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

reddening of the skin of the target person.

3)

Purposeful attack of others that causes

superficial injury or injuries requiring medical attention.

4)

Attacks with intent to cause severe injury (e.g.,

broken bones) using potentially lethal force with or without use of weapon.

Once or More Per:

Day

Week

Month

6 Mo.

j)

Property Theft

1)

Takes others' belongings of little or no

monetary value or importance – may be indicative of hoarding.

2)

Steals for personal use; or steals belongings

of moderate or greater monetary value or importance (advance planning is involved); may barter or sell goods taken.

Once or More Per:

Day

Week

Month

k)

Substance Abuse

1)

Uses alcohol or non-addictive substances to become

intoxicated.

2)

Has an alcohol dependency.

3)

Is addicted to a controlled substance.

Persons who use tobacco products or alcohol at levels that do not produce intoxication should not be scored on this item.

Check box if condition is present regardless of frequency.

Once or More Per:

Day

Week

l)

Extreme Irritability

1)

Acts fretful or annoyed in an overly reactive manner to an extent

that interferes with own social functioning and/or upsets others.

2)

Displays anger in an overly reactive manner that staff perceive

as potentially resulting in physical aggression.

Once or More Per:

Min.

Hour

4 Hrs.

Day

m)

Hyperactivity

1)

Moves about area continuously in a somewhat

predictable and moderately-paced manner.

2)

Moves around area continuously in a seemingly

random and very rapid manner.

3)

Bounces up and down or is in and out of chair/

place/work station continuously.

Once or More Per:

Day

Week

Month

n)

Temper Tantrums

1)

Makes inconsequential verbal threats and/or cries loudly,

jumps up and down or stamps feet when angered.

2)

Threatens others physically when upset and/or curses

and kicks or hits objects briefly.

3)

Yells loudly, thrashes about, kicks, cries and presents

what appears to be an imminent danger to others.

Once or More Per:

Day

Week

Month

6 Mo.

o)

Wanders, Roams, Runs Away

1)

Wanders away from immediate supervision 

but returns when called.

2)

Runs away or wanders out of sight and does 

not return when called even though still within hearing distance.

3)

Sneaks away for hours or longer. 

Once or More Per:

Week

p)

Depression or Excessive Withdrawal

1)

Is under-responsive to normal social interactions; inactive;

may be quiet and unusually passive.

2)

Rejects contact with others; refuses formerly preferred

reinforcers; may be inactive, quiet and passive; refuses to eat.

Once or More Per:

Day

Month

6 Mo.

Year

q)

Hallucinations

Talks or acts as if experiencing sensory events that

others do not (e.g., hearing voices) at various times and places and to an extent that it disrupts or interferes with socially adaptive responses.

Once or More Per:

Day

Month

6 Mo.

Year

r)

Delusions

Talks about ideas and events that have no basis in

fact and, in spite of evidence to the contrary, to an extent that it disrupts or interferes with his or her socially adaptive responses.

Once or More Per:

Day

Week

Month

6 Mo.

Year

s)

Fire-Setting

1)

Plays with matches, open flames

and/or cigarette lighters.  May have accidentally set objects on fire; potential small danger to self or others.

2)

Collects or locates flammable

materials, such as paper or leaves, to use in setting small fire; or starts fires in contained vessels, such as waste-baskets, garbage cans. Overall potential moderate danger to others.

3)

Sets a large fire, such as a bed or

draperies, which has the potential for burning a room or a building; may or may not use an accelerant.

Once or More Per:

Min.

4 Hrs.

Day

t)

Self-Injurious Actions

1)

Purposefully inflicts a blow or bite to self that 

causes reddening of the skin.

2)

Purposefully inflicts a blow or bite to self that 

causes superficial injury requiring medical attention.

2)

Purposefully inflicts on oneself a blow that causes 

severe injury (e.g., broken bone) or a bite that removes a large amount of tissue.

Once or More Per:

4 Hrs.

Day

Week

u)

Handles/Plays With Bodily Wastes

1)

Plays or touches rectum or genitals; small amount  

of fecal materials or urine found on hands.

2)

Smears feces or urine on own clothing and body;  

hoards feces on person or in room.

3)

Smears feces or urine on others or on nearby  

objects.

4)

Eats feces or urine.

Once or More Per:

Day

Week

Month

6 Mo.

v)

Property Destruction (excluding firesetting).  (Please note that the primary maladaption here is property destruction rather than self-injurious actions or assaults that may also cause property destruction.)

1)

Purposefully damages own or others' property 

resulting in a projected negligible or minor repair/replacement cost.

2)

Purposefully damages own or others' property 

with a projected major repair/replacement cost.

Once or More Per:

Day

Week

Month

w)

Resists Supervision

1)

Will not comply with staff request to act in a considerate

manner (e.g., plays radio too loud, cuts in line) or refuses to comply with staff instructions to correct behaviors or engage in behaviors affecting self in a minor way (e.g., with not bathe regularly, will not brush teeth).  

2)

Refuses to comply with demands to cease behavior

or to cooperate, thus significantly disrupting ongoing activities or the living unit in general.

3)

Refuses to cease behavior constituting imminent and 

significant danger to self or others.

Once or More Per:

Min.

Hour

4 Hrs.

Day

v)

Stereotypical Behavior 

Repetitive motor or verbal activity, including

self-stimulation, which does not serve meaningful purposes (e.g., string twirling, bizarre limb or body movements, rocking, repeated verbalizations; DOES NOT INCLUDE self injurious behavior or masturbation.