The following is a list of behaviors that are associated with the risk of youth violence. Check those items that describe the youth you are concerned about. Professional consultation is always appropriate if you have concerns regarding mental, emotional or behavioral problems. This questionnaire should not be used to screen for medical, psychiatric or mental health disorders. No questionnaire can replace or substitute for professional consultation or face to face evaluation. This questionnaire is designed to help you clarify your concerns, help you discuss issues with appropriate professionals or authorities and to give you an indicator of the approximate risk.
Child's Name: ____________________________________________
Date Of Birth: ____________________________ Sex: M F
Name Of Person Completing The Form: _____________________________________
Immediate Danger (At least one represents an immediate danger)
Critical Warning Signs (At least 1 sign is critical. A greater number of signs indicates a greater risk.)
Has the child made any veiled destructive or threatening statements in writing?
Has the child made statements or implied they might have a plan for violent or suicidal behavior?
Has the child made statements or implied they might have reasons to become violent?
Has the child made statements or implied they might have opportunities to become violent?
Has the child stated, implied or made any gesture that they might have identified a target for violence?
Critical Warning Signs (2 or more signs are critical.A greater number of signs indicates a greater risk.)
Contributing Risk Factors
Has trouble paying attention.
Often disrupts classroom activities.
Does poorly in school.
Enjoys violent TV shows, movies, or violent video games.
Has few friends; is often rejected by other children because of his or her behavior.
Makes friends with other children known to be unruly or aggressive.
Consistently does not listen to adults.
Is insensitive to the feelings of others.
Is easily frustrated.
Withdrawn or isolated.
An immediate Danger means that action must be taken immediately. This includes a response from 911 and Law Enforcement and then a comprehensive evaluation and intervention by a qualified crisis intervention professional.
Significant critical warning signs indicate that some reasonable action should be taken immediately and that must include a comprehensive evaluation and intervention.
Contributing risk factors are early warning signs that indicate the possibility of a problem that should be investigated carefully and cautiously.
copyright 1999 to 2008, Michael G. Conner