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Psychosocial Assessment
of Youthful Victims of Interpersonal Violence* Leslie S. Zun, MD, MBAa Jodi Rosen, MPHb aDepartment of Emergency Medicine Finch University/Chicago
Medical School Chairman, Department of
Emergency Medicine Mount Sinai Hospital Medical
Center, Chicago, Illinois bBoys & Girls Club of Chicago Chicago, Illinois *Presented at the 9th
Annual Midwest Regional SAEM Research Forum, September 27, 1999, Ann
Arbor, Michigan. Supported by the Joyce Foundation, Woods Fund of
Chicago, Michael Reese Health Trust, The Center on Crime, Communication,
Culture, Open Society Institute and Baxter International.
KEY
WORDS: violence prevention,
psychosocial assessment ABSTRACT Objectives: Although interpersonal intentional injuries are frequently
treated in acute care facilities and clinics, there is little or no
psychosocial assessment of these patients. The purpose of this project
was to describe a needs assessment tool for making appropriate referrals
from the acute care facility for youth that are victims of interpersonal
violence. Methods: A team consisting of an emergency physician, social
worker/criminologist, and public health administrator worked together
to develop the tool. The youth assessment tool was a 10-page document
composed of 13 constructs used to determine the needs of the youth:
identification and contact information, exposure to violence, legal
issues, drug and alcohol use/abuse, mental health, gang involvement,
education, employment, life skills, pregnancy/parenting, medical care
and recreational activities. Answers to the constructs trigger referrals
to medical, mental health, or social service agencies or services.
The assessment was performed on a random group of consenting victims
of violence between the ages of 10 and 24 in the hospitals service
area with the ability to follow up. Results: The assessment tool was offered to 238 youths who were
victims of violence from May 1998 to October 1999. Sixteen of the
youths refused to enter into the study. The rest (93.3%) consented
and were randomized to receive the assessment. All youth who received
the assessment tool completed it. Conclusions:
An assessment tool has been successfully developed to determine the
psychosocial needs of young people and appropriate referrals after
they have become victims of violence. The instrument was well received
by the youth and needs further study. INTRODUCTION Young victims of intentional violence
are frequently seen in acute care facilities and clinics with little or no assessment of their psychosocial
needs. The need for a psychosocial assessment instrument for young
victims of interpersonal violence is well documented in the literature.
The American Academy of Pediatrics
Task Force on Adolescent Assault Victims Needs suggests that an assessment
leads to an individualized plan that is based on the developmental
and emotional needs of the victim, psychosocial risk factors for revictimization,
and available local resources.1 Young victims of violence commonly
suffer from the immediate consequences of psychological injury.2 This
injury pattern can include depression, stress, fears and worries,
aggression, anxiety, low self-esteem, posttraumatic stress, and self-destructive
behaviors. Depression, anxiety, posttraumatic stress, anger, and dissociation
have a rate of occurrence from 19% to 27%.3,4 The Task Force on
Adolescent Assault Victim Needs comments on the various responses
found in children exposed to violence: behavioral, academic, and psychiatric
disturbances. The common psychiatric symptoms include posttraumatic
stress disorder, psychic numbing, sleep disturbances, avoidance behavior,
exaggerated startle response, trauma-specific fears, and difficulty
forming close personal relationships.1 Violence exposure in the adolescents
environment is highly associated with violent behaviors.3 Pediatricians have
taken the lead in recommending violence prevention programs.2 Treating
violence as a high-priority, preventable health problem has been recommended.5
The Task Force on Adolescent Assault Victims Needs states, The
goal of the emergency care of the assaulted adolescent includes the
identification and treatment of injury, an emotional status assessment,
crisis intervention, and establishment of follow-up.1 The National
Medical Associations Surgical Section passed a resolution to
emphasize violence prevention activities.6 Physicians for a Violence-Free
Society has a similar recommendation.7 Psychosocial assessment
of young victims of interpersonal violence needs to be started as
soon as the patient arrives into the health care system. A review
of the literature has not demonstrated an assessment tool for the
psychosocial needs of victims of intentional injuries currently being
used. An assessment instrument is needed to screen for the psychosocial
needs and refer the victims to appropriate resources. This paper describes
the development and success of an assessment instrument. METHODS Tool The
assessment tool was developed to fill the need to determine the psychosocial
needs of young persons who are victims of intentional violence. The
tool was not designed for victims of sexual assault, child abuse,
or domestic violence because psychosocial assessments already exist
for these problems. Health care providers are commonly mandated to
identify and report many of these later victims to authorities for
needs assessment and counseling. A review of the literature demonstrated
some of the constructs that need to be considered for an assessment.
