Fort Worth Independent School District

Violent Behavior Risk Assessment

Elementary

FORT WORTH INDEPENDENT SCHOOL DISTRICT

STUDENT SUPPORT SERVICES

STRUCTURED INTERVIEW WORKSHEET for ASSESSING RISK OF

VIOLENT BEHAVIOR - ELEMENTARY

Student Name ______ID# ______Grade ______

School ______Principal ______

Interviewer Signature/Title ______Date ______

Initial Assessment Questions:

I. Did the student harm someone else? Yes ____ No ____

ü If yes, call 911 if the student is in a state of injury (bleeding, etc.), tell the school nurse, then inform the parent.

ü In this situation, Risk is HIGH and the Violent Behavior Risk Assessment does not need to be completed. Immediate action is required.

II. Did the student recently make a threat? Yes ____ No ____

Student was referred by a teacher based on information he/she shared

Student was referred by another student based on information he/she shared

Student turned in writing or drawing of concern

If Yes, complete the Violent Behavior Risk Assessment and follow through with parent. Level of risk must be determined. Complete all sections of the Violent Behavior Risk Assessment.

III. Has the student experienced a traumatic event recently? Yes ____ No ____

If Yes, complete Trauma Assessment and follow through with parent.

III. Parent was notified Date ______Time ______

Name ______Phone #______

Parent’s Response ______

VI. If the student drew a picture ask them about it, “Tell me about the picture you drew.” If the student made a statement, clarify exactly what they said, what they meant and why it was said.

Please answer the following questions after completing assessment and send this page to: FAX 817-814-2905 OR EMAIL

YES NO_

1) Assessed Risk Score ______ÿ Low ÿ Moderate ÿ High

2) Has this student been referred for Student Support services this year? ______

If so, reason______

3) Was a Suicide Risk Assessment previously completed? ______

If yes, assessed risk______Date ______

4) Was a Violent Behavior Risk Assessment previously completed? ______

If yes, assessed risk______Date ______

5) Has a Trauma Response Team meeting been conducted/Student Support

Plan been initiated? ______

6) Did the parent/legal guardian sign a Notification of Emergency

Conference Form? ______

7) Did the parent/legal guardian sign a Release of Information? ______

8) Did the parent/legal guardian agree to obtain treatment for the student? ______

9) Did the student sign an Agreement to Participate in Care form? ______

10) Is the student involved in their treatment? ______

11) Did student commit violation of COC/Disciplinary action______

12) Did the student return to school? Date ______ ______

13) Has there been follow-up with the student? Date ______ ______

14) Has there been follow-up with student’s family? Date ______ ______

15) Has there been follow-up with educational team? Date ______

Indicator

Risk present, but low=1

Moderate risk = 3

High risk = 5

1. Plan

Details –Have you thought about hurting yourself or others on purpose? How have you thought about doing that?
Access to weapons – What would you use? How will you get it (name the weapon)?
Time – When do you plan to do this?
Validity of plan – How likely is this to be implemented?
/ ____ No Plan
____ Not available, have to attain
____ No specific time or in future
____ Plan unrealistic unlikely to be implemented / ____ Vague Plan
____ Available, easy access
____ Within a few hours
____ Some details are plausible / ____ Well thought out, knows when, where, how
____ Have in hand, close by
____ Immediately
____ Plan realistic

2. Aggressive behavior

Does student have a history of aggression or violence, outbursts, aggression that has escalated to setting fires, harm to another, etc.? /

____ When angry, does not hurt or threaten to hurt others or property

/ ____ Displays little anger control; considered aggressive; has explosive outbursts; believes has been treated unfairly / ____ Has set fires; has frequent explosive outbursts; believes in violence to solve problems

3. Discipline record

____ No previous discipline record

____ Record of fighting, harassing, verbal abuse

____ History includes serious disciplinary problems, criminal offenses, suspension or expulsion

4. History of previous threats

____ No history of previous threats

____ Friends are aware of threats

____ Has been disciplined in past for terroristic threat

5. Exposure to violence

What type of video games do you play/movies do you watch? Have you seen other people fighting or hurting someone? /

