Self Management Response to Consequences Decision-Making Skills Commitment to Self Control Ability to Pay Attention Treatment Involvement Bullying 0 1 2 3 SEXUALLY AGGRESSIVE BEHAVIOR Bullied by Others Relationship Student Life Domain Needs Physical Force/Threat Parenting Responsibilities Planning Gang Involvement Age Differential Student Strengths Type of Sex Act Clubs/ Athletics Response to Accusation Leadership Temporal Consistency Peer Relationships History of Sexually Abusive Behavior Relationship with Teachers Severity of Sexual Abuse 0 1 2 3 Prior Treatment DEVELOPMENTAL NEEDS 0 1 2 3 Cognitive RUNAWAY Developmental Frequency of Running Communication Consistency of Destination Self Care/ Daily Living Skills Safety of Destination 0 1 2 3 Involvement of Illegal Acts SUBSTANCE ABUSE Likelihood of Return on Own Severity of Use Involvement of Others Duration of Use Realistic Expectations Stage of Recovery Planning Peer Influences Parental Influences JUVENILE JUSTICE 0 1 2 3 Environmental Influences Seriousness History TRAUMA 0 1 2 3 Arrests Traumatic Stress Symptoms Planning Affective/Physical Dysregulation Community Safety Intrusions Legal Compliance Traumatic Peer Criminal Behavior (Influences) Re-experiencing Parental Criminal Behavior (#50) Hyper arousal Environmental Influences Avoidance 0 1 2 3 Numbing FIRE SETTING Dissociation Seriousness Time Before Treatment History Sexual Abuse (4a) Arrests Emotional Closeness of Perpetrator Planning Frequency of Abuse Use of Accelerants Duration Intention to harm Physical Force Community Safety Reaction to Disclosure Response to Accusation Remorse SUICIDE RISK MODULE 0 1 2 3 Likelihood of Future Fire setting History of Attempts Suicide Ideation Suicide Intent Suicide Planning Substance Use (#35) Depression (# 30) CAREGIVER NEEDS (Optional) SUICIDE RISK MODULE continued 0 1 2 3 Not applicable; no caregiver identified. Conduct (#33) 0 = No evidence of need; potential resource for the Caregiver Mental Health (#194) 1 = Watchful waiting; monitoring or possibly preventive action. Accessible Firearm/Medication 2 = Need for action. Some strategy needed to address problem/need. 0 1 2 3 DANGEROUSNESS/VIOLENCE 3 = Need for Immediate action. Safety concern; priority for intervention. Historical Risk Factors Caregiver Information History of Physical Abuse First name: History of Violence Witness to Community Violence (#45) Last name: Witness to Family Violence (#44) Emotional/Behavioral Risks Caregiver type Frustration Management Adoptive parent Godparent Uncle Hostility Aunt Grandparent Other Paranoid Thinking Secondary Gains from Anger Biological parent Legal guardian Violent Thinking Foster parent Stepparent Resiliency Factors 0 1 2 3 Aware of Violence Potential
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
CANS_6-17_Scoresheet.docx