Clinician Assessment Tool - School-Based Health Alliance
Clinician Assessment Tool
Risk and Stress Factors
Student Name: ____________________________________________
Clinician: ________________________________________________
Student’s stress:
Ask, “What 3 things do you think are causing you the most stress lately?”
Mark the student’s top three areas of stress with 1, 2, and 3. Place a checkmark beside other areas of stress or risk factors that apply for this student:
__ ο School failure
__ ο Negative attitude about school
__ ο Low IQ/Learning problems
__ ο Attention problems
__ ο Hopelessness
__ ο “I don’t care anymore”(Apathy)
__ ο Bored all the time
__ ο Medical problems
__ ο Obesity
__ ο Drug use
__ ο Alcohol use
__ ο Cigarette use
__ ο Poor self-esteem
__ ο Problems with friends
__ ο Problems with family
__ ο Problems with dating
__ ο Being picked on/bullied/teased
__ ο Homosexuality
__ ο Minority
__ ο Pregnancy
__ ο Death in family
__ ο Death of friend/other
__ ο Recent move
__ ο Recent change in schools
__ ο Traumatic experience
__ ο Been abused or molested
__ ο Witness to violence
__ ο My friends get into trouble
__ ο No one to talk to
__ ο No one understands me
__ ο Change in who is taking care of me (foster care, moved in with relative, etc)
__ ο No longer seeing parent or family member
__ ο Other __________________________
__ ο Other _________________________
__ ο Other __________________________
Family’s stress:
Ask, “What 3 things do you think are causing your family the most stress lately?”
Mark the student’s family’s top three areas of stress with 1, 2, and 3. Place a checkmark beside other areas of stress or risk factors that apply for this student’s family:
__ ο Parent(s) under a lot of stress
__ οSingle parent
__ ο Mental illness
__ ο Medical illness/injury
__ ο Violence at home
__ ο Family member in jail/legal trouble
__ ο Drug use
__ ο Alcohol problems
__ ο Recent move
__ ο Parent lost job
__ ο Parent works long hours or multiple jobs
__ ο Poverty
__ ο New baby in home
__ ο Parent remarried
__ ο Too many people living in home
__ ο Divorce/separation
__ ο Problems with neighbors/friends
__ ο Family conflict
__ ο Death in family
__ ο Home broken into
__ ο Had something stolen
__ ο Other __________________________
__ ο Other __________________________
__ ο Other __________________________
School stress:
Ask, “What 3 things do you think are most stressful about your school?”
Mark the student’s school’s top three areas of stress with 1, 2, and 3. Place a checkmark beside other areas of stress or risk factors that apply for this student’s neighborhood:
__ ο High student/teacher ratios
__ οCurriculum isn’t relevant
__ οLow academic achievement
__ οApathy
__ οDisruptive students
__ οViolence
__ οSchool building in bad shape
__ οWeak adult leadership
__ οHigh staff turnover
__ οTeachers aren’t available
__ οFew allowances for individual differences
__ ο Police presence
__ ο Lack of police presence
__ ο Noise
__ ο Trash/pollution
__ ο Fighting between neighbors
__ ο Drug use
__ ο Alcohol use
__ ο Drug dealing
__ ο Overcrowding
__ ο Other __________________________
__ ο Other __________________________
__ ο Other __________________________
Community stress:
Ask, “What 3 things do you think are most stressful about your neighborhood?”
Mark the student’s neighborhood’s top three areas of stress with 1, 2, and 3. Place a checkmark beside other areas of stress or risk factors that apply for this student’s neighborhood:
__ ο Violence
__ ο Police presence
__ ο Lack of police presence
__ ο Noise
__ ο Trash/pollution
__ ο Fighting between neighbors
__ ο Drug use
__ ο Alcohol use
__ ο Drug dealing
__ ο Prostitution
__ ο Nothing to do
__ ο Not safe to go outside
__ ο Nowhere to play
__ ο Poor transportation
__ ο No grocery stores, drug stores, etc.
__ ο Few community organizations
__ ο Rats, bugs, other animals
__ ο No successful adults around
__ ο Neighborhood affected by disaster (fire, earthquake, flood, etc.)
__ ο Overcrowding
__ ο Other __________________________
__ ο Other __________________________
__ ο Other __________________________
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