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|NAME OF CHILD |      |DOB |      |

|NAME OF SCREENER |      |TITLE |      |DATE |      |

Areas of Immediate Concern

| Suicidal Thoughts | Assaultive Thoughts | Under the Influence of: Illicit | Alcohol |

| | |Drugs | |

| Suicidal Plans | Homicidal Thoughts | | Sexualized Behaviors |

|General Appearance |Speech |Orientation | |

|Within Normal Limits |Within Normal Limits |Disoriented |THIS SECTION COMPLETED BY MENTAL HEALTH|

| | |Oriented |PROFESSIONAL |

|Bizarre |Excessive | | |

|Disheveled |Soft |Memory |Thought Process |

|Poor Hygiene |Loud |Intact |Normal |

|Visible Marks/Bruises |Minimal |Impaired |Tangential |

| |Delayed | |Flight of Ideas |

|Affect/Behavior | |Insight Re: Removal |Loose Associations |

|Cooperative |Motor Activity |Normal |Circumstantial |

|Uncooperative |Calm | |Perseveration |

|Guarded |Very Active |Minimal |Hallucinations |

|Impulsive |Agitated |Moderate |Delusions |

|Angry |Tremors/Tics |Unrealistic | |

|Tearful |Unusual Gait | | |

|Withdrawn |Enuresis |Judgment | |

|Sad |Encopresis |Within Normal Limits | |

|Flat | |Impaired | |

|Labile |Mood | | |

|Frightened |Within Normal Limits |Education | |

|Accomodation Behaviors | |Special Education | |

|Regressive Behaviors |Euphoric |Regular Education | |

| |Depressed |Attending School | |

| |Anxious/Worried |Not Attending School | |

| | |Unknown | |

| | | | |

| | | |Content of Thought |

| | | |Within Normal Limits |

| | | | |

| | | |Antisocial Attitudes |

| | | |Suspiciousness |

| | | |Ideas of Hopelessness |

| | | |Thoughts of Running Away |

| | | |Ideas of Guilt |

| | | |Ideas of Worthlessness |

| | | |Sexual Preoccupation |

| | | |Illogical Thinking |

|YOUTH’S STRENGTHS: |

|      |

| |

|SCREENER’S IMPRESSIONS: |

|      |

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ALAMEDA COUNTY ASSESSMENT CENTER

BEHAVIORAL HEALTH CARE SCREENING

(FOR USE WITH AGES 6 AND OLDER) CWW CHART ONLY

䈍䡅噁佉䅒⁌䉏䕓噒呁佉华഍഍

BEHAVIORAL OBSERVATIONS

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