD/ADHD:
Confirmed by a professional in the social service/healthcare field. |
O
No history of
ADD/ADHD
O
Diagnosed with
ADD/ADHD
O
Only ADD/ADHD
medication prescribed
O
Only ADD/ADHD
treatment prescribed
O
ADD/ADHD
medication and treatment prescribed |
|
History of mental
health problems:
Such as schizophrenia, bi-polar, mood, thought, personality, and
adjustment disorders. Exclude conduct disorder, oppositional defiant
disorder, substance abuse, and ADD/ADHD.
Confirmed by a professional in the social service/healthcare field. |
O
No history of
mental health problem(s)
O
Past history of
mental health problem(s) diagnosis (more than six months ago)
O
Diagnosed with
mental health problem(s)
O
Only mental
health medication prescribed. If yes, list ___________________
O
Only mental
health treatment prescribed
O
Mental health
medication and treatment prescribed |
|
History of anger or
irritability |
O
No history of
anger/irritability
O
History of
occasional feelings of anger/irritability
O
History of
consistent feelings of anger/irritability
O
History of
aggressive reactions to feelings of anger/irritability |
|
History of depression
or anxiety |
O
No history of
depression/anxiety
O
History of
occasional feelings of depression/anxiety
O
History of
consistent feelings of depression/anxiety
O
History of
impairment in everyday tasks due to depression/anxiety |
|
History of somatic
complaints:
Bodily or physical discomforts associated with distress, such as
stomachaches or headaches. |
O
No history of
somatic complaints
O
History of one
or two somatic complaints
O
History of
three or four somatic complaints
O
History of 5 or
more somatic complaints |
|
History of thought
disturbance |
O
No unusual
thoughts or beliefs
O
Presence of
hallucinations (auditory or visual)
O
Presence of
beliefs that the youth is controlled by others |
|
History of traumatic
experience:
Lifetime exposure to events such as rape, abuse or observed violence,
including dreams or flashbacks. |
O
No presence of
traumatic event
O
History of
traumatic event
O
History of
flashbacks to traumatic event |
|
Currently has health
insurance: |
O
No health
insurance
O
Public
insurance (Medicaid, KIDCARE)
O
Private
insurance |
|
Current mental health
problem status:
|
O
No current
mental health problem(s), do not complete Domain 9B
O
Current mental
health problem(s), must complete Domain 9B |
|
DOMAIN 9B: Current Mental
Health |
|
O
For Initial
Assessments, current means
behaviors during the last 6 months.
O
For
Re-assessments and Final Assessments,
current means behaviors during the last
4 weeks. |
|
1.
Current
suicidal ideation: |
O
Does not have
serious thoughts about suicide
O
Has serious
thoughts about suicide
O
Has recently
made a plan to commit suicide. If yes, describe _______________________
O
Has recently
attempted to commit suicide. If yes, describe attempts and dates
______________________
O
Feels life is
not worth living—no hope for future
O
Knows someone
well who has committed suicide. If yes, who, when and how
_______________________
O
Engages in
self-mutilating behavior |
|
2.
Currently diagnosed with ADD/ADHD:
Confirmed by a professional in the social service/healthcare field.
Type of medication:
_________________________ |
O
No ADD/ADHD diagnosis
O
No ADD/ADHD
medication currently prescribed
O
Currently
taking ADD/ADHD medication
O
ADD/ADHD
medication currently prescribed, but not taking |
|
3.
Mental
health treatment currently prescribed excluding ADD/ADHD treatment: |
O
No current
mental health problem
O
No mental
health treatment currently prescribed
O
Attending
mental health treatment
O
Treatment
currently prescribed, but not attending |
|
4.
Mental
health medication currently prescribed excluding ADD/ADHD medication:
Type of medication: _________________________ |
O
No current
mental health problem
O
No mental
health medication currently prescribed
O
Currently
taking mental health medication
O
Mental health
medication currently prescribed, but not taking |
|
5.
Mental
health problems currently interfere in working with the youth: |
O
No current
mental health problem
O
Mental health
problem(s) do not interfere in work with youth
O
Mental health
problem(s) interfere in work with youth |
DOMAIN 10: Attitudes/Behaviors |
|
O
For Initial Assessments, current
means behaviors during the last 6 months.
O
For Re-assessments and Final Assessments,
current means behaviors during the last 4 weeks. |
|
1.
