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13th JD Youth Diversion Screening
51
Questions
START
1
Name of Youth
*
This field is required.
First Name
Last Name
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2
Date of Birth
*
This field is required.
Youth's birthdate
-
Date
Month
Day
Year
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3
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
County
Morgan
Logan
Washington
Yuma
Sedgwick
Phillips
KitCarson
Other
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5
Parent Name
First Name
Last Name
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6
Parent Phone
Area Code
Phone Number
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7
Case Number
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8
Primary Concerns
select all that apply
Alcohol
Sexting
Vaping
Fighting
Substance Use
Stealing
Behavior at School
Other
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9
Agreement Date
-
Date
Month
Day
Year
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10
Agreement
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
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11
Review Date
-
Date
Month
Day
Year
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12
School
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13
Current Grade Level
6th
7th
8th
9th
10th
11th
12th
Other
6th
7th
8th
9th
10th
11th
12th
Other
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14
Disciplinary History
In-school Detention
Out of School Suspension
Expulsion
Other
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15
Do you currently have an IEP?
YES
NO
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16
What are your current grades in school?
Please Select
Straight As
Mostly As and Bs
Mostly Bs and Cs
Mostly Cs and Ds
Mostly Ds and Fs
Failing All Classes
Please Select
Please Select
Straight As
Mostly As and Bs
Mostly Bs and Cs
Mostly Cs and Ds
Mostly Ds and Fs
Failing All Classes
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17
Do you ever meet with the school counselor?
YES
NO
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18
Name of School Counselor
if you are working with them
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19
Respond YES or NO to the following questions:
Don't overthink, just common sense yes or no.
YES
NO
Does your family fight a lot? (physical or screaming that the neighbors can hear)
Row 0, Column 0
Row 0, Column 1
Have you ever been assaultive? (beat someone up)
Row 1, Column 0
Row 1, Column 1
Have you used drugs in the past year?
Row 2, Column 0
Row 2, Column 1
Are you NOT enrolled in school right now?
Row 3, Column 0
Row 3, Column 1
Have you missed more than 10 days of school?
Row 4, Column 0
Row 4, Column 1
Do you have a mental health diagnosis? (bipolar, ADHD, etc)
Row 5, Column 0
Row 5, Column 1
Do your friends get in trouble with law enforcement?
Row 6, Column 0
Row 6, Column 1
Have you been charged with a crime before? (not counting this situation)
Row 7, Column 0
Row 7, Column 1
Have you ever run away from home?
Row 8, Column 0
Row 8, Column 1
Is this current crime a status offense? (only a crime due to your age)
Row 9, Column 0
Row 9, Column 1
Does your family fight a lot? (physical or screaming that the neighbors can hear)
Have you ever been assaultive? (beat someone up)
Have you used drugs in the past year?
Are you NOT enrolled in school right now?
Have you missed more than 10 days of school?
Do you have a mental health diagnosis? (bipolar, ADHD, etc)
Do your friends get in trouble with law enforcement?
Have you been charged with a crime before? (not counting this situation)
Have you ever run away from home?
Is this current crime a status offense? (only a crime due to your age)
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
YES
Row 3, Column 0
NO
Row 3, Column 1
YES
Row 4, Column 0
NO
Row 4, Column 1
YES
Row 5, Column 0
NO
Row 5, Column 1
YES
Row 6, Column 0
NO
Row 6, Column 1
YES
Row 7, Column 0
NO
Row 7, Column 1
YES
Row 8, Column 0
NO
Row 8, Column 1
YES
Row 9, Column 0
NO
Row 9, Column 1
1
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20
Score
Each of the above YES answers count as 1 point
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
Based on the Arizona Risk/Need Assessment Instrument
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21
Notes (if any)
related to the above answers
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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22
In the PAST YEAR, have YOUR FRIENDS used the following substances:
Friends being those that you spend time with
YES
NO
NICOTINE: Smoking, vaping, chewing, etc.
Row 0, Column 0
Row 0, Column 1
ALCOHOL: Drinking
Row 1, Column 0
Row 1, Column 1
WEED/THC: Smoking, vaping, edibles, etc.
Row 2, Column 0
Row 2, Column 1
HARD DRUGS: fentanyl, meth, etc.
Row 3, Column 0
Row 3, Column 1
PRESCRIPTION MEDS: using them to get high
Row 4, Column 0
Row 4, Column 1
OVER THE COUNTER MEDS: using them to get high
Row 5, Column 0
Row 5, Column 1
NICOTINE: Smoking, vaping, chewing, etc.
ALCOHOL: Drinking
WEED/THC: Smoking, vaping, edibles, etc.
HARD DRUGS: fentanyl, meth, etc.
PRESCRIPTION MEDS: using them to get high
OVER THE COUNTER MEDS: using them to get high
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
YES
Row 3, Column 0
NO
Row 3, Column 1
YES
Row 4, Column 0
NO
Row 4, Column 1
YES
Row 5, Column 0
NO
Row 5, Column 1
1
of 6
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23
In the PAST YEAR, have YOU used the following substances:
Be honest
YES
NO
NICOTINE: Smoking, vaping, chewing, etc.
Row 0, Column 0
Row 0, Column 1
ALCOHOL: Drinking
Row 1, Column 0
Row 1, Column 1
WEED/THC: Smoking, vaping, edibles, etc.
