start av comprehensive rating form...strengths vulnerabilities follows rules at home, in school, and...

START:AV Comprehensive Rating Form

Name: ________________________ D.O.B.: ___ /___ /______ (MM/DD/YYYY) Sex: Male Female Other

Date of Assessment: ___ /___ /_____ (MM/DD/YYYY) Deadline for Next Assessment: ___ /___ /_____ (MM/DD/YYYY)

Status: Institution/inpatient Community/outpatient Other ___________

Purpose: Referral Admission Review Other _________

Step 1: Gather Information

Obtain necessary consents.

Obtain information from multiple sources (e.g., interview adolescent and caregivers, review records).

Check all sources of information that were used in the START:AV Assessment:

Interview with adolescent

Interview with caregiver(s)

Interview with other collateral source (if yes, specify the type of collateral source): ________________________________________

_______________________________________________________________________________________________________________________________

School records

Treatment records (if adolescent has received prior treatment)

Justice records (if adolescent has had justice system contact)

Social service or maltreatment records (if adolescent has had social service contact)

Results of formal testing or assessment tools (if yes, specify the type of testing or tools): _________________________________

_______________________________________________________________________________________________________________________________

Other (if yes, specify):

Do you have any concerns about the quality of information used in this START:AV assessment (e.g., difficulty accessing records)?

If yes, please describe.

© 2014 by the authors. This work is licensed under a Creation Commons Attribution 4.0 International License.

1 of 14

Step 2: Rate Strengths and Vulnerabilities

Rate Strengths and Vulnerabilities as Low (minimal), Moderate (some), or High (substantial).

In making these ratings, focus on the reference period; usually this is the period from three months ago to current date:

_______________________________ (MM/DD/YYYY) to ________________________________ (MM/DD/YYYY)

Identify Key Strengths and Critical Vulnerabilities (i.e., these are items that play an instrumental role in contributing to or

protecting against Adverse Outcomes); even items that are currently rated as Low can be Key or Critical.

Record notes or underline descriptors as needed.

Individual Adolescent

STRENGTHS VULNERABILITIES

Appreciates the value of education and work. Performs as

well as he or she can. Has good work habits (e.g., reliable,

does assignments on time, accepts assistance).

Demonstrates a strong commitment to school/work (e.g.,

shows initiative, seeks out opportunities). Succeeds in

academic or work environment.

1: School &

Work

Lacks interest in education or work. Does not perform to

potential. Has poor work habits (e.g., fails to complete

tasks, requires inordinate help). Experiences difficulties

achieving success (e.g., due to learning challenges).

Demonstrates poor commitment to school/work (e.g.,

refuses assistance, consistently late or does not attend at

all). Experiences academic or work failures.

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Uses leisure time for safe, appropriate pursuits.

Participates in prosocial and positive activities with

assistance. Uses leisure time constructively. Shows good

balance of activities. Actively or independently seeks out

and engages in positive, healthy, or prosocial activities.

2: Recreation

Has few, if any, appropriate prosocial or positive hobbies or

interests. Refuses to participate in appropriate or prosocial

activities. Spends inordinate amounts of time in

unsupervised and unstructured activities. Preoccupied with

antisocial or destructive activities.

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Aware of the consequences of irresponsible use and

makes active efforts to control use. Accepting of

treatment (if needed). Respectful of pertinent laws (e.g.,

drinking age, driving under the influence). Avoids

substances and/or declines when offered. Abstains from

use or shows responsible and age-appropriate use.

3: Substance

Use

Fails to acknowledge health risks or consequences of use.

Misuses illegal substances, alcohol, medication, or other

substances. Use results in adverse effects on self or others.

Denies need for treatment (if indicated). Preoccupied with

acquiring and using substances. Use is out of control

and/or is dependent.

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

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Follows rules at home, in school, and in other settings.

Shows appreciation of the need for rules. Obeys caregiver

and legally-stipulated conditions (e.g., curfew, avoidance of

specific places/people, school attendance). Cooperates with

routine assessments/tests (e.g., urine tests). Demonstrates

independent, responsible behaviors and compliance across

contexts and settings.

4: Rule

Adherence

Only complies if considerable supervision is provided.

