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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


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 hospital’s 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.


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 Association’s 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.



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 victim’s 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 patient’s 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 patient’s interest in obtaining services and the interviewer’s judgment that the youth needed the service established the referral to the appropriate service. This tool contained the following constructs:

Identifying and contact information—These questions determined the family structure, job, school and means to contact the person. Basic demographic information was also obtained.

Exposure to violence—The 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 hospital’s psychiatric services or community mental health clinic.

Legal Issues—Legal 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/Abuse—Numerous 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 Health—Questions 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 Issues—Gang 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.

Education—The 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.

Employment—An 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 driver’s license was provided.

Life Skills—This 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 Issues—This 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 Care—This section determined what clinic is closest to the youth’s home and his need for a doctor, optometrist, and dentist. Individuals were referred to a clinic, optometrist, and/or dentist.

Recreational Activities—This section determined the youth’s recreational activities, daily routines, and spiritual pursuits. Individuals were referred to the appropriate service, if requested.13

Gun Access Questionnaire—This 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.



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 hospital’s 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 hospital’s 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.


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.


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%.23–25 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.


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.


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 O’Sullivan, Catherine Ryan, Lisa Nauce-Griffin, Linda Miller, David Miller, John Pallohusky, Kimberlie Boone, Ester Jenkins, PhD, Tom Fashing, and Robert Flynn.


 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 98:991–1001, 1996.

 2. Singer MI, Anglin TM, Song LY et al: Adolescents’ exposure to violence and associated symptoms of psychological trauma. JAMA 273:477–482, 1995.

 3. Slabey RG, Stringhorn P: Prevention of Peer and Community Violence: The Pediatrician’s Role. Pediatrics 94:608–616, 1994.

 4. Annest JL, Mercy JA, Gibson DR, Ryan GW: National estimates of nonfatal firearm-related injuries: Beyond the tip of the iceberg. JAMA 273:1749–1754, 1995.

 5. Koop CE, Lundberg GD: Violence in America: A public health emergency. JAMA 267:3075–3076, 1992.

 6. Coenwell EE, Jacobs D, Walker M, et al: National Medical Association Surgical Section position paper on violence prevention. A resolution of trauma surgeons caring for victims of violence. JAMA 273:1788–1789, 1995.

 7. Physicians for Violence Free Society;, accessed 1999.

 8. Prothrow-Stith D: Can physicians help curb adolescent violence? Hosp Prac June 15:193–207, 1992.

 9. Ginsburg KR: Teen violence prevention: How to make a brief encounter make a difference. Physician Sports Med 25:69–83, 1997.

10. Ginsberg CS, Benesch B, Bennett B: Violence in the United States-Characteristics and Issues for Safety Net Health Systems, monogram VI. National Assoc Public Hosp & Health Systems, 1997.

11. Anderson RJ, Taliaferro EH: Injury prevention and control. Am J Emerg Med 15:489–498, 1997.

12. Martinez R: Injury control: A primer for physicians. Ann Emerg Med 19:72–77, 1990.

13. Melzer-Lange M, Lye PS, Calhoun: Advised follow-up after emergency treatment of adolescents with violence related injuries. Ped Emerg Care 14, 334–337, 1998.

14. Rodriquez RM, Kreider WJ, Baraff LJ: Need and desire for preventative care measures in emergency department patients. Ann Emerg Med 26(5):615–620, 1995.

15. Berger P, Luskin M, Krishel S: Preventative health pamphlets in the emergency department. J Emerg Med 16(5):691–694, 1998.

16. Bersten E, Berstein J, Levenson S: Project ASSERT: An ED-based intervention to increase access to primary care, preventative services and the substance abuse treatment system. Ann Emerg Med 30(2):181 189, 1997.

17. Robinson PF, Gaushe M, Gerardi MJ, et al: Immunization of the pediatric patient in the emergency department. Ann Emerg Med 28;334 341, 1996.

18. Cherpitel CJ, Soghikian K, Hurley LB: Alcohol-related health services use and identification of patients in the emergency department. Ann Emerg Med 28:418–423, 1996.

