The following is a list of behaviors that are associated with Youth at Risk. Circle the items that describe the youth you are concerned about.  Add the numbers up. A list of ranges are provided below.  You may also check the boxes next to each question and submit the form to us by e-mail for feedback. These ranges indicate a level of risk that your child's problem behavior will escalate without intervention. 

Professional consultation is always appropriate if you have concerns regarding mental, emotional or behavioral problems.  This questionnaire should not be used to screen for medical, psychiatric or mental health disorders.  No questionnaire can replace or substitute for professional consultation.  This questionnaire is designed to help you clarify your concerns, help you discuss issues with a counselor or mental health professional and to give you an indicator of approximate risk.

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Date Form Completed:  
Month select December January February March April May June July August September October November     Day of Month:    Year: select 2006 2007

Child's First Name:      Last Name:

Date Of Birth:      
Month: Month December January February March April May June July August September October November select     Day Of Month:    Year: 1982 1983 1984 1985 1986 1987 1988 1989 select adolescents

Age:  12 13 14 15 16 17 18 select    Gender:   select Male Female

Person Completing The Form: 
First Name:     Last Name:

Your Relationship To The Child:  select Father Mother Step Mother Step Father Adoptive Mother Adoptive Father Other Relative Friend of Family Mental Health Professional Teacher Other

E-mail Address:

State Where You Live:

Please be sure your e-mail address is correct if you want a response.

After you submit this form, a results page will appear along with a brief list of resources,  helpful interpretation material and additional screening resources.