Does not make effort to understand the reasons for rules

or restrictions. Breaks rules at home, in school, and in

other settings. Refuses to cooperate with routine

assessments/tests (e.g., personality assessment). Disobeys

legally-stipulated conditions and laws (e.g., speeding,

curfew, school attendance, shoplifting, drugs).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Engages in prosocial and positive behaviors (e.g., respects

persons and property, punctual, cooperative). Creates

positive atmosphere (e.g., kind, considerate, accepts

responsibility). Makes efforts to protect self from harm

(e.g., avoids dangerous circumstances). Promotes safety,

comfort, and care of others (e.g., helps others, engages in

altruistic behavior).

5: Conduct

Unintentionally jeopardizes the safety, comfort, or care of

self or others (e.g., texting while driving, horseplay).

Creates a negative atmosphere (e.g., sexist or racist

comments, disrespectful, disruptive). Non-accidental

behavior that could result in serious harm to self or others.

Engages in self-injury, suicidal behaviors, antisocial

behaviors, or aggression (e.g., bullying).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Maintains hygiene and personal appearance, and obtains

sufficient sleep, exercise, and nutrition. Engages in safe

sexual practices (e.g., abstinence, condom use). Takes care

of physical health and shows healthy behaviors across

domains (e.g., obtains regular exercise, eats healthy foods).

6: Self-Care

Shows poor personal hygiene or grooming (e.g.,

unkempt). Does not obtain adequate sleep, exercise, or

nutrition. Engages in behaviors that may harm physical

health (e.g., tobacco use, extreme diets, binging, purging,

risky sexual behaviors).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Manages transitions and life changes satisfactorily.

Responds in an adaptive manner to perceived stressors or

changing circumstances. Seeks out and utilizes appropriate

help. Consistently solves problems effectively and with

appropriate initiative. Shows resilience and adaptability.

7: Coping

Finds it difficult to adapt to stressors, changing life

circumstances, or transitions. Fails to seek or use help or is

overly dependent on others. Unable to solve problems

adaptively or marshal personal resources in times of crisis.

Becomes immobilized or deteriorates under pressure.

Engages in serious or frequent maladaptive or harmful

coping strategies.

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

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Considers potential consequences of actions. Thinks and

plans through before acting. Tolerates frustration well.

Makes efforts to avoid or minimize risks (e.g., follows

safety rules, contemplates various options). Shows

restraint, control, and composure.

8: Impulse

Control

Does not anticipate consequences. Acts without thinking.

Shows poor frustration tolerance. Appears excitable,

overwrought, or unpredictable. Engages in frequent or

serious risk-taking without consideration of potential

consequences. Behaves in an out-of-control manner.

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Shows good attention and memory. Understands difficult

or abstract concepts. Thinks in a focused and flexible

manner. Demonstrates coherent and logical reasoning.

Learns new information quickly and easily. Shows good

judgment.

9: Mental/

Cognitive

State

Shows impaired attention, memory, or reasoning. Makes

poor judgments. Experiences difficulties learning.

Demonstrates disturbances in thinking (e.g., disorganized

thinking, obsessional thoughts, confusion, flashbacks of

traumatic events, hypervigilance, delusions, hallucinations).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Experiences frequent positive emotions (e.g., content,

happy, hopeful, enthusiastic, in good spirits). Regulates

negative and positive emotions in an effective manner

(e.g., calms him or herself down if upset, sad, worried, or

angry). Shows emotional resilience (i.e., withstands difficult

circumstances without developing emotional difficulties).

10: Emotional

State

Shows a limited range of emotions or is emotionally

withdrawn. Experiences frequent negative emotions (e.g.,

depressed, anxious, pessimistic, irritable, angry, hostile).

Feels worthless or hopeless. Has rapid, unpredictable mood

changes. Unable to regulate or control emotions.

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Views risk behaviors (e.g., violence, substance use, sexual

risk-taking) as negative and harmful. Holds prosocial and

positive beliefs towards self or others (e.g., appropriate

self-esteem, positive body image, respectful, remorseful).

Anticipates positive results from prosocial behaviors (e.g.,

working hard will help him/her achieve successes).