____ Exposed to violence only through movies, stories, computer software, video games

____ Has directly witnessed a violent argument or fight at home, in the neighborhood, or school

____ Repeated exposure to violence at home, neighborhood, or school

6. Victim of violence or abuse (verbal, sexual, or physical)

Have you been hurt or bullied by someone else? /

____ No evidence that student is a victim of violence or abuse

____ Perceives self as being taken advantage of or a victim but no evidence that abuse has occurred

____ Student has been a victim or violence or abuse; has been removed from home by Child Protective Services

7. Exhibits cruelty to animals

____ No tendency to be cruel to animals

____ Discussed cruelty of animals

____ Has tortured or mutilated animals

8. Victim or perceived victim of discrimination or harassment

____ No history of discrimination or harassment

____ Has history of being teased or bullied

____ Documented instances of harassment or discrimination

9. Gang, cult, or antisocial group membership

____ No history of affiliation or interest

____ Past affiliation or current interest in membership

____ Current membership; see membership as source of power and protection

10. Family Support

Tell me about your family and friends. Who can you depend on?

____ Evidence of caring and supportive family relationships

____ History of neglect or lack of parental supervision

____ Failed to demonstrate attachment/affection toward caregivers at an early age or now

Subtotal (Count each item)

/ / /

Indicator

Risk Present but Low =1

Moderate risk = 3

High risk = 5

11. Empathy

Do you feel sad when you see others hurting?

____ Displays normal capacity to feel for others

____ Some indication that development of these feelings was delayed or absent

____ Seems unable to express or feel empathy, sympathy, or remorse

12. Interpersonal and relationship skills

Do you have many friends? Tell me about your friends? /

____ Has friends, respected among peers and teachers

____ Identified as a bully; poor interpersonal skills; picked on

____ Others afraid of child; intensely withdrawn; takes advantage of others; is considered a loner or an outsider.

13. Preoccupation with weapons, death, and violent themes – Do you enjoy thinking about, reading, watching other people get hurt?

____ No unusual history of thinking about violence does not enjoy reading about or watching violence

____ Prefers and enjoys violence on TV or in movies; shows interest in weapons; talks about violence

____ Preoccupation with violence and death in writings, fantasy, drawings, or conversations

14. Drug or alcohol usage; impulsivity

Have you ever used drugs or alcohol? How much/often?

____ Does not use drugs or alcohol, is not considered impulsive

____ Some experimentation with drugs or alcohol, one or two times per month

____ Frequent use of drugs or alcohol; has little impulse control

15. Psychiatric History – Have you ever seen a Dr. or been in a hospital because of this?
Medication – Do you take any medication? / ___ Present in treatment
____ Compliant with medication / ___ None reported
____ Sporadically compliant / ___ Previous hospitalization
____ Non-compliant

Total (pages 1+2)=

/ /

Scoring: ______

Risk assessment: Minimal/Low = 19-30 Moderate/Urgent = 31-50 High/Emergent = 51-95

Be sure to give a score for ALL items, particularly each of the 4 items within #1.

*If most items in indicator #1 are marked “high risk”, the assessed risk is automatically ranked “High.”

Chronic Risk:

Please note that students who have a history of multiple threats to themselves or others are considered to be at chronic risk regardless of acute status with the likely need for ongoing care. If the student has a history of multiple assessments/threats, but is not active and consistent in treatment then recommend to the parent that they consider getting consistent care.

Also consider other CHRONIC RISK INDICATORS in the student’s history that might warrant referral for therapeutic services. Such as:

¨ Prior Psychiatric Hospitalization

¨ History of Abuse or Neglect

¨ Significant Changes in Environment

¨ Severe Loss

Note: Risk assessments cannot be performed with complete accuracy, and do not predict with certainty the future behavior of this student. The findings and recommendations contained in this assessment represent the best professional judgment of the examiner on this date. This assessment tool is confidential and will be maintained by examiner.

Revised 7/15/11