The American Academy of Pediatrics Task Force on Adolescent
Assault Victims Needs recommends a number of helpful tools to be part
of the assessment in the emergency department, including toxicology
screening, pregnancy evaluations, and rapid HEADSS (home, education,
activities, drug use and abuse, sexuality, and suicide) and depression
evaluation of the emotional status.1 They also recommend spiritual
care and guidance be provided and that this may play a role in treatment
of stress from trauma.1 Two authors have described the essential
elements needed in such a tool. Prothrow-Stith recommends including
the following in the assessment: circumstances of the injury event,
the victims relationship to the assailant, use of drugs and
alcohol, underlying emotional or psychosocial risk, history of intentional
injuries or violent behaviors, predisposing biologic risk factors,
and intent to seek revenge.8 On the other hand, Ginsburg suggests
that sense of future, exposure to violence, perception of safety,
threshold for fighting, and the acute injury setting be part of a
violence screen for teens.9 The National Association of Public Hospitals
and Health Systems comments that the role of gang involvement in violent
activity should also be explored.10 A research team consisting of an emergency
physician, criminologist/social worker, and master in public health
developed the assessment tool. The development process included determining
the appropriate constructs, referral sources, and questions to use
in the assessment. The assessment tool consisted primarily of yes/no,
multiple-choice, and open-ended questions. The psychosocial
assessment tool was used to make proper referrals to social, health
care, and mental health services. The AAP Task Force recommends fostering
links with organizations, community centers, police, and religious
groups as a means for prevention.1 Links with others, even competitors,
in the health care community with referral and treatment programs
have also been recommended.11 After the questions were completed,
referral sources and contact persons were identified for each of the
needed services. A list of health care, mental health, and social
service referral sources were cataloged. The selection of services
were determined based on the location of the service to the patients
home, matching of the service with the patients needs, population
served, and cost of the service. To minimize difficulties of the coordination
and referral for services, we limited the referrals to a health care
system and a social service agency. However, because not all the needed
services could be provided by these two entities, other appropriate
referral sources outside those entities were found. The policy and advisory
board consisting of legal, medical, and social service professionals
with expertise in violence prevention provided construct and content
validity of the tool. The tool was also piloted in the emergency department
on a small number of youths who were victims of violence. The revisions
resulted in inclusion of additional constructs, clarification of some
of the questions, and modification of the referral sources. The assessment tool was a 10-page document
consisting of 13 constructs used to determine the needs of the youth
(Appendix 1). A positive response to any of the constructs triggered
a referral to a medical, mental health, or social service agency.
Each construct contains narrative and quantifiable questions to determine
the needs in each area. The patients interest in obtaining services
and the interviewers judgment that the youth needed the service
established the referral to the appropriate service. This tool contained
the following constructs: Identifying and contact informationThese questions
determined the family structure, job, school and means to contact
the person. Basic demographic information was also obtained. Exposure to violenceThe questions explored how
the person was injured and prior violent injuries. The administrator
also determined whether the youth has symptoms of a stress-related
illness. The client was referred to a hospitals psychiatric
services or community mental health clinic. Legal IssuesLegal problems, including probation,
parole, and arrests were addressed in this section. The interviewer
determined the need for legal aid services and which services would
be the most appropriate for the patient. Intervention with legal assistance
or a parole or probation officer was offered. Drug Use/AbuseNumerous questions about drug and
alcohol use were asked in this section, including the CAGE assessment.
If a drug or alcohol problem was identified, the patient was referred
to the alcohol and substance abuse services. Mental HealthQuestions about prior counseling or
therapy and paranoid, suicidal, and homicidal ideation were asked.
Inquires into depression and emotional problems were also discussed.
The client was referred to psychiatric services if needed. Gang IssuesGang involvement personally or in the
family or friends was inquired. The relationship of the gang activity
to the injury was determined. If the individual was interested in
disaffiliating with the gang, he or she was referred to peer counseling,
tattoo removal, and/or a guidance program. EducationThe individual was questioned about level
of school education completed, high school diploma, and current grade
or GED status. An assessment for the need for further education was
determined. The client was referred to GED classes, English as Second
Language training, alternative high schools, computer classes, and/or
homework assistance. EmploymentAn assessment of their employment status
or employability was made. Concerns about their financial condition
as well as their hospital bill were questioned. Referrals were made
for financial counseling, career determination, computer classes,
and employment services. In order to prepare the young person for
a job, assistance in obtaining a social security card, state identification
card, and drivers license was provided. Life SkillsThis section determined the stress that
the individual was facing, how he dealt with stressors, and his handling
of anger and conflict. The interviewers provided the youth with counseling
in anger management and conflict resolution. Referrals were made to
other counseling services, if needed. Pregnancy/Parenting IssuesThis area determined
the status of family relationships,
possibilities of pregnancy, history of sexually transmitted
diseases, and parenting responsibilities. Referrals were made to obstetric
and gynecologic services, parenting programs, and male responsibility
classes. Medical CareThis section determined what clinic
is closest to the youths home and his need for a doctor, optometrist,
and dentist. Individuals were referred to a clinic, optometrist, and/or
dentist. Recreational ActivitiesThis section determined
the youths recreational activities, daily routines, and spiritual
pursuits. Individuals were referred to the appropriate service, if
requested.13 Gun Access QuestionnaireThis section determined
the accessibility of youth to guns. There were no referrals located
for this psychosocial risk factor. The last sections of the document included an overall
assessment and summary. These sections included a prioritization of
the needs of the patient, barriers of participation, and general impression
of the patient. A time frame for completion of the goals for the youth
was also documented.
