Student Intake Questionnaire

Student Information

Student Date Staff Completing Form

ACES Questionnaire

Swear at you, insult you, or humiliate you?

Push, grab, slap, or throw something at you?

Sexual abuse by adult or older youth?

Felt unloved or unsupported?

Neglect or lack of basic needs?

Parents separated or divorced?

Domestic violence toward mother/stepmother?

Lived with substance abuse?

Mental illness or suicide in household?

Household member incarcerated?

Questions Left Blank / Notes

ITP Planning Information

Career Interests Employment Post Discharge Social Support Behavioral / Mental Health Needs

ICMP

Strengths & Preferences When Happy I Describe Myself As Things That Make Me Angry / Upset

Warning Signs

Tense Muscles
Heavy Breathing
Speak Louder/Faster
Sweaty Palms
Tremble/Shaking
Leg Shaking
Fist Clenching
Pacing
Hit Things
Jaw Tightens
Face Gets Hot
Crying
Get Quiet

Support People

People Who Help Me People Who Make Things Worse

Coping Skills

Time By Myself
Visit
Writing/Journaling
Drawing
Thinking Alone
Music
Follow Crisis Plan
Other
Talk To Additional Coping Skills How Others Can Help Additional Notes