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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|Withdrawn |Enuresis |Judgment | |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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