Study The emergency department staff identified the victim,
and the research assistant was contacted. The research assistants
included trained health care, mental health, and social service providers.
A research assistant administered the tool, which took approximately
1 hour to complete. The administration of the tool began in the emergency
department and may have been completed in the hospital or in the community,
depending the availability of the patient and their clinical condition.
The participant could determine whether he wanted anyone else present
during the interview. The
assessment was given to all consecutive consenting youth (with parental
consent if younger than 18 years) in the emergency department of an
inner-city level I pediatric and adult trauma center with approximately
43,000 visits per year. The inclusion criteria were an age range of
10 to 24 years old, victim of interpersonal violence with life- or
limb-threatening emergencies, residing in the hospitals service
area, and the ability to communicate. The exclusion criteria included
victims of child abuse, sexual assault, or domestic violence; severe
disability; or inability to follow-up with the study. The study was
approved by the hospitals Institutional Review Board. The
data were input into laptop computers while interviewing the youth.
Descriptives, frequencies, and chi-squared analysis were performed
using SPSS version 9 (Chicago, Illinois). A level of .05 was chosen
as the a priori level of statistical significance. RESULTS The
assessment tool was offered to 238 youths who were victims of violence
from May 1998 to October 1999. Sixteen of the youths refused to enter
the study. Most of these youths or their parents refused after 3 attempts
because they did not want to be bothered by the study.
The rest (93.3%) consented and were randomized to receive the assessment.
All youths who received the assessment tool completed it. DISCUSSION This
study demonstrated that this assessment instrument could be used in
the acute care setting to determine the psychosocial needs of the
young victims of interpersonal violence. The mind set of physicians
needs to change. Prothrow-Stith stated, We just stitch
them up and send them out, knowing that they are at risk for
subsequent violence.8 The American Academy of Pediatrics (AAP)
states that medical care can heal the body but cannot prevent recurrence
of violence.1 Acute care providers are experts at acute care but limited
in understanding the preventive nature of injuries from violence.12
They usually provide acute care for victims of violence but do not
commonly assess or provide preventive care for these patients. Physicians typically assess and stabilize
these young victims of violence with little or no attention to their
psychosocial needs. One study found that social service consultations
were received by only 21% of patients with violence-related injuries
in the emergency department.13 Even more concerning is the fact that
these victims of violence were significantly less likely to have follow-up
advised from the emergency department than those with other problems. The value for screening services in the
acute care setting has been well documented.14-20 Screening for breast,
prostate, colon, and cervical cancer; cholesterol levels; osteoporosis;
hypertension; and substance abuse has been conducted in the emergency
department setting. Anderson and Taliaferro stated that screening
and counseling for high-risk behaviors should be incorporated into
the daily practice of medicine.11 Such screening is routinely performed
on victims of child abuse, sexual assault, or attempted suicide.8
Violence exposure screening has been advocated in the emergency department
setting.21 The greatest lesson
learned from the development and implementation of this assessment
tool was its length and the time it takes to complete the material.
The most frequent needs of the youth could be aggregated to form a
short instrument with 4 to 6 constructs instead of the 13 used in
this study. The reduced length would also enable the staff rather
than a test administrator to absorb the performance of the assessment
and referral process. There were a number
of problems in the development and application of the assessment instrument.
Referrals for illegal aliens who entered into the study were limited.
This population was highly mobile, and many times it was difficult
to locate an adolescent once he left the emergency department. Some
of the referral sources were found to not be providing the promised
services, and some were not available at certain times of the year.
A dilemma occurred when a few of the youths who needed services refused
to accept the referral. The assessment tool
has a few limitations. The interview technique depends primarily on
self-reporting, which is less exact than direct observation or testing.