19. Lo Veechio F, Bhatia A, Sciallo D: Alcohol-related health services use and identification of patients in the emergency department. Ann Emerg Med 28:418-423, 1996.

20. Feldhaus KM, Koziol-McLain J, Amsbury HI, et al: Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA 277:1357–1361, 1997.

21. Song L, Singer MI, Anglin TM: Violence exposure and emotional trauma as contributors to adolescents’ violent behaviors. Arch Pediatr Adolesc Med 142:531–536, 1998.

22. Schwartz DF, Gisso JA, Miles CG, et al: A longitudinal study of injury morbidity in an African-American population. JAMA 271:755–760, 1994.

23. Sims DW, Bivins BA, Obeid FN, et al: Urban trauma: A chronic recurrent disease. J Trauma 29:940–947, 1989.

24. Morrissey TB, Byrd CR, Deitch EA: The incidence of recurrent penetrating trauma in an urban trauma center. J Trauma 31:1536–1538, 1991.

25. Smith RS, Fry WR, Morabito DJ, Organ CH: Recidivism in an urban trauma center. Arch Surg 127:668 670, 1992.



Appendix #1




Youth’s initials: ____________                       ID# _______       

Assessed by: _____________                        Date entered ED: _____________

Today’s date: _______________                   Primary language: ______________________

Consent signed by:

o parent

o legal guardian

o self      date consent signed: ____________________

Date of birth (   /   /   )                                          Age when entered program _________


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 caseworker’s 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 person’s 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? ___________________________________________________



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?



Mount Sinai Psychiatry & Behavioral Health Clinical Services

Outpatient scheduling:

Inpatient: Sinai emergency psychiatric services (emergency department)




Have you ever been in involved with the law?

Yes _______  No ________  Explain: __________________________________________

If yes, can you tell me a little bit about what’s 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 officer’s 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)? ______





Northwestern Legal Aid Clinic

contact: Angela Coin  (773) 342-5071

o Mendel Legal Clinic at the University of Chicago
contact: (773) 702-9611

o Loyola University Legal Clinic
contact: (312) 915-6481

o Northwestern Legal Aid Clinic
(specializes in special education needs)
contact: (312) 503-8576

o Street Law Program (legal education)
contact: (312) 503-8576

o Legal Aid Bureau: (312) 922-5625

o Legal Assistance Foundation (West): (773) 638-2343

o Sinai – Victim’s Compensation Program contact:



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 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 _______




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
your nerves or get rid of a hangover? (For other substances: “Have you found
that you have to take some __________ most days/some days to feel OK?                 Y     N

*Note: Please note at end of assessment {in current life stressors} section if individual responds with a yes to any question above.


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
steady your nerves or get rid of a hangover? (For other substances: “Have you
found that you have to take some ________ most days/some days to feel OK?          Y     N

*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)




o Mt. Sinai Community Institute
Treatment Today Center (outpatient only)
Contact name: _____________________  Phone: (x4750)
Substance Abuse Treatment (under 18)
Services for individuals over the age of 18
Interventions assessment procedure (central intake): (312) 850-9411

o Interventions contact (for assessment): (312) 850-9411 x302
Or (women only): (312) 850-0080
Or main line: (773) 737-4600

o Gateway contact: put in fax

o Haymarket: (773) 226-7984

o Grant Hospital (outpatient and inpatient services): *need insurance
(773) 883-3898

Case manager: Please check contact book for additional substance abuse services



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 wasn’t 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)____________________________________________



Case manager: Would you identify the individual’s  mental status as a problem?

Yes _____ No _____ Needs further referral _____ (mental health professionals in ED)



o Mount Sinai Psychiatry & Behavioral Health Clinical Services
Services: Outpatient, Child & Adolescent Psychiatry & Behavioral Health and Treatment Today Center
Program: Under the Rainbow (6th floor)
Contact person: (x4750)

o Sinai Psychiatry and Behavioral Health at Mile Square
2040 W. Washington Boulevard
(312) 850-5800
Contact for all mental health appointments (also see mental health handout): extension 5031 to match client with closest mental health center and set up appointment.

