Home Life/Living Situation
Notes (include risks and protective factors):
Education/Employment
Notes (include risks and protective factors):
Sleeping, Eating and Exercise
Notes (include risks and protective factors):
Activities and Peer Relationships
Notes (include risks and protective factors):
Drug Use Including Alcohol
Notes (include risks and protective factors):
Sexuality
Notes (include risks and protective factors):
Mood
Notes (include risks and protective factors):
Self Harm
Notes (include risks and protective factors):
Depression
Notes (include risks and protective factors):
Suicide
Notes (include risks and protective factors):
Safety
Notes (include risks and protective factors):
Spirituality/Culture
Notes (include risks and protective factors):
Other
Other Details:
School Year:
Used Youth Chat Screening Tool: