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Positive Achievement Change Tool (PACT) 1.0
Pre-Screen
Assessments.com
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DOMAIN 1: Record of
Referrals |
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Referrals, rather than offenses, are used to assess the persistence of
re-offending by the youth. Include only referrals that resulted in
diversion, adjudication withheld, adjudication, deferred prosecution or
referral to adult court (regardless of whether successfully completed). |
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1.
Age
at first offense:
The age at the time of the offense for which the youth was referred to
juvenile court for the first time on a non-traffic misdemeanor or felony
that resulted in diversion, adjudication withheld, adjudication,
deferred prosecution or referral to adult court.
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O
Over 16
O
16
O
15
O
13 to 14
O
12 and Under |
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Felony and misdemeanor referrals:
Items 2 and 3 are mutually exclusive and should add to the total number
of referrals that resulted in diversion, adjudication withheld,
adjudication, deferred prosecution or referral to adult court. |
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2.
Misdemeanor referrals:
Total number of referrals for which the most serious offense was a
non-traffic misdemeanor that resulted in diversion, adjudication
withheld, adjudication, deferred prosecution or referral to adult court
(regardless of whether successfully completed).
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O
None or one
O
Two
O
Three or four
O
Five or more |
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3.
Felony referrals:
Total number of referrals for a felony offense that resulted in
diversion, adjudication withheld, adjudication, deferred prosecution or
referral to adult court (regardless of whether successfully completed). |
O
None
O
One
O
Two
O
Three or more |
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Against-person or weapon referrals:
Items 4, 5, and 6 are mutually exclusive and should add to the total
number of referrals that involve an against-person or weapon offense,
including sex offenses that resulted in diversion, adjudication
withheld, adjudication, deferred prosecution or referral to adult court
(regardless of whether successfully completed). |
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4.
Weapon referrals:
Total referrals for which the most serious offense was a
firearm/weapon charge or a weapon enhancement finding. |
O
None
O
One or more |
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5.
Against-person misdemeanor referrals:
Total number of referrals for which the most serious offense was an
against-person misdemeanor – a misdemeanor involving threats, force, or
physical harm to another person or sexual misconduct (assault, coercion,
harassment, intimidation, etc.). |
O
None
O
One
O
Two or more |
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6.
Against-person felony referrals:
Number of referrals involving force or physical harm to another
person including sexual misconduct as defined by FDLE as violent
felonies. |
O
None
O
One or two
O
Three or more |
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Sex offense referrals:
Items 7 and 8 are mutually exclusive and should add to the total number
of referrals that involve a sex offense or sexual misconduct that
resulted in diversion, adjudication withheld, adjudication, deferred
prosecution or referral to adult court. |
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7.
Sexual misconduct misdemeanor referrals:
Number of referrals for which the most serious offense was a sexual
misconduct misdemeanor including obscene phone calls, indecent exposure,
obscenity, pornography, or public indecency, or misdemeanors with sexual
motivation. |
O
None
O
One
O
Two or more |
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8.
Felony sex offense referrals:
Referrals for a felony sex offense or involving sexual motivation
including carnal knowledge, child molestation, communication with minor
for immoral purpose, incest, indecent exposure, indecent liberties,
promoting pornography, rape, sexual misconduct, or voyeurism. |
O
None
O
One
O
Two or more |
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9.
Confinements in secure detention where youth was held for at least 48
hours:
Number of times the youth was held for at least 48 hours physically
confined in a detention facility. |
O
None
O
One
O
Two
O
Three or more |
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10.
Commitment orders where youth served at least one day confined under
residential commitment:
Total number of commitment orders and modification orders for which the
youth served at least one day confined under residential commitment. A
day served includes credit for time served. |
O
None
O
One
O
Two or more |
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11.
Escapes:
Total number of attempted or actual escapes that resulted in
adjudication. |
O
None
O
One
O
Two or more |
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12.
Pick Up Orders for failure-to-appear in court or absconding supervision:
Total number of failures- to-appear in court
or absconding supervision that resulted in a pick up order being issued.
Exclude failure-to-appear warrants for non-criminal matters. |
O
None
O
One
O
Two or more |
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Domain 2 : Social History |
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Current is
defined as behaviors occurring within the last six months |
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1.
Youth’s Gender |
O
Male
O
Female
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2a.