*Case manager: Please try to refer based on geographic residence of the client.



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 ___





o Logan Square________        _________ Phone: (773) 342-8800

o Or Keystone program for individuals 14 years old or older (in every club) _________
Contact person: ______________

o Torch Program _______________________
Contact person _______________________

Mount Sinai Family Health Centers

o Gang Tattoo Removal Program
Contact person: ______________________________  Contact number: (773) 288-6900

o Peer counseling review
Contact person: ______________________________  Contact number: 5878

*Case manager: Please try to refer based on geographic residence of the client.



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?
  Yes _______  No _______

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)?




o Homework help

o Computer classes at BGCC

General Wood

Contact person: ______________________________  Phone: (773) 247-0700

o GED classes

o General Wood college classes


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)



You mentioned earlier that you have a job.

What kind of work do you do? ________________________________________________
Additional explanation: ______________________________________________________
Do you like your job?  Yes _______  No _______  Other ________________________

Additional explanation: ________________________________________________________

You mentioned earlier that you do not have a job.
Do you want or need a job? __________________________________________________
What type of job do you feel you would be best at or enjoy doing? __________________
Are you concerned or worried about your hospital bill (explain)? ____________________
Do you or any member of your immediate family get their source of income from any government funds?

Welfare ___________

WIC __________

Social Security _________________

Public Aid _____________________


Other _________________________




o Family Welfare-to-Sufficiency Partnership
Contact: ______________________________  x3694

o The Sinai Health Careers Club
Contact:  ______________________________  x4796

o Victims of Crime Assistance Program: Contact at x 6229

o Sinai Financial Assistance
Contact (Spanish speaking): ______________________________  x3108


Eisenberg Club

o Welfare-to-Work
Ph: (312) 226-6633    Fax: (312) 226-7094
or (adults only)    Ph: (312) 829-2865
or Sam Lopez at Little Village (Spanish speaking) ph: (312) 277-1800

General Wood – Little Village

o Computer classes

o ESL contact:

James Jordan Club and Family Health Center

o Computer Classes
Contact: for referral
Ph: (312) 226-2323    Fax: (312) 226-9788

o Employment Services
Contact: (same as immediate above)
Logan Square Boys & Girls Club
o Career job programs for youth
o Computer classes


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 Safer Foundation

o Illinois Employment and Training Center (Pilsen and near north)


o Emergency Shelters (CHA): 1-800-654-8595



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 ________





Anger and conflict resolution training (case managers)

Job readiness (case managers)



How do you feel you get along with your family? (explain)___________


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 _______  Don’t 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 _______


Is there a possibility you could be the father of any children at this time?
  Yes _______  No _______

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?
  Yes ______  No _______  Don’t know/other ___________________________________

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 _____




Sinai Community Institute

o Mount Sinai Community Institute: Reproductive Health Services, Pregnancy Prevention, The Parenting Institute (WIC program)
Contact: ____________________________x6370

o Reproductive Health Services
Contact: ____________________________x3635

o Adolescent Health Comprehensive Project
Contact: ____________________________(773) 733-1178

o Adolescent Health Delayed Pregnancy Project
Contact: ____________________________(773) 733-1178


o Forgotten Fathers program
Contact name: ____________________________Contact number (312) 226-5659

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)



Do you have a family doctor?___________________________________________________

If no, what do you (or your family) usually do if you’re 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? ____________________________





o Sinai Medical Group or Family Services (see handout of all individual sites by address)

o On-site dental clinic


o Vision screening program

Case manager: Please refer to medical center in closest proximity to individual’s home.


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



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? _______________________



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



1) Do you feel you could get a gun if you wanted one?

o Yes

o No

o Unsure
 2) Have you ever fired a gun?

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
11) During the past 30 days, on how many days did you carry weapon such as a gun, knife, or club
on school property?

o 0 days

o 1 day

o 2 or 3 days

o 4 or 5 days

o 6 or more days



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 _____________________________
REMINDER SHEET    Y ___  N ___


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?


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)



Date of review: _____________ Within Our Reach staff: _____________________________




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