Validation of the assessment tool by these means would be difficult,
if not impossible, to accomplish. The general acceptance of the assessment
of the adolescents in this study was limited by the specific population
of the youth and may not be extrapolated to other ages or locales. Victims of intentional violence have a
significant recurrence rate. This tool can be used not only to assess
the psychosocial needs of the youth but also to reduce the incident
of recurrence. The AAP Task Force believes that medical care can heal
the body but not prevent the recurrence of similar injuries.1 Schwartz
advocates counseling every patient who seeks care for interpersonal
injury about his recurrence risk.22 The incidence of recurrence of
trauma has been shown to be 6.4% to 44%.2325 Recidivism averaged
only 7.9 months between episodes of injury and had a 20% 5-year mortality
rate.23 A prospective, controlled trial is necessary to determine
whether this tool is effective in meeting the psychosocial needs of
youth and changing their high-risk behaviors. CONCLUSION This
article presents the first known description and acceptance of an
assessment tool that could be used to determine the psychosocial needs
of youth involved in interpersonal violence. It is speculated that
referral of patients to the identified services may prevent future
incidents of interpersonal violence. ACKNOWLEDGEMENTS The
authors appreciate the support and assistance of Andrea Kushner, LCSW,
and the advisory board. They also thank the Policy Advisory Board
for the Within Our Reach program: Elva Basulto, Jerome
Balkemore, Katherine Kaufer Christofel, MD, Steve Drizin, Debra Wesley-Freeman,
Sue Gamm, Mark Karlin, Deborah Grison, Katherine Klenish, Victor Ceballos,
Tine Sanders, Radhika Sharma, Lee Thorton, MD, Gary Slutkin, MD, John
Stephan, Kristin Donovan, Elena Rose, PhD, Mary Ann Mahon-Huehls,
Jeff Ingraffia, Katie Kirby, Jill Carter, Jennifer McDonough, Roseanna
Ander, Jean Rudd, Jim OSullivan, Catherine Ryan, Lisa Nauce-Griffin,
Linda Miller, David Miller, John Pallohusky, Kimberlie Boone, Ester
Jenkins, PhD, Tom Fashing, and Robert Flynn. REFERENCES 1. American
Academy of Pediatrics: Task Force on Adolescent Assault Victim Needs:
Adolescent assault victim needs: A review of issues and a model protocol.
Pediatrics 98:9911001, 1996. 2. Singer
MI, Anglin TM, Song LY et al: Adolescents exposure to violence
and associated symptoms of psychological trauma. JAMA 273:477482,
1995. 3. Slabey
RG, Stringhorn P: Prevention of Peer and Community Violence: The Pediatricians
Role. Pediatrics 94:608616, 1994. 4. Annest
JL, Mercy JA, Gibson DR, Ryan GW: National estimates of nonfatal firearm-related
injuries: Beyond the tip of the iceberg. JAMA 273:17491754,
1995. 5. Koop
CE, Lundberg GD: Violence in America: A public health emergency. JAMA
267:30753076, 1992. 6. Coenwell
EE, Jacobs D, Walker M, et al: National Medical Association Surgical
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surgeons caring for victims of violence. JAMA 273:17881789,
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for Violence Free Society; www.pvs.org, accessed 1999. 8. Prothrow-Stith
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KR: Teen violence prevention: How to make a brief encounter make a
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R: Injury control: A primer for physicians. Ann Emerg Med 19:7277,
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Appendix #1 YOUTH ASSESSMENT
I. IDENTIFYING AND CONTACT INFORMATION Youths initials: ____________ ID# _______ Assessed by: _____________ Date entered ED: _____________ Todays date: _______________ Primary language: ______________________
Consent signed by: o parent o legal guardian o self date
consent signed: ____________________ Date of birth ( / / ) Age when
entered program _________ Demographics: o Race:
Gender: o female o male o African American o Caucasian o Hispanic o Asian o Other (specify) _______ Guardian Name ____________________________ Relationship
_____________________ Home Address ___________________________City
_____________Zip code ___________ Home phone number: ( )
_______ ________________ Are you currently (or have you
ever) been a ward of the state (in the custody of the Department of
Children and Family Services)? yes ________ no __________ If
yes, please explain _______________________________ If yes, do you know your caseworkers
name _______________________________________ Do you know his/her telephone
number ( )
_______ ______________ Who lives in your home with you?
(case manager: please check all that apply) o Mother and father o Mother only
o Father only
o Mother and boyfriend o Father and girlfriend o Brothers (#)
o Sisters (#)
o Step-brother/sisters o Step-parents o Girlfriend
o Boyfriend
o Other family members o Own children (#) o Depends (explain) _________ o Foster parent(s)
o Alone o Other _________ o Other immediate family members whom youth does
not live with: __________________ How long have you lived there (approximately)?
Do you live in more than one household? _________________________________________ If yes, what is another place we can locate you? ____________________________________ Person that lives there: ______________________________________________
Address _______________________________ Phone
number ( ) _______
_________ Who is the member of your family
you feel the most close to? ________________________ What is that persons address:
__________________________________________________ Phone number: ( )
_______ _________ Do you have a: cell phone number: ( )
_______ _________ pager: ( )
_______ _________ Do you have a job? Yes
__________ No ________ If yes, what is your job? _______________________________________________________ Where is your job?__________________ Work
phone number ( ) _______
_________ Are you in school (or on summer vacation from school)? Yes
_____ No ______ If yes, provide the name of the
school ____________________________________________ Do you attend an alternative
school? _____________________________________________ If yes, please explain: _________________________________________________________ Is there a person at school you
feel close too? (teacher, coach, advisor) _________________ What is the best way to contact
you in an emergency? _______________________________ Who is the best person to contact
in an emergency? _________________________________ What is their phone number? ___________________________________________________ COMMENTS: II. EXPOSURE
TO VIOLENCE Can you tell me a little
bit about what happened to you today (tonight)? Have you been injured like
this in the past? How may times have you been the victim of violence before?