Primary emotion when committing crime(s): |
O
Nervous, afraid, worried, ambivalent,
uncertain, or indecisive
O
Hyper, excited, or stimulated
O
Unconcerned or indifferent
O
Confident or brags about not getting caught |
|
2.
Primary purpose for committing crime(s) within the last 6 months:
|
O
Anger / Revenge
O
Impulse
O
Sexual desire
O
Money or material gain, including drugs
O
Excitement, amusement, or fun
O
Peer status, acceptance, or attention |
|
3.
Optimism:
Youth talks about future in positive way with plans or aspirations of a
better life that could include employment, education, raising a family,
travel, or other pro-social life goals. |
O
High aspirations: sense of purpose, commitment
to better life
O
Normal aspirations: some sense of purpose
O
Low aspirations: little sense of purpose or
plans for better life
O
Believes nothing matters; he or she will be
dead before long |
|
4.
Impulsive; acts before thinking: |
O
Uses self-control; usually thinks before
acting
O
Some self-control; sometimes thinks before
acting
O
Impulsive; often acts before thinking
O
Highly Impulsive; usually acts before thinking |
|
5.
Belief
in control over anti-social behavior: |
O
Believes he or she can avoid/stop anti-social
behavior
O
Somewhat believes anti-social behavior is
controllable
O
Believes his or her anti-social behavior is
out of his or her control |
|
6.
Empathy, remorse, sympathy, or feelings for the victim(s) of criminal
behavior: |
O
Has empathy for his or her victim(s)
O
Has some empathy for his or her victim(s)
O
Does not have empathy for his or her victim(s) |
|
7.
Respect for property of others: |
O
Respects property of others
O
Respects personal property but not publicly
accessible property: “It’s not hurting anybody.”
O
Conditional respect for personal property: “If
they are stupid enough to leave it out, they deserve losing it.”
O
No respect for property: “If I want something,
it should be mine.” |
|
8.
Respect for authority figures: |
O
Respects most authority figures
O
Does not respect authority figures, and may
resent some
O
Resents most authority figures
O
Defies or is hostile toward most authority
figures |
|
9.
Attitude toward responsible law abiding behavior: |
O
Believes pro-social rules/conventions apply to
him or her
O
Believes some pro-social rules/conventions
sometimes apply to him or her
O
Does not believe pro-social rules/conventions
apply to him or her
O
Resents or is defiant toward pro-social
rules/conventions |
|
10.
Accepts responsibility for anti-social behavior: |
O
Accepts responsibility for anti-social
behavior
O
Minimizes, denies, justifies, excuses, or
blames others
O
Accepts anti-social behavior as okay
O
Proud of anti-social behavior |
|
11.
Youth’s belief in successfully meeting conditions of court supervision: |
O
Believes he or she will be successful
O
Unsure if he or she will be successful
O
Does not believe he or she will be successful |
|
DOMAIN 11: Aggression |
|
Items 1. through
4.:
O
For Initial
Assessments, rate items based on behavior during the last 6 months.
O
For
Re-assessments and Final Assessments,
rate items based on behavior
during the last 4 weeks. |
|
1.
Tolerance for frustration: |
O
Rarely gets
upset over small things or has temper tantrums
O
Sometimes gets
upset over small things or has temper tantrums
O
Often gets
upset over small things or has temper tantrums |
|
2.
Hostile
interpretation of actions and intentions of others in a common
non-confrontational setting: |
O
Primarily
positive view of intentions of others
O
Primarily
negative view of intentions of others
O
Primarily
hostile view of intentions of others |
|
3.
Belief
in yelling and verbal aggression to resolve a disagreement or conflict: |
O
Believes verbal
aggression is rarely appropriate
O
Believes verbal
aggression is sometimes appropriate
O
Believes verbal
aggression is often appropriate |
|
4.
Belief
in fighting and physical aggression to resolve a disagreement or
conflict: |
O
Believes
physical aggression is never appropriate
O
Believes
physical aggression is rarely appropriate
O
Believes
physical aggression is sometimes appropriate
O
Believes
physical aggression is often appropriate |
|
Items 5. and 6.:
O
For Initial
Assessments, include the entire history of report.
O
For
Re-assessments and Final Assessments,
include reports within the last 4 weeks. |
|
5.
Reports/evidence of violence not included in criminal history:
(Check all that apply.)
|
¨
No
reports/evidence of violence
¨
Violent
outbursts, displays of temper, uncontrolled anger indicating potential
for harm
¨
Deliberately
inflicting physical pain
¨
Using/threatening with a weapon
¨
Fire starting
¨
Violent
destruction of property
¨
Animal cruelty |
|
6.