Youth's current school enrollment status, regardless of attendance:
If the youth is in home school as a result of being expelled or dropping
out, check the expelled or dropped out box, otherwise check enrolled. |
O
Graduated, GED
O
Enrolled full-time
O
Enrolled part-time
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O
Suspended
O
Dropped out
O
Expelled |
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2b.
Youth's conduct in the most recent term:
Fighting or threatening students; threatening teachers/staff; overly
disruptive behavior; drug/alcohol use; crimes, e.g., theft, vandalism;
lying, cheating, dishonesty. |
O
Recognition for good
behavior
O
No problems with school
conduct
O
Problems reported by
teachers
O
Problem calls to
parents
O
Calls to police |
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2c.
Youth's attendance in the most recent term:
Full-day absence means missing majority of classes. Partial-day absence
means attending the majority of classes and missing the minority.
Habitual truancy as defined in FS includes 15 unexcused absences in a
90-day period. |
O
Good attendance with
few absences
O
No unexcused absences
O
Some partial-day
unexcused absences
O
Some full-day unexcused
absences
O
Habitual truant |
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2d.
Youth's academic performance in the most recent school term: |
O
Honor student (mostly
As)
O
Above 3.0 (mostly As
and Bs)
O
2.0 to 3.0 (mostly Bs
and Cs, no Fs)
O
1.0 to 2.0 (mostly Cs
and Ds, some Fs)
O
Below 1.0 (some Ds and
mostly Fs) |
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3a.
History of anti-social friends/companions:
Anti-social peers are youths hostile to or disruptive of the legal
social order; youths who violate the law and the rights of others and
other delinquent youth. (Check all that apply.) |
¨
Never had consistent
friends or companions
¨
Had pro-social
friends
¨
Had anti-social
friends
¨
Been a gang
member/associate |
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3b.
Current friends/companions youth actually spends time with:
(Check all that apply.) |
¨
No consistent friends
or companions
¨
Pro-social
friends
¨
Anti-social
friends
¨
Gang
member/associate |
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4.
History of court-ordered or DCF voluntary out-of-home and shelter care
placements exceeding 30 days:
Exclude DJJ residential commitments. |
O
No out-of-home placements exceeding 30 days
O
1 out-of-home placement
O
2 out-of-home
placements
O
3 or more out-of-home
placements |
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5.
History of running away or getting kicked out of home:
Include times the youth did not voluntarily return within 24 hours, and
include incidents not reported by or to law enforcement |
O
No history of running
away/being kicked out
O
1 instance of running
away/kicked out
O
2 to 3 instances of
running away/kicked out
O
4 to 5 instances of
running away/kicked out
O
Over 5 instances of
running away/kicked out |
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6a.
History of jail/imprisonment of persons who were ever involved in the
household for at least 3 months:
(Check all that apply.) |
¨
No jail/imprisonment
history in family
¨
Mother/female
caretaker
¨
Father/male
caretaker
¨
Older sibling
¨
Younger sibling
¨
Other member |
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6b.
History of jail/imprisonment of persons who are currently involved
with the household: (Check all that apply.) |
¨
No jail/imprisonment
history in family
¨
Mother/female
caretaker
¨
Father/male
caretaker
¨
Older sibling
¨
Younger sibling
¨
Other member |
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6c.
Problem history of parents who are currently involved with the
household: (Check all that apply).
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¨
No problem history of
parents in household
¨
Parental
alcohol problem history
¨
Parental drug
problem history
¨
Parental
physical health problem history
¨
Parental mental
health problem history
¨
Parental
employment problem history |
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7. Current
parental authority and control: |
O
Youth usually
obeys and follows rules
O
Sometimes obeys
or obeys some rules
O
Consistently
disobeys, and/or is hostile |
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8a. Youth’s
history of alcohol use:
(Check all that apply.)
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¨
No past alcohol
use
¨
Past alcohol
use
¨
Alcohol caused
family conflict
¨
Alcohol
disrupted education
¨
Alcohol caused
health problems
¨
Alcohol
interfered with keeping pro-social friends
¨
Alcohol
contributed to criminal behavior
¨
Youth needed
increasing amounts of alcohol to achieve same level of intoxication or
high
¨
Youth
experienced withdrawal problems |
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8b. Youth’s
history of drug use:
(Check all that apply.)
