III.

OTHER BEHAVIOR THAT THE CHILD SHOW

__Inconsistency in skills
__Self-destructive behaviors
__Struggle with developing positive
Relationship
__Explosive behaviors
__Hyperactive, distractible, inattentive
__Excessive aggression or violence to
_______________
Others/self
__Peculiar pattern of forgetfulness
__Sexual behaviors not typical for
child’s age
__Withdrawn or excessively shy
__Oppositional and/ or defiant
behavior
__Others (please specify)

IV.EEMOTION/MOODS THE CHILD EXHIBITS

__Excessive impulsivity ___Withdrawn behavior

__Excessive mood swings

Referred/ Reported by:

______________________________________________ _________ _________
Signature over Printed name/Designation Date Time

Profiling and Initial Risk Assessment Tools for Child-at-Risk

This form will help the guidance counselor/teacher quickly note down risk factors
That make the child vulnerable to coming in conflict with the law.

Initial assessment made using this form will not substitute for the professional
assessment and judgement of a licensed child psychologist and licensed social worker.

I.CHILD’S IDENTIFICATION INFORMATION

Case No. __________________________________ Date: __________

Name: _____________________________________B-Date: _____________
Grade/Section: _______________ Learner’s Reference Number: ________________________
Age: ___________ Sex: _________ Gender: ______________ Contact: _____________________