Row 2, Column 0
Row 2, Column 1
HARD DRUGS: fentanyl, meth, etc.
Row 3, Column 0
Row 3, Column 1
PRESCRIPTION MEDS: using them to get high
Row 4, Column 0
Row 4, Column 1
OVER THE COUNTER MEDS: using them to get high
Row 5, Column 0
Row 5, Column 1
NICOTINE: Smoking, vaping, chewing, etc.
ALCOHOL: Drinking
WEED/THC: Smoking, vaping, edibles, etc.
HARD DRUGS: fentanyl, meth, etc.
PRESCRIPTION MEDS: using them to get high
OVER THE COUNTER MEDS: using them to get high
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
YES
Row 3, Column 0
NO
Row 3, Column 1
YES
Row 4, Column 0
NO
Row 4, Column 1
YES
Row 5, Column 0
NO
Row 5, Column 1
1
of 6
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24
Notes (if any)
related to substance use
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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25
Respond to the following, based on your life circumstances TODAY:
maslow's heirarchy of needs
YES
NO
Does your family have plenty of food to eat every day?
Row 0, Column 0
Row 0, Column 1
Do you currently have a safe home to live in with a front door and electricity?
Row 1, Column 0
Row 1, Column 1
Do you currently have safe transportation to school and other appointments?
Row 2, Column 0
Row 2, Column 1
Do you currently work to earn money, outside of your school responsibilities?
Row 3, Column 0
Row 3, Column 1
Does your family have plenty of food to eat every day?
Do you currently have a safe home to live in with a front door and electricity?
Do you currently have safe transportation to school and other appointments?
Do you currently work to earn money, outside of your school responsibilities?
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
YES
Row 3, Column 0
NO
Row 3, Column 1
1
of 4
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26
Notes (if any)
related to basic needs
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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27
Respond to the following by rating yourself from 0 (not at all) to 5 (extremely)
to understand emotional health with other human beings
I'm afraid of people in authority.
Being embarrassed or looking stupid are some of my worst fears.
I avoid talking to people I don't know.
Parties and social events are scary.
I avoid doing anything I might be criticized for.
I'm afraid to do things when other people might be watching me.
I avoid hanging out with kids my age.
I'm afraid to speak to adults.
not at all
a little bit
somewhat
very much
extremely
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
I'm afraid of people in authority.
Being embarrassed or looking stupid are some of my worst fears.
I avoid talking to people I don't know.
Parties and social events are scary.
I avoid doing anything I might be criticized for.
I'm afraid to do things when other people might be watching me.
I avoid hanging out with kids my age.
I'm afraid to speak to adults.
not at all
a little bit
somewhat
very much
extremely
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
not at all
a little bit
somewhat
very much
extremely
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
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28
How comfortable are you with these physical responses when interacting with other humans?
slide the emoji to frown if you're scared of this to a big smile if it's not an issue
blushing/red face
heart racing
sweaty palms
pitting out (sweaty underarms)
shaky hands
stuttering
hives/stress rash
stupid words
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
blushing/red face
heart racing
sweaty palms
pitting out (sweaty underarms)
shaky hands
stuttering
hives/stress rash
stupid words
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
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29
Notes (if any)
related to anti-social concerns
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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30
0-10, How would you rate how your life is going, overall?
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
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31
In the past 2 weeks, how often have you had trouble sleeping?
Not at all
sometimes
half the time
a lot of times
Every Day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Not at all
sometimes
half the time
a lot of times
Every Day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
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32
Has there been a time in the past month when you have thought about hurting yourself?
YES
NO
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33
Have you ever, in your whole life, made a suicide attempt?
YES
NO
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34
Are you a victim of sexual assault?
YES
NO
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35
Have you been accused or convicted of a sexual offense?
YES
NO
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36
Have you been a witness to or victim of Domestic Violence?
YES
NO
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37
Does your family have an open Child Welfare case?
YES
NO
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38
Are you currently placed in Foster Care?
YES
NO
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39
Are you currently seeing a professional counselor or therapist?
YES
NO
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40
Name of Counselor
First Name
Last Name
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41
Agency
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42
Your Diagnosis
Depression
Anxiety
ADD
ADHD
ODD
PTSD
OCD
Bipolar
Other
Not Sure
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43
Type(s) of Services
What kind of things are you doing with your counseling program?
Individual Therapy Sessions
Group Therapy Sessions
Mentoring
Life Skills (case manager)
Substance Use Treatment
Addiction Recovery Group
Transition to Independence
Support Group (general)
Family Therapy
Family Support Group
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44
Notes (if any)
related to well-being
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45
Good Things at School
Favorite Teacher
Favorite Class
Favorite Activity (sport, music, club, etc.)
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46
Your People
Who understands you and has your back?
Family
Friends
Random adult (coach, church leader, neighbor, etc)
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47
Your Talents
Something you're good at
Something you're good at
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48
Your Hobbies
Something you're good at
Something you're good at
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49
Your Favorites
Favorite Movie
Favorite Song right now
Favorite Sports Team
Favorite TV Show
Favorite Color
Favorite Holiday
Favorite Book
Favorite Food
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50
Possible Career Plans
What are a couple of ideas for how you would like to earn a living?
Future Career Idea
Future Career Idea
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51
Notes (if any)
related to the student's strengths
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