_________________________ What happened? _____________________________________________________________ If yes, have you ever been admitted to an emergency department
for any type of injury? Have you ever been admitted here before? If yes, for
what?___________________________ ___________________________________________________________________________ Case manager:
do you feel this person exhibits stress-related symptoms to their
injuries, such as fears, anger, depression, disassociation, self-destructive
behavior, or numbing? COMMENTS: IDENTIFIED SERVICES: Mount Sinai Psychiatry & Behavioral Health Clinical
Services Outpatient scheduling: Inpatient: Sinai emergency psychiatric services (emergency
department) COMMENTS:
III. LEGAL
ISSUES Have you ever been in involved with the law? Yes _______ No ________ Explain:
__________________________________________ If yes, can you tell me a little
bit about whats going on (for example: Are you on probation?
Have you ever been in jail? Has there been a petition out for your
arrest? Have you been accused of some kind of criminal activity? Have
you been involved in any court mandated programs, electronic monitoring,
home confinement, or on parole?) ________ Are you currently on probation
or parole? Yes _____ No ______ Adult
or juvenile If yes, what are you on probation
or parole for? _____________________________________ Do you know your probation/parole
officers name? Yes ______ No _______ Do you know how to contact him/her? Yes
_________ No ________ If yes, how? __________________________________________ Case manager: do you
feel this individual could benefit from legal services? Yes _____ No _____ Do you feel you need legal help at this
time? Yes ______ No _________ What do you think would
be helpful for you in this area? (be as specific as possible)? ______ ___________________________________________________________________________ COMMENTS:
IDENTIFIED
SERVICES Northwestern
Legal Aid Clinic contact:
Angela Coin (773) 342-5071 o Mendel Legal Clinic at the University of Chicago o Loyola University Legal Clinic o Northwestern Legal Aid Clinic o Street Law Program (legal education) o Legal Aid Bureau: (312) 922-5625 o Legal Assistance Foundation (West): (773) 638-2343
o Sinai Victims Compensation Program
contact:
IV. DRUG
USE/ABUSE Can you tell me about your history
with drugs and alcohol?___________________________ Do you use drugs now? Yes
________ No ________ Other answer _________________ If yes, does your use of drugs
cause any kinds of problems for you? ____________________ Have you ever been concerned
about your drug or alcohol use? ________________________ Do you use alcohol now? Yes
________ No________ Other answer ________________
If yes, does your use of alcohol
cause any kinds of problems for you (headaches, hangovers, tardiness
to work or school)? ___________________________________________________ Have you ever been concerned
about your drug or alcohol use? _______________________ Has anyone else expressed a concern
about your drug or alcohol use?___________________ What types of drugs have you
used? (case manager: please check all that apply) o Alcohol (types: )
Over-the-counter o Marijuana o Heroin
o Inhalants o Hashish
o Over-the-counter medicines o Cocaine
1) ______________________ o Crack
2) ______________________ o Acid
3) ______________________ o LSD o PCP o Angel dust o Uppers o Downers o Other 1) __________________ 2) __________________ 3) __________________ When is the last time you used
(ask for each listed above)? 1) _____________________ 2) _____________________ 3) _____________________ How often would you say you use
(identified drug[s] from above)? 1) _____________________ 2) _____________________ 3) _____________________ Were you using drugs or alcohol at the time of this incident? Yes
______ No _______
CAGE ASSESSMENT Alcohol 1. Have
you ever felt you ought to CUT DOWN on your drinking (use of ____
)? Y N 2. Have
people ANNOYED you by criticizing your drinking (use of _____ )? Y N 3. Have
you ever felt bad or GUILTY about your drinking (use of ______ )? Y N 4. Have
you ever had a drink first thing in the morning (EYE OPENER) to steady *Note: Please note at end of assessment
{in current life stressors} section if individual responds with a
yes to any question above. Drugs 1. Have
you ever felt you ought to CUT DOWN on your use of _____ ? Y N 2. Have
people ANNOYED you by criticizing your use of _____ ? Y
N 3. Have
you ever felt bad or GUILTY about your use of ______ ? Y
N 4. Have
you ever had to use __ first thing in the morning (EYE OPENER) to *Note: Please note at end of assessment
{in current life stressors} section if individual responds yes to
any question above. Case manager: Would you identify this
as a problem? Yes ______ No______ Are you interested in
receiving services in this area? Yes ______ No
______ Have you received services for
drug use in the past? Yes ______ No ______ If yes, where? _______________________________________________________________ Can you tell me how that experience
was for you? (problems, concerns, helpfulness) COMMENTS:
IDENTIFIED
SERVICES o Mt. Sinai Community Institute o Interventions contact (for assessment): (312)
850-9411 x302 o Gateway contact: put in fax o Haymarket: (773) 226-7984 o Grant Hospital (outpatient and inpatient services):
*need insurance Case manager: Please
check contact book for additional substance abuse services
V. MENTAL
