Page 89 - Meeting with Children Manual

P a g e | 3 Child and Youth Intake Form

Child Name____________ File Number _____________

CHILD SAFETY CONCERNS
Parent description of any history that indicates the possibility of Child Trauma

Child  Family history Child Risks Direct Indirect
Screening indicates concern Indicators History of controlling  
Family for Child History of violence  
Violence  Child reports fear Threats to other parent  
of one or both Threats to child  
parents Weapons access  
 Risk Indicators Weapons use  
Present Strangulation other parent  
Strangulation child  
CURRENT OR HISTORIC Sexual assault other parent  
 Police Sexual assault child  
involvement with Physical violence  
the Family Drug/alcohol  
 Y Threats to suicidal  
 N Use of pets  
 Number of Killing Pets  
callouts: Use of children  
_________ Stalking  
Monitoring/surveillance  
 Charges against Other  
individuals: Other  
 PPO/AVO
o Copy on
file
 Charges
o Copy on
file
 Conviction
o Copy on
file
Risk  Y Decision on  RED Comments
Assessment  N case Risk  ORANGE
Tool  Attached Colour  YELLOW
Completed  GREEN
Child at  Y ROSH  Y Mandatory  Y Date of Report
Risk  N tree  N Report  N
Concern Ref No.

© Lorri Yasenik and Jon Graham 2016
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We acknowledge and pay respect to the traditional owners and custodians of the land on which we work and live.
The Institute of Specialist Dispute Resolution Pty Ltd
ABN 46 105 820 791
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