Intake Assessment Screening Form for Expect Respect Support Groups (Intake Assessment)

Intake Assessment

Expect Respect Support Group Evaluation

Form Approved

OMB No. 0920-0861

Exp. Date: 8/31/2013

Public Reporting burden of this collection of information is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-0861).

School:_____________________________

Data Collector:___________________________

Student ID: ­­­­­­­­­­­­­­­­­­­___________________

Screening Date: ___________________

Student is eligible to participate in ERSG Evaluation because (check all that apply):

_____ Is between age 11 to 17

_____ Reports history of witnessing domestic violence

_____ Reports history of experiencing child abuse (emotional/mental, physical, sexual, neglect)

_____ Is or has been involved in abusive peer and/or dating relationships

_____ Other (e.g. community violence)

Student is not eligible to participate in ERSG Evaluation because (check all that apply):

_____ Student is under age 11 or over age 17

_____ Has never experienced (i.e., been a victim, perpetrator, or witness of) any form of violence

_____ Student requires higher level of care than ERSG can provide (i.e., student is in crisis – acute emotional upset, suicidal or homicidal ideations)

Next steps:

_____ Participation in ERSG

_____ Participation in control group

_____ Referral: ________________________

_____ 1-3 sessions of psychoed

_____ Student received info packet and resources.

Does the student give permission to be contacted for follow-up by phone, by e-mail or by mail?

______ YES (phone #____________________________, e-mail, address )

______ NO