Client Name

Client Identification

Residential Facility

Client Birthdate

Day Program

Assessment Date

Assessor

Once or More Per:

Day

Week

Month

Year

a)

Coercive Sexual Behavior

1)

Touches or grabs others' genitals without their

consent and/or is aggressively affectionate but will cease engaging in behavior(s) upon request.

2)

Intimidates (without injuring) another to engage

in sexual behaviors not including penetration of bodily orifices.

3)

Intimidates (without injuring) another to engage

in sexual behaviors including penetration of bodily orifices.

4)

Injures victim in the course of a sexual attack

which may or may not include penetration of bodily orifices.

Once or More Per:

Day

Week

Month

Year

b)

Offensive Bodily Exposure

1)

Engages in partial or full nudity or genital

exposure in view of others in inappropriate locations within the treatment setting only.

2)

Exposes self (not including genitals) in a

manner offensive to others when outside the treatment setting.

3)

Exposes self (including genitals) in a manner

offensive to others when outside the treatment setting.

Once or More Per:

Day

Week

Month

Year

c)

Suicide Threats and Attempts

(These behaviors imply purposeful suicidal action as opposed to self-injurious actions or pica behavior devoid of conscious suicidal intent.)

1)

Threatens to commit suicide, may or may not

be specific how and does not attempt to injure self (e.g., states, "I'm going to kill myself," but does not follow statement with action).

2)

Purposefully engages in behavior that could be

fatal, with or without precursory threats, but discontinues behavior upon verbal intervention without injuring self.

3)

Purposefully engages in behavior that could be

fatal, with or without precursory threats. Injures self, or is prevented from self-injury only by physical staff intervention.

Once or More Per:

Hr.

4 Hrs.

Day

Week

Month

d)

Pica

1)

Mouthing and licking of non-food

objects or compulsive and excessive eating and/or drinking of food and liquids.

2)

Consumption of non-food objects in

volume small enough to be not life-threatening, e.g., small pieces of rubber, plastic or fabric, soil, small nuts and bolts, grass, etc.

3)

Consumption of life-threatening

materials such as paint, cleaning compounds, soap, boiling liquids, sharp objects, large objects that may cause alimentary blockages, or small objects (as in subsection (d)(2) above) in large enough volume to be life-threatening.

Once or More Per:

Day

Week

Month

e)

Verbal Abuse

1)

Uses mocking and teasing language.

2)

Uses language hostile in tone (e.g., sarcastic or

intimidating) or content, whether obscene or not; may yell or scream threats of violence without designating a specific person as a target.

3)

Directly and explicitly threatens specific others with

physical harm or violence.

Once or More Per:

Day

Month

6 Mo.

f)

Mania

Engages in constant activity marked by bizarre behavior,

incoherent speech and a nasty response if ignored or crossed.

Once or More Per:

Day

Month

6 Mo.

g)

Inappropriate Affect

Displays emotional tone that is incongruent in general form or

degree, with the idea, object or thought accompanying it.  Lack of emotional tone ("flat" affect) or incongruent and changing emotional tone ("labile" affect).

Once or More Per:

Day

Week

Month

h)

Manipulative Behavior

1)

Circumvents authority by asking successive individuals

in authority the same question/request until receiving the desired answer or permission.

2)

Exchanges items of unequal values to own benefit, e.g.,

trading a candy bar to get a coat.

3)

Lies about others to get them into trouble or to obtain a 

self-serving goal; or uses another person as an agent to perform unlawful, unacceptable or dangerous acts.

Once or More Per:

4 Hrs.

Day

Week

Month

i)

Physical Assault

1)

Light striking, kicking, pushing of others that

is purposeful, but does not appear to cause pain to the target person.

2)

Purposeful attack of others that causes