HEALTH Have you ever been seen by a
mental health counselor or a therapist? Yes ____ No
____ If yes, do you remember what
the reason was? _____________________________________ Do you remember the name
of the agency of the person you were working with? __________ Have you ever: thought you saw or heard something
that really wasnt there? Yes _______ No
_______ If yes, explain _______________________________________________________________ felt someone or something was
after you? Yes _______ No _______ If yes, explain _______________________________________________________________ Case manager: If yes,
do you feel there is sufficient basis to this person feeling as if
there was someone or something after them? Yes _____ No
____ Explain: _____________________________________________ thought about hurting
yourself? Yes _____ No ______ If yes, are you currently feeling
like hurting yourself? Yes ________ No ________
If yes, do you have a plan? Yes
________ No ________ If yes, please explain __________________________________________________________ thought about hurting someone
else? Yes ________ No ________ If yes, are you currently feeling
like hurting someone else? Yes ________ No ________
If yes, do you have plan? If
yes, please explain _____________________________________ *Case manager: If the
individual answers yes to having a specific current plan for hurting
himself or others please refer him to EPS (x 6031). During the past few weeks,
have you often felt sad or down as though you have nothing to look
forward to? _____________________________________________________________ Do you feel it would be beneficial
to talk to somebody about your emotional problems or things you have
on your mind? __________________________________________________ If you have had experience talking
to someone in the past, can you tell me how that was for you? (problems,
benefits, helpfulness)____________________________________________ COMMENTS:
Case
manager: Would you identify the individuals
mental status as a problem? Yes _____ No _____
Needs further referral _____ (mental health professionals in ED)
IDENTIFIED
SERVICES o Mount Sinai Psychiatry & Behavioral Health
Clinical Services o Sinai Psychiatry and Behavioral Health at Mile
Square *Case manager: Please
try to refer based on geographic residence of the client.
VI. GANG
ISSUES Are any of your close friends involved in a gang? Yes
_______ No _______ Are any of your family members involved in a gang? Yes
_______ No _______ If yes, how are they related
to you? ______________________________________________ Have you ever been involved or
affiliated with a gang? Yes _______ No _______ Would you consider yourself involved
or affiliated with a gang at this time? Yes _______ No _______ Other
___________ Can you tell me the name of gang?
______________________________________________ If involved, how long
have you been involved or affiliated with this or any other gang?______ ____________________________________________________________________________ Do you have tattoos that represent
gang involvement? _____________ If yes, would you be interested
in getting them removed? _____________________________ Was your current injury the result
of gang involvement? Yes _______ No _______ Can you tell me a little bit
about what this experience has been like for you? _____________ ___________________________________________________________________________ If you are not currently involved with a gang, are you
currently being heavily recruited or pressured into joining a gang?
__________________________________________________ If yes, are you interested in considering options besides
being involved and/or joining a gang?______________________________________________________________________ Case manager: Do
you feel this person is in need of this service? Yes _____ No ______ Are you interested in
participating in a program to help you in this area? Yes
___ No ___ COMMENTS:
IDENTIFIED
SERVICES BGCC o Logan Square________ _________
Phone: (773) 342-8800 o Or Keystone program for individuals 14 years old
or older (in every club) _________ o Torch Program _______________________ Mount Sinai Family Health
Centers o Gang Tattoo Removal Program o Peer counseling review *Case manager: Please try to refer based
on geographic residence of the client.
VII. LEARNING
PROBLEMS/GED PROGRAMMING/EDUCATION Are you currently attending
school? Yes _______ No _______ Or, last grade completed (if
summer or out of school)_______ If not attending school, why not? ________________________________________________ Have you ever been held back
in school for any reason? Yes _______ No _______ If yes, reason: _______________________________________________________________ Have you earned your high school diploma or GED? Yes
_______ No _______ Would you be interested in obtaining a high school diploma
or GED? What kinds of subjects
are you interested in (school based)? __________________________ Are you interested in participating in an English as
a second language class? (Case manager: only ask if applicable) _________________________________________________________ If you have graduated from high school or have obtained
your GED, are you interested in attending college classes or vocational
school? Case manager: Do
you feel services in this area would benefit this individual? Yes _______ No
_______ Would you be interested
in receiving this type of service (e.g., GED, extra help in school)?
