Time Indicated a plan to harm or kill others now or in near future? 9. Specify: Plan is (time and location)? specific 10. Specify: Opportunity Has access to guns/weapons (i.e., at home, at relatives)? 11. Specify: Had made efforts to get hold of a gun(s)/weapons? 12. Specify: Ability Is the plan (can access means and enact plan)? viable 13. Specify: Thoughts of how to get around security measures? 14. Desire Thoughts about whom he/she would target? 15. Thoughts about how he/she would get close to this target (persons 16. or building)? Expressed strong motivations or reasons for the planned violence? 17. Grievances? Stressors/ Had a personal connection to, or identified with, someone who has 18. committed targeted violence? Stimulus Who: Had a recent death of a loved one or a significant loss? 19. (i.e. breakup of a romantic relationship) Experienced a new trauma/stressor? 20. Specify: What: Experienced a chronic/ongoing stressor? (feelings of loneliness, life stress ) 21. Specify: Experienced a significant health concern? (self or other) 22. Specify: Experienced abuse or victimization? 23. Specify: Prior Behavior Previously tried to hurt others? 24. Specify: Previously tried to hurt him/herself? 25. Specify: Previously practiced violent acts or carrying out the plan? 26. Specify: Additional Assessment Questions Yes No ? Categories Changes in In the past year, felt so sad he/she stopped doing regular activities? 27. Mood /Behavior Specify: Demonstrated abrupt changes in behaviors? (e.g. aggression, thoughts of 28. revenge; changes in eating, sleeping, decline in school performance, quit club/sports activities, gave away personal possessions) Demonstrated recent, dramatic changes in mood? 29. (e.g., change from depression to contentment, happiness to depression, etc.) Mental Illness Has a history of mental illness? (i.e., depression, conduct, or anxiety) 30. Specify: Currently in counseling? 31. With whom:
Time 9. Indicated a plan to harm or kill others now or in near future? Specify: 10. Plan is specific (time and location)? Specify: Opportunity 11. Has access to guns/weapons (i.e., at home, at relatives)? Specify: 12. Had made efforts to get hold of a gun(s)/weapons? Specify: Ability 13. Is the plan viable (can access means and enact plan)? Specify: 14. Thoughts of how to get around security measures? Desire 15. Thoughts about whom he/she would target? 16. Thoughts about how he/she would get close to this target (persons or building)? 17. Expressed strong motivations or reasons for the planned violence? Grievances? Stressors/ Stimulus 18. Had a personal connection to, or identified with, someone who has committed targeted violence? Who: 19. Had a recent death of a loved one or a significant loss? (i.e. breakup of a romantic relationship) 20. Experienced a new trauma/stressor? Specify: What: 21. Experienced a chronic/ongoing stressor? (feelings of loneliness, life stress ) Specify: 22. Experienced a significant health concern? (self or other) Specify: 23. Experienced abuse or victimization? Specify: Prior Behavior 24. Previously tried to hurt others? Specify: 25. Previously tried to hurt him/herself? Specify: 26. Previously practiced violent acts or carrying out the plan? Specify: Additional Categories Assessment Questions Yes No ? Changes in Mood /Behavior 27. In the past year, felt so sad he/she stopped doing regular activities? Specify: 28. Demonstrated abrupt changes in behaviors? (e.g. aggression, thoughts of revenge; changes in eating, sleeping, decline in school performance, quit club/sports activities, gave away personal possessions) 29. Demonstrated recent, dramatic changes in mood? (e.g., change from depression to contentment, happiness to depression, etc.) Mental Illness 30. Has a history of mental illness? (i.e., depression, conduct, or anxiety) Specify: 31. Currently in counseling? With whom:
6.Threat_%20Assessment_Interv_Plan_Sample_.docx