11: Attitudes

Views risk behaviors (e.g., offending, self-injury, school

drop-out, extreme diets) as acceptable and justified. Holds

antisocial and negative beliefs toward self or others (e.g.,

low self-esteem, callous, uncaring, mistakes others as being

hostile). Anticipates positive results from antisocial or risk

behaviors (e.g., self-injury will lead to emotional relief,

aggression will lead to peer respect).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

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Joins in and enjoys social activities. Communicates well

with others (e.g., initiates conversations, pleasant, polite,

appropriately assertive). Accurately reads and responds to

social cues. Able to adapt and fit into diverse social

contexts. Effectively navigates social situations, such as

managing or avoiding interpersonal conflicts.

12: Social Skills

Avoids social activities (e.g., shy, withdrawn, isolated).

Does not communicate well (e.g., lacks manners, difficult

to engage). Misinterprets social cues. Unable to

appropriately relate to others or navigate interpersonal

situations (e.g., immature, intrusive, reacts inappropriately

to interpersonal conflicts).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Relationships and Environment


Feels a sense of connectedness to caregivers or other

adults (e.g., values and builds close relationships, confides

in adults as appropriate, appropriate boundaries).

Adolescent treats caregivers and other adults well (e.g.,

considerate, empathetic, respectful, forgiving). Builds

healthy, reciprocal attachments and connections with

caregivers and adults.

13a.

Relationships

with Caregivers

& Adults

Does not feel a sense of connectedness to caregivers or

other adults (e.g., derives little satisfaction from

relationships, aloof). Mistreats caregivers and other adults

(e.g., inconsiderate, deceptive, manipulative). Has

inappropriate or unhealthy relationships with caregivers

and other adults (e.g., takes advantage of others, overly

trusting, easily manipulated, high conflict relationships).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Feels a sense of connectedness to peers (e.g., values and

builds close relationships, confides in peers as appropriate,

appropriate boundaries). Adolescent treats peers well (e.g.,

considerate, empathetic, respectful, forgiving). Builds

healthy, reciprocal attachments and connections to peers.

13b.

Relationships

with Peers

Does not feel a sense of connectedness to peers (e.g.,

derives little satisfaction from relationships, aloof).

Mistreats peers (e.g., inconsiderate, deceptive,

manipulative). Has inappropriate or unhealthy

relationships with peers (e.g., takes advantage of others,

overly trusting, easily manipulated, high conflict

relationships).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

5 of 14


Adequate social network of adults. Feels supported by an

adult(s) (e.g., teacher, therapist, grandparent). Adolescent

is receptive and accepting of support. Has an adult to turn

to when he or she needs help. Adults in the adolescent’s

life can be relied on for appropriate emotional and

practical assistance.

14a: Social

Support from

Adults

(do not include

caregivers)

Inadequate social network of adults. Does not feel

supported by an adult(s) (e.g., teacher, therapist,

grandparent). Social support is not consistently available.

Refuses needed help. Has no adult to turn to when he or

she needs help. Practical and emotional assistance is

unavailable or unhealthy.

Notes: Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Adequate social network of peers. Feels supported by

peers. Adolescent is receptive and accepting of support.

Has peers to turn to when he or she needs help. Peers can

be relied on for appropriate emotional and practical

assistance.

14b: Social

Support from

Peers

Inadequate social network of peers. Does not feel

supported by peers. Social support is not consistently

available. Refuses needed help. Does not have peers to turn

to when he or she needs help. Practical and emotional

assistance from peers is unavailable or unhealthy.

Notes: Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Caregivers provide a structured and stable environment.

Appropriately monitor the adolescent’s well-being, school

functioning, and social activities. Establish and enforce

clear, consistent, and fair rules, and implement

appropriate rewards and consequences. Create a

nurturing environment, and respond empathically,

appropriately, and consistently to adolescent’s needs.

15: Parenting

Caregivers do not provide structure and stability. Are

inconsistent or not available (e.g., changes in caregivers)

and do not provide adequate supervision or appropriate

consequences (e.g., overly harsh, overly lenient,

inconsistent). Contribute to or fail to shield adolescent from

unstructured, chaotic, and/or volatile environment. Are

rejecting, demeaning, neglectful, or abusive.

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Caregivers are responsible and deal with problems

constructively (e.g., seek and utilize assistance when

needed, have proactive and positive coping skills).

