R.R. 1 Dover Centre, Ontario N0P 1L0
Phone: (519) 351-2447 Fax: (519) 351-8265
Risk Factor Inventory
Please complete, in consultation with the current caregiver, reflecting the child’s current risk profile in the following areas. This information will be kept confidential and is used for placement preparation and matching.
Social Worker
/Child/Youth
/Date
Please note the level of severity for each of these risk factors. Examples of each level are as follows:
0 = No concerns at all. This is not an issue
1 = A mild area of risk. This requires monitoring and/or occasional attention, and could potentially be a risk if
severe stress occurs.
2 = A moderate area of risk. This requires attention much of the time, and is often an area of difficulty.
3 = A high area of risk. This requires constant and immediate attention, and without attention the emotional or
physical safety of the youth or others is at risk.
Presenting Concern / 0 1 2 3 /Comments
Suicide RiskPhysical Aggression
Towards Others
Verbal Aggression
Towards Others
Depression
Truancy
AWOL
Substance Abuse
Psychiatric Disorder
Sexual Risk-Taking
Behaviour
Grief Reaction
Please note the level of severity for each of these risk factors. Examples of each level are as follows:
0 = No concerns at all. This is not an issue
1 = A mild area of risk. This requires monitoring and/or occasional attention, and could potentially be a risk if
severe stress occurs.
2 = A moderate area of risk. This requires attention much of the time, and is often an area of difficulty.
3 = A high area of risk. This requires constant and immediate attention, and without attention the emotional or
physical safety of the youth or others is at risk.
Presenting Concern
/ 0 1 2 3 /Comments
Ability to Attach To CaregiversEncopresis (Soiling)
Enuresis (Wetting)
Other Child Behaviour Problems
(please specify)
Please rate the impact of these events/circumstances on the youth’s current functioning for each of these areas:
0 = Not applicable to this child
1 = No distress or impairment in daily functioning
5 = Moderate levels of distress and impairment in daily functioning
10 = Severe/major levels of distress and impairment in daily functioning
Events/Circumstance
/ Rating (0-10) /Comments
Previous Sexual AbusePrevious Physical Abuse
Previous Emotional Abuse
Neglect
Caregiver Conflict
Family Substance Abuse
Physical Problems
Health History
_____--
Psychiatric and Psychological History (please specify age of onset)
Diagnosis/Treatment ForNumber / Date(s) /
By Whom
/Contact
Lifestyle Habits
Psychological Testing (please attach copies of previous reports)
______
______
Psychiatric Assessment/Treatment (please attach copies of previous reports)
______
______
History of [please specify age of onset, or age range – example, sexual abuse (6-8 yrs)]
Age of Birth Birth Family Members
Client Onset Mother Father (please specify)
Birth Defects / □ / □ / □ / □Diabetes / □ / □ / □ / □
Neurological Disease / □ / □ / □ / □
Seizure Disorders / □ / □ / □ / □
Head Injury/Aches / □ / □ / □ / □
Vision Problems (wears glasses) / □ / □ / □ / □
Hearing Problems / □ / □ / □ / □
Any specific genetic condition (specify) / □ / □ / □ / □
Developmental Delays / □ / □ / □ / □
Other Developmental Disabilities (specify) / □ / □ / □ / □
Learning Disorders / □ / □ / □ / □
Attention Deficit / □ / □ / □ / □
Hyperactivity / □ / □ / □ / □
Depression / □ / □ / □ / □
Bipolar / □ / □ / □ / □
Anxiety / □ / □ / □ / □
Psychosis/Schizophrenia / □ / □ / □ / □
Tourette’s Disorder / □ / □ / □ / □
Physical Abuse / □ / □ / □ / □
Sexual Abuse / □ / □ / □ / □
Substance Use Disorder (Alcohol/Inhalants) / □ / □ / □ / □
Substance Use Disorder (Drugs) / □ / □ / □ / □
Alcoholism / □ / □ / □ / □
Drug Addiction / □ / □ / □ / □
Delinquency/Criminal Behaviour / □ / □ / □ / □
Suicides/Attempts / □ / □ / □ / □
FASD (Diagnosed) / □ / □ / □ / □
FASD (Suspected) / □ / □ / □ / □
Physically Aggressive / □ / □ / □ / □
Anger Management Difficulties / □ / □ / □ / □
Prostitution / □ / □ / □ / □
Sexual Assault or Interference / □ / □ / □ / □
Theft / □ / □ / □ / □
Eating Disorders / □ / □ / □ / □
Intermittent Explosive Disorder / □ / □ / □ / □
Other (specify) / □ / □ / □ / □
Medical History
Speech and Language Pathology History ______
Occupational Therapy History ______
Physiotherapy History ______
______
Education History (please attach copies of previous report cards/educational reports)
Grade ______School ______Program ______
Contact Name ______Position ______
Phone Number ______Previous School ______
IQ Description ______
Youth Justice History (please attach copies of previous reports)
Previous Charges ______Dates ______
______
______
Consequences/Results ______
Current Charges ______Date ______
______
Consequences/Results ______
P.O. Contact Name ______Phone Number ______
Upcoming Appearance Date(s) ______
List of Required Supporting Documents
To assist Choices Child and Adolescent Services Ltd. to review this referral and appropriately match your client’s needs to the appropriate level of placement, education, treatment and support services, please send us the following pre-admission supporting documents:
Please submit the following prior to admission along with a completed Pre-Admission Package and any required Release of Information Forms:
Child Welfare History or Social History – current information including case analysis and services
· A list of prior placements of the child including the reason for any changes in placements
· Other relevant data, such as documents detailing the child/family history
Health History – provide a copy of the most recent medical form, plus any relevant medical reports and
hospital discharge reports
Dental and Optical History – provide dates of last optical and dental examination and names and
addresses of the service providers
Psychological and Psychiatric History – please attach copies and reports
Academic History – provide copies of relevant school reports and latest report card
Youth Justice History – please attach copies of court reports and orders
On the DAY OF INTAKE please bring with you or provide the following:
· Photocopy of birth certificate
· Immunization records
· Current medications, prescribing Doctor’s name and include a 30-day supply
· Discharge plans for the youth
· Names and addresses and telephone numbers of significant adults for the children
· Description of the youth’s current legal status and access arrangements (if any)
· Health Card