Clinician Assessment Tool



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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