Within Within Within Over RISK INDICATORS Last Last The One Three Six Last Year Check ALL data columns and factors that apply Months Months Year Ago Victim of Physical Abuse ( confirmed, alleged) Victim of Sexual Abuse Perpetrator of Sexual Abuse Victim of Emotional Abuse Victim of Neglect Verbally Threatens Suicide Suicidal Gestures Actual Suicide Attempt(s) Hurt Someone Threatened to Hurt Self Injurious Behavior Significant School Problems: Failure Truancy Suspension Behavior ________ Frequent Unmanageable Behavior Noncompliant Behavior Run Away Age/Socially Inappropriate Sexual Behavior Damaged Property Stole Property Avoids Social Contact Frequently moved for poor behavior Frequently Anxious Frequent Nightmares Fire Setting Cruelty to Animals Frequent Bed Wetting Chronic Eating Disorder Pregnancy Abandonment Used Drugs or Alcohol Others (describe): None Known ATTACHMENT B CONSENT TO STAFFING
Within Last Three Months Within Last Six Months Within The Last Year Over One Year Ago RISK INDICATORS Check ALL data columns and factors that apply Victim of Physical Abuse ( confirmed, alleged) Victim of Sexual Abuse Perpetrator of Sexual Abuse Victim of Emotional Abuse Victim of Neglect Verbally Threatens Suicide Suicidal Gestures Actual Suicide Attempt(s) Hurt Someone Threatened to Hurt Self Injurious Behavior Significant School Problems: Failure Truancy Suspension Behavior ________ Frequent Unmanageable Behavior Noncompliant Behavior Run Away Age/Socially Inappropriate Sexual Behavior Damaged Property Stole Property Avoids Social Contact Frequently moved for poor behavior Frequently Anxious Frequent Nightmares Fire Setting Cruelty to Animals Frequent Bed Wetting Chronic Eating Disorder Pregnancy Abandonment Used Drugs or Alcohol Others (describe): None Known ATTACHMENT B CONSENT TO STAFFING
CAREReferral.docx