District-Wide Safe Schools and Crisis Plan - Blytheville Public Schools

NO YES
j. lack of interest in previous activities that were once pleasurable? ___ ___
3. If previously depressed, has the student shown a recent,
unexplained mood elevation and/or energy increase? ___ ___
4. Does the student show recent signs of significant:
a. irritability, anger, or rebellion? ___ ___
b. evidence of marked rage or masked depression (fire setting, vandalism?) ___ ___
c. impulsive or accident-prone behavior? ___ ___
5. Has there been a history of truancy or running away? ___ ___
6. Has there been a recent loss of:
a. loved person by death, separation/divorce, alienation (who, when)? ___ ___
b. a warm adult parental figure? ___ ___
c. peer relationships, breakup with boyfriend/girlfriend? ___ ___
d. school/sports success, decreased school performance? ___ ___
7. Has there been significant family changes or dysfunction?
(unemployment, frequent moves, frequent fights, physical, sexual, emotional abuse) ___ ___
8. Is the student experiencing internal or external pressure to achieve? ___ ___
9. Has there been significant medical problems concerning
student/other family members: ___ ___
a. alcohol/drug misuse. Who? (pattern and quantity) ___ ___
b. chronic or debilitating illness (mental/physical) which has
involved considerable change in self-image/self-concept. Who? Describe ___ ___
c. a significant change in general physical health including pregnancy.
Who? Describe, ___ ___
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