Reports
of problem with sexual aggression not included in criminal
history:
(Check all that apply.)
|
¨
No
reports/evidence of sexual aggression
¨
Aggressive sex
¨
Sex for power
¨
Young sex
partners
¨
Child sex
¨
Voyeurism
¨
Exposure |
|
DOMAIN 12: Skills |
|
O
For Initial
Assessments, current means
behaviors during the last 6 months.
O
For
Re-assessments and Final Assessments,
current means behaviors
during the last 4 weeks.
O
Use a
general pattern of current behaviors and not a single incident. |
|
1.
Consequential thinking: |
O
Does not
understand there are consequences to actions
O
Understands
there are consequences to actions
O
Identifies
consequences of actions
O
Acts to obtain
desired consequences—good consequential thinking |
|
2.
Goal
setting: |
O
Does not set
goals
O
Sets
unrealistic goals
O
Sets somewhat
realistic goals
O
Sets realistic
goals |
|
3.
Problem-solving: |
O
Cannot identify
problem behaviors
O
Identifies
problem behaviors
O
Thinks of
solutions for problem behaviors
O
Applies
appropriate solutions to problem behaviors |
|
4.
Situational perception:
Ability to analyze the situation, choose the best pro-social skill, and
select the best time and place to use the pro-social skill. |
O
Cannot analyze
the situation for use of a pro-social skill
O
Can analyze but
not choose the best pro-social skill
O
Can choose the
best skill but cannot select the best time and place
O
Can select the
best time and place to use the best pro-social skill |
|
5.
Dealing
with others:
Basic
social skills include listening, starting a conversation, having a
conversation, asking a question, saying thank you, introducing yourself,
introducing other people, and giving a compliment.
Advanced social skills include asking for help, joining in, giving
instructions, following instructions, apologizing, and convincing
others. |
O
Lacks basic
social skills in dealing with others
O
Has basic
social skills, lacks advanced skills in dealing with others
O
Sometimes uses
advanced social skills in dealing with others
O
Often uses
advanced social skills in dealing with others |
|
6.
Dealing
with difficult situations:
Incl. making a complaint, answering a complaint, dealing with
embarrassment, dealing with being left out, standing up for a friend,
responding to frustration, responding to failure, dealing with
contradictory messages, dealing with accusation, getting ready for a
difficult conversation, and dealing with group pressure. |
O
Lacks skills in
dealing with difficult situations
O
Rarely uses
skills in dealing with difficult situations
O
Sometimes uses
skills in dealing with difficult situations
O
Often uses
skills in dealing with difficult situations |
|
7.
Dealing
with feelings/emotions:
Includes knowing his or her feelings, expressing feelings, understanding
the feelings of others, dealing with someone else’s anger, expressing
affection, dealing with fear, and rewarding oneself. |
O
Lacks skills in
dealing with feelings/emotions
O
Rarely uses
skills in dealing with feelings/emotions
O
Sometimes uses
skills in dealing with feelings/emotions
O
Often uses
skills in dealing with feelings/emotions |
|
8.
Monitoring of internal triggers, distorted thoughts, that can
lead to trouble: |
O
Cannot identify
internal triggers
O
Identifies
internal triggers
O
Actively
monitors/controls internal triggers |
|
9.
Monitoring of external triggers, events or situations, that can
lead to trouble: |
O
Cannot identify
external triggers
O
Identifies
external triggers
O
Actively
monitors/controls external triggers |
|
10.
Control
of impulsive behaviors that get youth into trouble:
Reframing, replacing anti-social thoughts with pro-social thoughts,
diversion, relaxation, problem solving, negotiation, relapse prevention. |
O
Never had a
problem with impulsive behavior
O
Does not know
techniques to control impulsive behavior
O
Knows
techniques to control impulsive behavior
O
Uses techniques
to control impulsive behavior |
|
11.
Control
of aggression:
Includes asking permission, sharing thoughts, helping others,
negotiating, using self control, standing up for one’s rights,
responding to teasing, avoiding trouble with others, and keeping out of
fights. |
O
Never had a
problem with aggression
O
Lacks
alternatives to aggression
O
Rarely uses
alternatives to aggression
O
Sometimes uses
alternatives to aggression
O
Often uses
alternatives to aggression |
|