IDENTIFIED
SERVICES BGCC o Homework help o Computer classes at BGCC General Wood Contact person: ______________________________ Phone:
(773) 247-0700 o GED classes o General Wood college classes Other o Urban Youth High School (18 years or older) o Malcolm X o Association house contact: (getting phone number) o Schools that provide training for certain jobs
(i.e., driving school): Need to get contact o City Colleges: (See list in contact book of all
schools)
VIII. EMPLOYMENT
You mentioned earlier that you have a job. What kind of work do you do? ________________________________________________ Additional explanation: ________________________________________________________ You mentioned earlier that you do not
have a job. Welfare ___________ WIC __________ Social Security _________________ Public Aid _____________________ Medicaid_______________________ Other _________________________
IDENTIFIED
SERVICES Sinai o Family Welfare-to-Sufficiency Partnership o The Sinai Health Careers Club o Victims of Crime Assistance Program: Contact at
x 6229 o Sinai Financial Assistance BGCC Eisenberg Club o Welfare-to-Work General Wood
Little Village o Computer classes o ESL contact: James Jordan
Club and Family Health Center o Computer Classes o Employment Services Other o Malcolm X classes or City Colleges o STRIVE Job Place Program (24 years or older): (773)
244-0609 o Spanish Action Committee of Chicago (heating, water,
and jobs): (773) 292-1052 o Project Match: (773) 266-6464 o Easy Employment (18 years and older): (312) 274-0717 o Jobs for Youth o Illinois Employment and Training Center (Pilsen
and near north) Shelters o Emergency Shelters (CHA): 1-800-654-8595
IX.
LIFE SKILLS What are some of your stressful problems? ________________________________________ When you get angry, how do you handle things? ____________________________________ What do you feel is the most stressful issue in your
life? _____________________________ How do you handle this issue? __________________________________________________ What do you think would help? _________________________________________________ When you have a conflict (i.e., disagreement with someone),
how do you handle it? ___________________________________________________________________________ Would you be interested in receiving services in this
area? Yes ____ No ____ Other ____ Case manager: Do you
feel this individual would benefit from services in this area? Yes
_______ No ________
COMMENTS:
IDENTIFIED
SERVICES Anger and conflict resolution training (case managers) Job readiness (case managers) X.
PREGNANCY/PARENTING ISSUES BOTH GENDERS How do you feel you get along with your family? (explain)___________
Female Is there a possibility
you could be pregnant? Yes _______ No _______ If yes, how far along do you think you are? _____________________ Are you seeing a doctor for the pregnancy? Yes
_______ No _______ Do you feel you need help with an issues related to the
pregnancy? Yes _____ No _____ If yes, please explain __________________________________________________________ Do you know what a sexually transmitted disease is? Yes
____ No _____ Other ______ Do you think there is a possibility you could have gotten
something like this from someone? Yes _______ No
_______ Dont know/other __________________________________ Do you have any other children? Yes _______ No
_______ If yes, how many? _________ How old are they?
_________________________________ Where do they live? ___________________________________________________________ Who has custody? ____________________________________________________________ Do you receive any public assistance for you and/or your
children? _____________________ Do you feel you need help with care for the kids? Yes
_____ No _____ Other ________ Would you be interested in receiving services in this
area? Yes _______ No _______ Male Is there a possibility you could
be the father of any children at this time? Do you have children? Yes
_______ No _______ If yes, how many ______ How old are they?
______________________________________ Where do they live? ___________________________ Who
has custody? ______________ What type of responsibility do you have
for the children? (e.g., rights, payments) __________ _______________________________________________________________________________ Do you feel you need help with care for the kids? Yes
_____ No _____ Other ________ Do you know what a sexually transmitted disease is? Yes
____ No _____ Other ______ Do you think there is a possibility you could have gotten
something like this from someone? Caseworker: Do
you feel this would be an appropriate/helpful service? Yes ______ No _______ Would you be interested
in receiving services in this area? Yes ___ No
___ Other _____ COMMENTS:
IDENTIFIED
SERVICES Sinai Community Institute o Mount Sinai Community Institute: Reproductive Health
Services, Pregnancy Prevention, The Parenting Institute (WIC program) o Reproductive Health Services o Adolescent Health Comprehensive Project o Adolescent Health Delayed Pregnancy Project BGCC o Forgotten Fathers program o James Jordan Club and Family Life Center (home
and extended day care) o Headstart Coordinator (312) 733-8324 o Childcare/daycare facility Contact number:
(312) 432-4296 o Headstart all clubs o SMART girls program (including pregnancy prevention)
XI. MEDICAL
CARE Do you have a family doctor?___________________________________________________ If no, what do you (or your family) usually do if youre
not feeling well or something is wrong? Have you seen a dentist in the last 12 months (1 year)?
Yes ________ No ________ Other
__________________________________________ Do you have any medical problems? Do you take any type of medication for these problems? When was the last time your eyes were checked? ___________________________________ Do you ever experience blurriness or have trouble seeing?
