unknown to me. attention. attention. If the needs / functioning fall within a shaded box, explain why: child’s A. EMOTIONAL CHARACTERISTICS (Ages 5 to 21) (Continued) I-16. Other Self Harm (PAST 30 DAYS) No evidence of behavior that History of engaging in Engages in reckless or Engaged in reckless or places child at risk of physical reckless or risk-taking taking behaviors that put the risk-taking behavior that harm. Any concerns are age behaviors that put the child at child at risk of serious places child at immediate appropriate or this risk of physical harm. physical harm. risk of death. information is unknown to me. If the needs / functioning fall within a shaded box, explain why: child’s I-17. Exploited This item is used to examine a history and pattern of abuse, and / or includes a level of current risk for re-victimization (parentification of children, being bullied, prostituted, or taken advantage of by others). There is no evidence of a Suspicion or history of This level indicates a person This level indicates a history of exploitation or exploitation, but person has who has been recently person who has been history of victimization over not been exploited to any exploited (within the past recently exploited and has the past year or this significant degree during the year) but is not at acute risk an acute risk of information is unknown to past year. Person is not of re-exploitation. (Physical (Working as a me. presently at risk for or sexual abuse, significant prostitute, in an abusive psychological abuse, relationship, etc.). extortion violent crime, etc.). If the needs / functioning fall within a shaded box, explain why: child’s B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) II-1. Functioning in His / Her Current Living Situation (PAST 30 DAYS) Child’s No evidence of problems Mild problems functioning in Moderate to severe problems Profound problems with functioning in current living current home. Caregiver has functioning at home. functioning at home. Child Child’s situation. Concerns are age concerns about behavior is creating is in immediate risk of child’s appropriate or this behavior at home. significant difficulties for being removed due to his / information is unknown to others in the home. her behavior. me. If the needs / functioning fall within a shaded box, explain why: child’s
unknown to me. attention. attention. If the child’s needs / functioning fall within a shaded box, explain why: A. EMOTIONAL CHARACTERISTICS (Ages 5 to 21) (Continued) I-16. Other Self Harm (PAST 30 DAYS) No evidence of behavior that places child at risk of physical harm. Any concerns are age appropriate or this information is unknown to me. History of engaging in reckless or risk-taking behaviors that put the child at risk of physical harm. Engages in reckless or behaviors that put the child at risk of serious physical harm. Engaged in reckless or risk-taking behavior that places child at immediate risk of death. If the child’s needs / functioning fall within a shaded box, explain why: I-17. Exploited This item is used to examine a history and pattern of abuse, and / or includes a level of current risk for re-victimization (parentification of children, being bullied, prostituted, or taken advantage of by others). There is no evidence of a history of exploitation or history of victimization over the past year or this information is unknown to me. Suspicion or history of exploitation, but person has not been exploited to any significant degree during the past year. Person is not presently at risk for This level indicates a person who has been recently exploited (within the past year) but is not at acute risk of re-exploitation. (Physical or sexual abuse, significant psychological abuse, extortion violent crime, etc.). This level indicates a person who has been recently exploited and has an acute risk of (Working as a prostitute, in an abusive relationship, etc.). If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages 5 to 21) II-1. Child’s Functioning in His / Her Current Living Situation (PAST 30 DAYS) No evidence of problems functioning in current living situation. Concerns are age appropriate or this information is unknown to me. Mild problems functioning in current home. Caregiver has concerns about child’s behavior at home. Moderate to severe problems functioning at home. Child’s behavior is creating significant difficulties for others in the home. Profound problems with functioning at home. Child is in immediate risk of being removed due to his / her behavior. If the child’s needs / functioning fall within a shaded box, explain why: taking
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