Intrusions Seriousness Traumatic Grief History Re-experiencing Arrests arousal Planning Avoidance Use of Accelerants Numbing Intention to harm Dissociation Community Safety Time Before Treatment Response to Accusation Sexual Abuse (5a) Remorse Emotional Closeness of Perpetrator Likelihood of Future Fire setting Frequency of Abuse TRAUMA Continued 0 1 2 3 CAREGIVER NEEDS (Optional) Sexual Abuse (5a) continued Not applicable; no caregiver identified. Duration Physical Force 0 = No evidence of need; potential resource for the child/youth. Reactions to Disclosure 1 = Watchful waiting; monitoring or possibly preventive action. 2 = Need for action. Some strategy needed to address problem/need. SUICIDE RISK MODULE 0 1 2 3 3 = Need for Immediate action. Safety concern; priority for intervention. History of Attempts Caregiver Information Suicide Ideation Suicide Intent First name: Suicide Planning Last name: Substance Use (#42) Depression (# 37) Caregiver type Anti-Social Behavior (#40) Adoptive parent Godparent Uncle Caregiver Mental Health (CG Needs - optional) Accessible Firearm/Medication Aunt Grandparent Other Biological parent Legal guardian DANGEROUSNESS/VIOLENCE 0 1 2 3 Historical Risk Factors Foster parent Stepparent History of Physical Abuse 0 1 2 3 History of Violence Involvement with Care Witness to Community Violence (#52) Knowledge Witness to Family Violence (#51) Organization Emotional/Behavioral Risks Resources Frustration Management Physical Hostility Mental Health Paranoid Thinking Secondary Gains from Anger Substance Use Violent Thinking Developmental Resiliency Factors Safety Aware of Violence Potential Family Stress Response to Consequences Commitment to Self Control Additional Caregiver Treatment Involvement First name: SEXUALLY AGGRESSIVE BEHAVIOR 0 1 2 3 Relationship Last name: Physical Force/Threat Planning Caregiver type Age Differential Adoptive parent Godparent Uncle Type of Sex Act Aunt Grandparent Other Response to Accusation Biological parent Legal guardian Temporal Consistency History of Sexually Abusive Behavior Foster parent Stepparent Severity of Sexual Abuse 0 1 2 3 Prior Treatment Involvement with Care CRIME 0 1 2 3 Knowledge Seriousness Organization History Resources Arrests Physical Planning Mental Health Community Safety Substance Use Legal Compliance Developmental Peer Criminal Behavior (influences) Safety Parental Criminal Behavior (Influences) Environmental Influences Family Stress 0 1 2 3 FIRE SETTING
Intrusions Traumatic Grief Re-experiencing arousal Avoidance Numbing Dissociation Time Before Treatment Sexual Abuse (5a) Emotional Closeness of Perpetrator Frequency of Abuse TRAUMA Continued 0 1 2 3 Sexual Abuse (5a) continued Duration Physical Force Reactions to Disclosure SUICIDE RISK MODULE 0 1 2 3 History of Attempts Suicide Ideation Suicide Intent Suicide Planning Substance Use (#42) Depression (# 37) Anti-Social Behavior (#40) Caregiver Mental Health (CG Needs - optional) Accessible Firearm/Medication DANGEROUSNESS/VIOLENCE 0 1 2 3 Historical Risk Factors History of Physical Abuse History of Violence Witness to Community Violence (#52) Witness to Family Violence (#51) Emotional/Behavioral Risks Frustration Management Hostility Paranoid Thinking Secondary Gains from Anger Violent Thinking Resiliency Factors Aware of Violence Potential Response to Consequences Commitment to Self Control Treatment Involvement SEXUALLY AGGRESSIVE BEHAVIOR 0 1 2 3 Relationship Physical Force/Threat Planning Age Differential Type of Sex Act Response to Accusation Temporal Consistency History of Sexually Abusive Behavior Severity of Sexual Abuse Prior Treatment CRIME 0 1 2 3 Seriousness History Arrests Planning Community Safety Legal Compliance Peer Criminal Behavior (influences) Parental Criminal Behavior (Influences) Environmental Influences FIRE SETTING 0 1 2 3 Seriousness History Arrests Planning Use of Accelerants Intention to harm Community Safety Response to Accusation Remorse Likelihood of Future Fire setting CAREGIVER NEEDS (Optional) Not applicable; no caregiver identified. 0 = No evidence of need; potential resource for the child/youth. 1 = Watchful waiting; monitoring or possibly preventive action. 2 = Need for action. Some strategy needed to address problem/need. 3 = Need for Immediate action. Safety concern; priority for intervention. Caregiver Information First name: Last name: Caregiver type Adoptive parent Aunt Biological parent Foster parent Godparent Grandparent Legal guardian Stepparent Uncle Other 0 1 2 3 Involvement with Care Knowledge Organization Resources Physical Mental Health Substance Use Developmental Safety Family Stress Additional Caregiver First name: Last name: Caregiver type Adoptive parent Aunt Biological parent Foster parent Godparent Grandparent Legal guardian Stepparent Uncle Other 0 1 2 3 Involvement with Care Knowledge Organization Resources Physical Mental Health Substance Use Developmental Safety Family Stress
ANSA-T_Scoresheet.docx