Youth At Risk Screening Questionnaire
Mentor Research Institute
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.
Date Form Completed: Month select December January February March April May June July August September October November Day of Month: Year: 2005
Child's First Name: Last Name:
Date Of Birth (13 to 17 years old): Month: Month December January February March April May June July August September October November select Day Of Month: Year: 1981 1982 1983 1984 1985 1986 1987 1988 1989 select
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 (required):
Please be sure your e-mail address is correct if you want a response.
4. Has difficulty waiting or taking turns
5. Interrupts or intrudes on others
7. Is being used by other kids who are not good friends
8. Stealing without confronting a victim
9. Truancy from school
10. Easily frustrated or impatient with simple and reasonable rules
11. Swears
12. Pushes people away but then desperately wants them back
13. Touchy or easily annoyed by others
14. Easily frustrated and upset by events or circumstances
15. Blames others for circumstances without good reason
16. Blames others for his or her own mistakes
17. Avoids healthy family or social activities
18. Argues with adults over little things
19. Lying
20. Actively defies or refuses the requests of adults
21. Deliberately does things to annoy people
22. Quick to react with anger
23. Spiteful or vindictive
24. Often late without good reason
25. Frequent (at least daily) emotional outbursts and mood swings
26. Reckless or irresponsible behavior
27. Their efforts to solve their problems are not reasonable and are not effective
28. Doesn’t seem to learn from mistakes and then change their behavior
29. Seems unable to see things from another person’s point of view
30. Reacts to criticism or consequences with feelings of intense guilt, anger or depression
31. Responds with rage, profanity or yelling when their point of view is not accepted
32. Requires an excessive amount of attention and support
33. Avoids discussing or ignores the impact of their behavior on others
34. Tries to negotiate, get out of problems and avoid consequences
36. Does not follow through with promises
37. Running away from home
38. Deliberate destruction of property or the belongings of others
39. Mental or emotional cruelty to others
40. Justifies hurting others who resist being manipulated or controlled
41. Initiating physical fights
43. Breaking into someone's house, building or car
44. Stealing when confronting a victim
45. Friends and family suspect a drug problem
46. Refuses to acknowledge even the obvious consequences or symptoms of drug use
49. Denies solid evidence of their drug use
50. Cruelty to animals
_______ TOTAL (Print this page and add your scores)
Please be sure you e-mail address is correct
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