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¨
No past drug
use
¨
Past drug use
¨
Drugs caused
family conflict
¨
Drugs disrupted
education
¨
Drugs caused
health problems
¨
Drugs
interfered with keeping pro-social friends
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Drugs
contributed to criminal behavior
¨
Youth needed
increasing amounts of drugs to achieve same level of intoxication or
high
¨
Youth
experienced withdrawal problems |
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8c. Youth’s
Current alcohol use:
(Check all that apply.)
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¨
No current
alcohol use
¨
Current alcohol
use
¨
Alcohol causing
family conflict
¨
Alcohol
disrupting education
¨
Alcohol causing
health problems
¨
Alcohol
interfering with keeping pro-social friends
¨
Alcohol
contributing to criminal behavior
¨
Youth needs
increasing amounts of alcohol to achieve same level of intoxication or
high
¨
Youth
experiences withdrawal problems |
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8d. Youth’s
current drug use:
(Check all that apply.)
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¨
No current drug
use
¨
Current drug
use
¨
Drugs causing
family conflict
¨
Drugs
disrupting education
¨
Drugs causing
health problems
¨
Drugs
interfering with keeping pro-social friends
¨
Drugs
contributing to criminal behavior
¨
Youth needs
increasing amounts of drugs to achieve same level of intoxication or
high
¨
Youth
experiences withdrawal problems |
For abuse and
neglect, include any history that is suspected, whether or not reported
or substantiated; exclude reports of abuse or neglect proven to be
false. |
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9a. History
of violence/physical abuse:
Include suspected incidents of abuse if disclosed by youth, whether or
not reported or substantiated, but exclude reports investigated but
proven to be false.
(Check all that apply.) |
¨
Not a victim of
violence/physical abuse
¨
Victim of
violence/physical abuse at home
¨
Victim of
violence/physical abuse in a foster/group home
¨
Victimized by
family member
¨
Victimized by
someone outside the family
¨
Attacked with a
weapon |
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9b History
of witnessing violence:
(Check all that apply) Include perpetrators and victims of
violence as having witnessed violence. |
¨
Has not
witnessed violence
¨
Has witnessed
violence at home
¨
Has witnessed
violence in a foster/group home
¨
Has witnessed
violence in the community
¨
Family member
killed as result of violence |
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9c History
of sexual abuse/rape:
Include suspected incidents of abuse
if disclosed by youth, whether or not reported or substantiated,
but exclude reports investigated but proven to be false. (Check all
that apply.) |
¨
Not a victim of
sexual abuse/rape
¨
Sexually
abused/raped by family member
¨
Sexually
abused/raped by someone outside the family |
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10. History
of being a victim of neglect:
Include suspected incidents of neglect, whether or not reported or
substantiated, but exclude reports investigated but proven to be false. |
O
Not victim of
neglect
O
Victim of
neglect |
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11. History of
mental health problems: Such as schizophrenia, bi-polar, mood,
thought, personality, and adjustment disorders. Exclude substance abuse
and special education since those issues are considered elsewhere.
Confirm by a professional in the social service/healthcare field. |
O
No history of
mental health problem(s)
O
Past history of
mental health problem(s) diagnosis (more than six months ago)
O
Diagnosed with
mental health problem(s)
O
Only mental
health medication prescribed. If yes, list ____________________________
O
Only mental
health treatment prescribed
O
Mental health
medication and treatment prescribed |
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Domain 3:
Mental Health |
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1. History of
suicidal ideation: Include any previous thoughts, threats, plans and
attempts even if youth indicates they were manipulative or there was no
intent. (Check all that apply) |
¨
Has never had
serious thoughts about suicide
¨
Has had serious
thoughts about suicide
¨
Has made a plan
to commit suicide. If yes, describe _____________________
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Has attempted
to commit suicide. If yes, describe attempt(s) and
date(s)________________________
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Feels life is
not worth living – no hope for future.
¨
Knows someone
well who has committed suicide. If yes, who, when and how
__________________________
¨
Engages in self-mutilating behavior____________________ |
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2. History of
anger or irritability: |
O
No history of
anger/irritability
O
History of
occasional feelings of anger/irritability
O
History of
consistent feelings of anger/irritability
O
History of aggressive reactions to
feelings of anger/irritability. |
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3. History of
depression or anxiety |
O
No history of
depression/anxiety
O
History of
occasional feelings of depression/anxiety
O
History of
consistent feelings of depression/anxiety
O
History of impairment in every day tasks
due to depression/anxiety |
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