Caregivers engage in prosocial behaviors. Have a good

social support network and maintain healthy and stable

relationships. Caregivers role model healthy and

responsible physical, emotional, and social functioning.

16: Parental

Functioning

Caregivers have difficulties coping with stressors (e.g., do

not seek/utilize assistance). Caregivers have mental or

physical health difficulties. Do not have an adequate social

support network. Caregivers have unstable, unhealthy,

volatile, or violent relationships. Caregivers promote or

engage in irresponsible, negative, and unhealthy behaviors

(e.g., substance abuse, offending).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

6 of 14


Peer group is prosocial. Adolescent is able to resist

negative peer influences. Adolescent maintains strong

friendships with individuals who endorse or engage in

positive and healthy behaviors (e.g., peers are responsible,

hardworking, strive to do well in school, kind to others,

and/or involved in prosocial activities).

17: Peers

Peer network promotes or engages in negative and

unhealthy behaviors (e.g., violence, offending, non-suicidal

self-injury, unhealthy weight control methods, sexual risk-

taking). Adolescent is very susceptible to negative peer

influence. Experiences bullying, abuse, or putdowns from

peers. Entrenched in negative peer group (e.g., gang).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Caregiver(s)/adolescent has adequate means/income (e.g.,

stable and satisfactory housing; resources for clothing,

food, transportation, health/dental care). Manages income

in a responsible manner (e.g., no major financial drains or

debts). Has resources and uses them in the best interests of

the adolescent (e.g., paying for services to assist youth).

18: Material

Resources

Caregiver(s)/adolescent is financially restricted. Does not

manage income responsibly (e.g., large debts, spend

money on luxuries rather than needs). Does not have

resources for basic needs (e.g., poor or unstable housing;

cannot afford clothing, transportation, health/dental care;

uses food banks). Is below poverty line or homeless.

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Community has appropriate housing, schools, recreational

opportunities, and services. Neighborhood and/or school

are cohesive, stable, and safe. Neighborhood and school

are prosocial and positive environments (e.g., community

offers a range of youth services, school has effective anti-

bullying policies).

19: Community

Community provides limited or no access to appropriate

housing, schools, recreational activities, and services.

Community has high poverty, disadvantage, and

residential turnover. Neighborhood and school are unsafe

or have serious problems with substance use, violence,

crime, and/or gangs.

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Adolescent experiences salient and significant positive

event(s) that act as turning points or protective influences

(e.g., school success, positive feedback from peers or

caregivers and other adults, formation of positive and

healthy relationships).

20: External

Triggers

Adolescent is exposed to cues or means for engaging in a

risk behavior (e.g., exposure to drugs or weapons,

opportunities to offend). Experiences salient and serious

negative event(s) that act as triggers (e.g., relationship

conflicts, victimization).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

7 of 14

Response to Interventions


Appreciates the motivation and consequences behind

his/her actions. Recognizes signs of relapse at an early

stage. Acknowledges mental or substance use disorders,

personality traits, and emotional or behavioral problems.

Understands factors that increase or reduce his/her risks

for adverse outcomes (e.g., strengths, limitations).

Recognizes the need for interventions.

21: Insight

Fails to appreciate motivation or consequences behind own

actions. Does not adequately recognize early signs of

relapse. Does not recognize factors that increase or reduce

his/her risks for adverse outcomes (e.g., non-suicidal self-

injury, suicide). Denies mental or substance use disorders,

personality traits, and emotional or behavioral problems.

Does not recognize the need for interventions.

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Has specific, realistic, socially-acceptable, and prosocial

goals. Is future-oriented and goal directed. Adolescent

and his/her supports (e.g., caregivers, service providers,

etc.) have focused and appropriate plans to achieve

positive goals. Adolescent actively engages in planning to

achieve these goals, and takes steps to achieve short- and

long-term goals.

22: Plans

Lacks goals or has vague, unrealistic, or inappropriate goals.

Adolescent and his/her supports (e.g., caregivers, service

providers) do not have focused or appropriate plans.

