Behavioral Assessment

Pine Creek Ranch provides this behaviorial assessment service to you free of charge. The instrument measures a wide range of troublesome behaviors, situations, and moods which commonly apply to troubled teenagers including intrapersonal distress, psycho somatic, interpersonal relations, critical items, social problems and behavioral dysfunction. This is the same standardized instrument the University of Idaho used in their research regarding the outcome success of adolescent treatment programs. Through this assessment, we can help you determine what level of intervention may or may not be necessary according to national standards. Please complete the assessment according to the instructions and submit them to us. We are happy to give you the assessment results via e-mail, however, we have found that telephone interaction and discussion are far more insightful and helpful. If you prefer telephone interaction please make sure you leave a phone number and the best time to call you. It usually takes 1-2 business days to process the assessment. A representative will contact you at that time. Please make sure you mark every question so we can accurately process the assessment.

You may discover that some of the items do not apply to your child’s current situation. If so, please do not leave these items blank. Rather, select the “Never or almost never” category. When you begin to complete this evaluation, you will see that you can easily make your child look as healthy or unhealthy as you wish. Please do not do that. If you are as accurate as possible, it is more likely that you will be able to receive the help that you are seeking for your child.

We have learned through sad experience that some parents are trying to use this assesment tool in divorce and custody cases. The purpose of this assesment tool is informational in nature and is not to be used or represented as a diagnostic instrument.

DIRECTIONS:

• The assessment is only to be completed for children that are 13-18 years old.
• Fill out the evaluation test for ONE child only.
• Read each statement carefully.
• Select the number that most accurately describes your child.

Child Information

First Name

Last Name

Age of Child:

Gender of Child: Male Female

Parent/Guardian Information

First Name	Last Name
E-mail	Phone Number	Best time to call (optional)

How did you hear about Us? Word of Mouth Alumni Education Consultant Mental Health Professional Search Engine Other Name of the Education Consultant:

If Other, please specify

Assessment - Part I

	1. Wants to be alone more than other children of the same age.
	2. Complains of dizziness or headaches.
	3. Doesn't participate in activities that were previously enjoyable.
	4. Argues or is verbally disrespectful.
	5. Is more fearful than other children of the same age.
	6. Cuts school or is truant.
	7. Cooperates with rules and expectations.
	8. Has difficulty completing assignments or completes them carelessly.
	9. Complains or whines that things are unfair.
	10. Experiences trouble with her/his bowels, such as constipation or diarrhea.
	11. Gets into physical fights with peers or family members.
	12. Worries and/or can't get certain ideas out of his/her mind.
	13. Steals or lies.
	14. Is fidgety, restless, or hyperactive.
	15. Seems anxious or nervous.
	16. Communicates in a pleasant and appropriate manner.
	17. Seems tense, is easily startled.
	18. Soils or wets self.
	19. Is aggressive toward adults.
	20. Sees, hears, or believes things that are not real.
	21. Has participated in self-harm (e.g. cutting or scratching self, attempted suicide)
	22. Uses alcohol or drugs.
	23. Seems unable to get organized.
	24. Enjoys relationships with family and friends.
	25. Appears sad or unhappy.
	26. Experiences pain or weakness in muscles or joints.
	27. Has a negative or distrustful attitude toward friends, family members, or adults.
	28. Believes that others are trying to hurt him/her even when they are not.
	29. Threatens to or has run away from home.
	30. Experiences rapidly changing and strong emotions.
	31. Deliberately breaks rules, laws, or expectations.
	32. Appears happy with her/himself.
	33. Sulks, pouts, or cries more than other children of the same age.
	34. Pulls away from family or friends.
	35. Complains of stomach pains or feeling sick more than other children of same age.
	36. Doesn't have or keep friends.
	37. Has friends of whom I don't approve.
	38. Believes that others can hear his/her thoughts or that s/he can hear the thoughts of others.
	39. Engages in inappropriate sexual behavior (e.g. sexually active, exhibits self, sexual abuse toward family members or others).
	40. Has difficulty waiting his/her turn in activities or conversations.
	41. Thinks about suicide, says s/he would be better if s/he were dead.
	42. Complains of nightmares, difficulty getting to sleep, oversleeping, or waking up from sleep too early.
	43. Complains about or challenges rules, expectations, or responsibilities.
	44. Has times of unusual happiness or excessive energy.
	45. Handles frustration or boredom appropriately.
	46. Has fears of going crazy.
	47. Feels appropriate guilt for wrongdoing.
	48. Is unusually demanding.
	49. Is irritable.
	50. Vomits or is nauseous more than other children of the same age.
	51. Becomes angry enough to be threatening to others.
	52. Seems to stir up trouble when bored.
	53. Is appropriately hopeful and optimistic.
	54. Experiences twitching muscles or jerking movements in face, arms, or body.
	55. Has deliberately destroyed property.
	56. Has difficulty concentrating, thinking clearly, or attending to tasks.
	57. Talks negatively, as though bad things are all his/her fault.
	58. Has lost significant amounts of weight without medical reason.
	59. Acts impulsively without thinking of the consequences.
	60. Is usually calm.
	61. Will not forgive him/herself for past mistakes.
	62. Lacks energy.
	63. Feels that s/he doesn't have any friends or that no one likes him/her.
	64. Gets frustrated and gives up or gets upset easily.

Assessment - Part II

	1. Has offended numerous times.
	2. Has offended against more than one victim.
	3. Has offended against a victim in the home.
	4. Comes from an environment of family dysfunction.
	5. Has history of sexual abuse himself by family member.
	6. Tends to blame his victims.
	7. Is not able to appreciate the impact he has had upon the victims.
	8. Has a history of delinquent behavior.
	9. Has a history of substance abuse.
	10. Has a family that is unable to enforce restrictions on offender’s behavior.
	11. Admits to his offense.
	12. Has a family supportive of treatment.
	13. Has victims that are members of his immediate family.
	14. Has been physical or sexual abuse within the home.
	15. Has current substance abuse issues within the home.
	16. Has offended against only one victim.
	17. Has not used aggression in their sexual offenses.
	18. Shows a narrow range of sexual misconduct.
	19. Was caught in a first time offense.
	20. Shows no escalation in sexual offending.
	21. Has had no previous treatment for sexual offending.
	22. Has no established patterns of delinquent behavior.
	23. Demonstrates some capability in social relationships.
	24. Shows some school dysfunction, put is still enrolled.
	25. Has some understanding of why their sexual offenses were wrong.
	26. Can discuss their offenses.
	27. Does not blame the victim.
	28. Has some appreciation of the negative impact on their victim.
	29. Is willing to cooperate with treatment.