towards adults or this interfering with the involving the threat of child’s information is unknown to functioning and/or causing physical harm to others. me. emotional harm to others. If the needs / functioning fall within a shaded box, explain why: child’s B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) (Continued) II-18. Conduct (PAST 30 DAYS) No evidence of intentional History / suspicion of Clear evidence of behavior Evidence of a severe level misconduct. Any concerns problems associated with which includes lying, stealing, of behavior that places the are age appropriate or this behavior including lying, manipulating others, sexual child or community at information is unknown to stealing, manipulating others, aggression, violence towards significant risk of physical me. sexual aggression, violence property people or animals. harm due to these towards property people or behaviors. animals. If the needs / functioning fall within a shaded box, explain why: child’s 11-19. Anger Control (PAST 30 DAYS) No evidence of any Some problems with Moderate anger control Severe anger control significant anger control controlling anger. Child may problems. temper problems. temper Child’s Child’s problems. Any concerns are become verbally aggressive can become violent and has is likely associated with age appropriate or this when frustrated. gotten him / her in significant frequent fighting that is information is unknown to trouble with peers, family and often physical. Others me. / or school. likely fear him / her. If the needs / functioning fall within a shaded box, explain why: child’s 11-20. Substance Use (PAST 30 DAYS) No evidence of substance History or suspicion of Clear evidence of substance Child requires use or this information is substance use. abuse that interferes with detoxification OR is unknown to me. functioning in any area of life. addicted to alcohol / drugs. If the needs / functioning fall within a shaded box, explain why: child’s B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) (Continued)
towards adults or this information is unknown to me. interfering with the child’s functioning and/or causing emotional harm to others. involving the threat of physical harm to others. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) (Continued) II-18. Conduct (PAST 30 DAYS) No evidence of intentional misconduct. Any concerns are age appropriate or this information is unknown to me. History / suspicion of problems associated with behavior including lying, stealing, manipulating others, sexual aggression, violence towards property people or animals. Clear evidence of behavior which includes lying, stealing, manipulating others, sexual aggression, violence towards property people or animals. Evidence of a severe level of behavior that places the child or community at significant risk of physical harm due to these behaviors. If the child’s needs / functioning fall within a shaded box, explain why: 11-19. Anger Control (PAST 30 DAYS) No evidence of any significant anger control problems. Any concerns are age appropriate or this information is unknown to me. Some problems with controlling anger. Child may become verbally aggressive when frustrated. Moderate anger control problems. Child’s temper can become violent and has gotten him / her in significant trouble with peers, family and / or school. Severe anger control problems. Child’s temper is likely associated with frequent fighting that is often physical. Others likely fear him / her. If the child’s needs / functioning fall within a shaded box, explain why: 11-20. Substance Use (PAST 30 DAYS) No evidence of substance use or this information is unknown to me. History or suspicion of substance use. Clear evidence of substance abuse that interferes with functioning in any area of life. Child requires detoxification OR is addicted to alcohol / drugs. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) (Continued)
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