Adolescent fails to take steps to achieve positive short or

long-term goals. Adolescent plans to engage in behaviors

that are unhealthy, antisocial, or harmful (e.g., plans to

commit violence, attempt suicide, join a gang).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Adheres to medication regimen and accepts the need for

prescribed medication. Makes an effort to understand the

function of prescribed medications and/or how side

effects can be minimized or managed. Takes initiative and

displays independence in managing medication use.

23:

Medication

Adherence

Not Applicable

Only complies with prescribed medication under

supervision. Denies need for medication or does not follow

recommended regimen despite potential harm or negative

consequences. Refuses to take prescribed medication or

takes too much/too little (e.g., outward refusal, purging

medications, cheeking or hoarding).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Participates in programs and services likely to be of

benefit (e.g., therapy, probation, treatment programs).

Cooperative and meaningfully engaged. Motivated to

succeed, and responds well to interventions and services.

24:

Treatability

Perceives no point in attempting change. Attends services

but merely “goes through the motions.” Does not engage

or cooperate. Refuses to participate in interventions and

services (e.g., therapy, probation), or is unresponsive to

these interventions.

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

8 of 14


Notes:

25: Case-

Specific Item

(optional)

(additional items

that are not

important to the

particular

adolescent being

assessed)

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Interested in maintaining cultural identity (e.g., speaks

primary language at home) or learning further about his or

her culture or others’ cultures (e.g., interested in receiving

culturally-relevant services). Has pride in his or her culture.

Has strong, positive role models within his/her culture (e.g.,

Elders). Participates in cultural events or ceremonies.

Respectful of other cultures and feels comfortable moving

across cultural groups (e.g., has friends from various

cultures). Strong, healthy connectedness to his/her

culture(s).

25: Case-

Specific –

CULTURE

(optional)

(you may use

this with youth

from ethnic,

racial, and

national minority

groups)

Holds inaccurate or discriminatory views of his/her culture

or other cultures. Disconnected from the dominant culture

and/or his/her culture. Ashamed of his or her culture.

Experiences put-downs, stigma, or discrimination as a

result of culture (e.g., racist comments). Feels he/she does

not fit in to any cultural group. Condones or engages in

discriminatory acts or aggression based on cultural values

(e.g., violence against women, terrorism) or cultural

identity (e.g., belongs to a gang organized or defined by

ethnicity or race).

Notes:

Notes:

Key

High

Moderate

Low

Low

Moderate

High

Critical

Signature Risk Signs: No Yes

These are highly idiographic or individualized signs that an adverse outcome is about to occur or that the adolescent has decompensated.

Signature risk signs are optional to include.

9 of 14

Step 3: Rate History and Future Risks

Check the circle to indicate if an adolescent has a Prior History and/or Recent History of each Adverse Outcome.

Rate the adolescent’s future risk as as Low, Moderate, or High Risk for each Adverse Outcome (as compared to an

average adolescent in the general population). Take into account the likelihood of the outcome and its severity.

Focus on short-term risk from the current date to three months from now. Or, you can specify an earlier reassessment:

__________________________ (MM/DD/YYYY – current date) to ___________________________ (MM/DD/YYYY – reassessment date)

Harm to Others and Rule Violations

HISTORY FUTURE RISK

Prior History

(prior to 3 months ago)

Recent History

(in past 3 months)

1: Violence

Includes actual, attempted, or threatened

physical harm to others (e.g., assaults,

thwarted attempts to assault another

person, threats made with weapon in

hand, robbery while holding a gun or

weapon). The violence does not need to

have led to an arrest.

Low Moderate High

Notes:

Notes:

Is there a T.H.R.E.A.T.? No Yes

Specify:

Prior History


Recent History

(in past 3 months)

2: Non-Violent Offenses

Includes property offenses (e.g., theft),

drug offenses (e.g., selling a controlled

substance), and other miscellaneous

offenses (e.g., mischief). It does not include

minor traffic violations (e.g., speeding

tickets) or status offenses (e.g., school

truancy). The offense does not need to

have led to an arrest.

Low Moderate High

Notes:

Notes:

Prior History


Recent History

(in past 3 months)

3: Substance Abuse

Includes problematic use or misuse of

controlled substances (e.g., alcohol,

cocaine), prescription drugs (e.g., misuse

of psychostimulant medication), or

common household substances (e.g.,

inhaling solvents). Focus on use that

results in adverse consequences. Do not

include tobacco here.