____________________________ COMMENTS:
IDENTIFIED
SERVICES Sinai o Sinai Medical Group or Family Services (see handout
of all individual sites by address) o On-site dental clinic BGCC o Vision screening program Case manager: Please refer to medical
center in closest proximity to individuals home. BGCC o Free Health Screenings o On-site family health center (Jordan) contact:
UIC/Mile Square Health Center o On-site dental clinic (McCormick): (773) 271-8400
o On-site pediatric clinic (Logan Square) o On-site podiatry clinic contact: (773) 271-8400 o James Jordan Club and Family Life Center o Medical Facility: (312) 355-1026 o Health Education Coordinator contact: (312) 226-2323
XII. RECREATIONAL
ACTIVITIES What do you do in your free time? _______________________________________________ What is your favorite activity/sport/hobby? ________________________________________ What is your religion? ________________________________________________________ Are you interested in becoming involved
(or more involved) with religious or spiritual activities? ____________________________________________________________________________ Where do you spend most of your free time? ______________________________________ How do you feel this program
could be most beneficial to you? _______________________
IDENTIFIED SERVICES James Jordan Club and
Family Life Center or General Wood Case manager: Ask
individual Which activity would you like to participate in?
and link with specific worker at each site. o Physical education o Recreational activities o Peer and monitoring o Daycare facility o Cultural services o SMART girls program (including pregnancy prevention
at all 3 clubs) o Keystone Youth Leadership program o Computers Sinai Community Institute o Spiritual & Religious Services Contact: _______________________________
Contact number: x5146
XIII. GUN
ACCESS QUESTIONNAIRE 1) Do you feel you could get a gun if you wanted
one? o Yes o No o Unsure o Yes, but not in the last 6 months o Yes (in the last 6 months) o No 3) Do you share ownership of a gun with some
friends? o Yes o No 4) Is there a gun in your home, garage, or
car? o Yes, what kind? _____________________ o No 5) Who in the home owns the gun? o I do o My mother or father does o Another relative o A nonrelative o More than 1 person in the home does 6) Where did you get your first and last gun? o I bought it from the gun store. o I bought if from a friend or relative. o I bought or traded for it on the street. o I received it as a gift. o I stole it. 7) Why do you own a gun? o Target shooting or hunting o It makes me feel safe. o To get respect from others o To frighten or scare other people o Because a lot of my friends have them 8) Would it be difficult for you to get a
handgun? o I already have one. o Very easy (within one day) o It would take a few days, but I could get one. o It would be impossible. 9) During the past 30 days, on how many days
did you carry a weapon such as a gun, knife, or club? o 0 days o 1 day o 2 or 3 days o 4 or 5 days o 6 or more days 10) During the past 30 days, on how many days did
you carry a gun? o 0 days o 1 day o 2 or 3 days o 4 or 5 days o 6 or more days o 0 days o 1 day o 2 or 3 days o 4 or 5 days o 6 or more days
XIII. ADDITIONAL
INFORMATION Is there anything else you would
like to tell me about that might help me to get to know you better?
_____________________________________________________________________ If you could change one thing
about your life or yourself what would it be? ______________ ___________________________________________________________________________ What do you think your biggest
strengths are or what things are you good at? ____________ ___________________________________________________________________________ Is there anything else you would
like to tell me about? _______________________________ Do you have any questions you
would like to ask me? _______________________________ Do you think you would be interested in taking advantage
of our program? If not, can you explain why so I can help you become
involved? ____________________________________ Thank you for your help in completing this information.
You will soon be assigned a case manager (either myself or another
individual) for the program. I know this program can be really helpful
for you. As part of the program I (or another case manager) will ask
you additional questions about yourself and your life. This will take
about 1 hour. Do you feel we could do that now? If not, within the next day or two, when and where do
you think we could complete the additional questions? (Offer an incentive.) WHEN _____________________________ WHERE _____________________________ CASE MANAGER: After interviewing this individual, how
would you identify the nature of current stressors in his life? o Problems related to alcohol or drug abuse (specify)
______________________________ o Educational problems (specify) ______________________________________________ o Family problems (specify) __________________________________________________ o Occupational problems (specify) _____________________________________________ o Housing problems (specify) _________________________________________________ o Financial problems (specify) _________________________________________________ o Problems with access to health care (specify) ___________________________________ o Problems related to interaction with the legal
system/crime (specify) _________________ o Mental health (specify) _____________________________________________________ o Other problems (specify) ___________________________________________________ Of the ten items listed above, which three problems do
you feel are the most severe or in need of immediate attention? SHORT TERM: 1) ________________________________________________________________________ 2) ________________________________________________________________________ 3) ________________________________________________________________________ 4) ________________________________________________________________________ 5) ________________________________________________________________________ Do you see barriers to this client participating
in our program? (e.g., attitude, lack of interest) What is your general impression of this person? Can you briefly assess them? (e.g., age, gender, circumstances) COMMENTS/RECOMMENDATIONS:
Date of review:
_____________ Within Our Reach staff: _____________________________
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