Team of Concern - Summary of ConcernPlease complete this form and a member of our team will contact you within 48 hours. Student:* Guardian(s):* Street Address:* DOB:* Phone:* City:* Age:* Guardian Alternative Phone: State:* Grade:* Guardian Email* Postal / Zip Code:*GENETIC RISK FACTORS Genetic Risk Factors:Parent or Sibling Substance Use/Addiction Parent or Sibling Psychological Disorder/Concerns ENVIRONMENTAL FACTORS Family Functioning:Family Conflict Low Level of Parental Monitoring Family Aggression/Violence Frequent Family MovesFamily History of Problem Behaviors Unrealistic Parent ExpectationsSingle Parent HouseholdLow Socioeconomic Status Child Maltreatment Trauma:Illness of Family MemberLoss Due to Divorce/Separation/Death/Incarceration Suspected or Reported Abuse, Neglect or Violence in HomeHas Witnessed Acts of ViolenceCommunity Violence/Economic Deprivation Other Social Influence:Friends Engaged in Problem BehaviorsGang Involvement Drug Using PeersBullying Others or Is being Bullied by Others Social Media Concerns Availability of Alcohol or Other DrugsOpportunity to Use Alcohol or Other DrugsAvailability of Firearms Community Laws/Norms favorable towards drugs/firearms/crimeLow Neighborhood Attachment and Community Disorganization SUBSTANCE USE CONCERNS Substance Use Concerns:Suspected UseAdmitted UseNicotine Marijuana Misuse of Prescription Drugs Excessive Use of Caffeine Parent Reports Student has Used 1 or More of the Above SCHOOL INTERVENTIONS School Interventions:DetentionIn school SuspensionOut of School SuspensionOther Please Describe:SIGNS OF PSYCHOLOGICAL DYSREGULATION Behavioral:Regularly Lies and/or StealsDecision Making Concerns Impulse Control Concerns Anger Management Concerns Poor Hygiene or Change in Dress HabitsGave up Valued Activity (church, track, etc)Carrying a WeaponDoes Not Follow RulesVerbal FightingPhysical FightingSelf-Regulation ConcernsExhibits Antisocial BehaviorsStruggles with Attention Discipline ProblemsTruancy Self Harming Behaviors Suicidal Talk or ThreatsYesNo Date Did they have a planYesNo Suicide AttemptYesNo Date Attempted Cognative:Learning Disability/IEP/504Academic ConcernsOppositional Defiant Disorder ADD/ADHDAnxietyDepression Emotional:Social Skills Concerns Self-Esteem Concerns Lack of Motivation/ApathyConcerns about StressDepressed MoodAppears Anxious OftenConcerns with Impulsivity MEDICATION Are Medications Given at School?YesNo What Medication(s): By Whom:SCHOOL INFORMATION School* Referral Made By:*SubmitReset