Low Moderate High

Notes:

Notes:

Prior History


Recent History

(in past 3 months) 4: Unauthorized Absences

Includes absences from: school (e.g.,

school dropout, serious school truancy),

residences (e.g., running away or absence

from home, a detention center, or a

residential facility), treatment and other

services (e.g., failure to attend services,

treatment dropout, probation violations).

Low Moderate High

Type: School (e.g., truancy, drop-out)

Residences (e.g., running away)

Services (e.g., treatment drop-out)

Notes:

Type: School (e.g., truancy, drop-out)

Residences (e.g., running away)

Services (e.g., treatment drop-out)

Notes:

10 of 14

Harm to the Adolescent

HISTORY FUTURE RISK

Prior History


Recent History

(in past 3 months)

5: Suicide

Includes suicide attempts, whether or not

they result in death. Only include those

behaviors in which the adolescent had at

least some intention to die.

Low Moderate High

Notes:

Notes:


Specify:

Prior History


Recent History

(in past 3 months)

6: Non-Suicidal Self-Injury

Includes deliberate self-injury, involving

harm to bodily tissues, in which the

adolescent does not have any intention

to kill him or herself.

Low Moderate High

Notes:

Notes:


Specify:

Prior History


Recent History

(in past 3 months)

7: Victimization

Includes physical, sexual, emotional, and

relational victimization, property crime,

and neglect, which is perpetrated towards

the adolescent by any individual(s) (e.g.,

caregivers, other known adults, peers,

strangers). It includes victimization that

does not result in charges (e.g., bullying)

and online victimization. It does not

include witnessing violence.

Low Moderate High

Type: Physical Sexual Emotional

Relational (e.g., being bullied) Neglect

Other: ________________________

Notes:

Type: Physical Sexual Emotional

Relational (e.g., being bullied) Neglect

Other: ________________________

Notes:


Specify:

Prior History


Recent History

(in past 3 months)

8: Health Neglect

Includes harmful physical health

behaviors that the adolescent engages in,

such as unhealthy diet (e.g., unhealthy

weight control practices), exercise

patterns (e.g., inadequate exercise), sleep

patterns (e.g., inadequate sleep), or risky

sexual behaviors (e.g., failure to use

condoms). It also includes tobacco use

and failure to obtain needed medical and

dental services.

Low Moderate High

Notes:

Notes:

11 of 14

HISTORY FUTURE RISK

Prior History


Recent History

(in past three months)

9: Case-Specific Adverse Outcome:

_____________________________________________

Includes additional case-specific risk

domains that are not addressed in the

other Adverse Outcomes. These are

optional to include.

Low Moderate High

Notes:

Notes:

Periods of Stability:

Describe recent or historical periods of time in which the adolescent was doing better than he or she is currently. Pay attention to why

this period of relative stability may have occurred (e.g., “Allison showed reduced substance abuse after she moved in with her aunt”).

12 of 14

Step 4: Intervention Plan

Specify which Adverse Outcomes you plan to focus on in your Intervention Plan:

______________________________________ _____________________________________ _____________________________________

Systematically complete the questions below; refer to the START:AV User Guide for examples.

What are the primary Adverse Outcomes that this adolescent

is at risk for?

What intensity of interventions is needed to address these

risks? (Step 1)

What Critical Vulnerabilities contribute to or drive this

adolescent’s risk?

What interventions should be used to reduce these Critical

Vulnerabilities? (Step 2)

Which Key Strengths may reduce this adolescent’s risks? What interventions should be used to leverage or build these

Key Strengths? (Step 3)

If you run out of space above, you may add additional pages as needed.

13 of 14

What are specific scenarios or situations that could lead to

Adverse Outcomes (i.e., Scenarios of Concern)?

What interventions should be used to help prevent these

Scenarios of Concern? (Step 4a)

1.

2.

3.

What could happen that could lead to recovery, reduced risk,

or progress (i.e., Scenarios of Improvement)?

What interventions should be used to bring about these

Scenarios of Improvement? (Step 4b)

Are there additional goals that are important to this

adolescent’s healthy development?

What interventions should be used to work towards these

goals for healthy development? (Step 5)

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