Intake ID: Case: (Case Name) Individual: Interview Interview Native American Refused to be interviewed No Unable to be interviewed Unknown Yes Declined to disclose Adult Health and Functioning Risk Factors Protective Factors Alcohol abuse Accepts assistance that enhances functioning Attention seeking Candid and/or cooperative Dishonest and/or manipulative Copes or functions despite a disability Disregard for others’ safety or wellbeing Demonstrates logic/reasoning ability Drug abuse No mental health issues Hostile to authority figures or service providers No physical health issues Impulsive or unpredictable Primary relationships are stable Intellectual or cognitive disability Realistic awareness of self and reality Irrational or disconnected from reality Respects the rights and feeling or others Lacks insight into their own behavior Seeks and give affection to loved ones Mental health issue that affects functioning Paranoid Physical disability or debilitating illness Selfish, self-centered decision-making Unable to apply logic to solve problems Unable to assess (due to inability to interview) No Risk Factors Ability to Manage Daily Life and Stress (High Risk Behaviors) Risk Factors Protective Factors Abuses substances (drugs/alcohol to escape or deal College or career training
Intake ID: Case: (Case Name) Individual: Interview Interview Native American Refused to be interviewed Unable to be interviewed No Unknown Yes Declined to disclose Adult Health and Functioning Risk Factors Alcohol abuse Attention seeking Dishonest and/or manipulative Disregard for others’ safety or wellbeing Drug abuse Hostile to authority figures or service providers Impulsive or unpredictable Intellectual or cognitive disability Irrational or disconnected from reality Lacks insight into their own behavior Mental health issue that affects functioning Paranoid Physical disability or debilitating illness Selfish, self-centered decision-making Unable to apply logic to solve problems Unable to assess (due to inability to interview) No Risk Factors Protective Factors Accepts assistance that enhances functioning Candid and/or cooperative Copes or functions despite a disability Demonstrates logic/reasoning ability No mental health issues No physical health issues Primary relationships are stable Realistic awareness of self and reality Respects the rights and feeling or others Seeks and give affection to loved ones Ability to Manage Daily Life and Stress (High Risk Behaviors) Risk Factors Abuses substances (drugs/alcohol to escape or deal Protective Factors College or career training
ADT%20Concurrent%20CPS%20DV%20Assessment.docx