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Columbia Assessment

If a student expresses suicidal (self-harm verbally or in writing), homicidal (harm another person verbally or in writing), or child maltreatment (sexual abuse, physical abuse, or neglect) please complete The Columbia ASSESSMENT and contact Crisis Team (JB or Melinda) immediately.

Public Health Referral

Name of Location

Student First Name

Student Last Name

Grade

Teacher/Director Name

Teacher/Director Email

Classroom Number

Are you expereincing any thoughts of hurting yourself or someone else? If yes, please complete the Columbia Assessment above. *

Yes

No

Does your family needs help with getting groceries, or paying late rent or utilities?

Yes

No

Not Sure

Adverse Childhood Experiences (leave black if none)

Did a parent or other adult in the household often … Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?

Did a parent or other adult in the household often … Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?

Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Try to or actually have oral, anal, or vaginal sex with you?

Did you often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?

Did they often feel that … They didn’t have enough to eat, had to wear dirty clothes, and had no one to protect them? or Their parents were too drunk or high to take care of them or take them to the doctor if they needed it?

Were your parents ever separated or divorced?

Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her? or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

Was a household member depressed or mentally ill or did a household member attempt suicide?

Did a household member go to prison?

What is the ACE Score? (Each check mark is 1 point)

Are you interested in starting counseling services? *

Yes

No

Note Sure

Thanks for submitting!

The Movement Center

2225 Freedom Dr, Suite 2

Charlotte NC 28208

Office (704) 537-7775

Fax (704) 705-1546

ADMIN@C4PLLC.COM

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