The reasons below are currently occurring behaviors or conditions (not previous, attempted or possible) of the person that the provider or family has tried to address, but has been unable to address and now challenges the person's ability to live in their home:

  1. Self-Abuse:  Injures own body. Also self-inflicted violence, self-injurious behavior, self-harm.  Examples: banging head, hitting head with fists, cutting self, pulling hair, pinching self, biting nails, not letting wounds heal, throws self from chair -- with resulting injury. Threatens suicide.
  2. Physical aggression:  Causes physical pain to other people or to animals - for example, by hitting, kicking, biting, pinching, scratching, pushing, pulling hair or striking with an object. 
  3. Verbal aggression:  Demeaning, hurtful, or threatening comments.  Bullying, pestering, teasing, arguing, or complaining. Yelling or screaming.
  4. Elopement: The act of leaving (without permission) the place you are supposed to be, running away. 
  5. Inappropriate Sexual Behavior:  Unwanted sexual advances or touching, making comments of a sexual nature that offend those who hear, masturbation in inappropriate settings, exposing genitalia to others, voyeurism.
  6. Property Destruction:  Deliberately breaks, defaces or destroys things - for example by hitting, tearing, cutting, throwing, burning, marking or scratching things.
  7. Pica: Eating non-food objects. Examples include eating cigarette butts, paper or safety pins.
  8. Overutilization of emergency services: Excessive, repeated use of the 911, fire or police services by person calling or the staff feeling the need to use these.
  9. Recurrent Psychiatric Hospitalizations: Multiple psychiatric hospitalizations over a few months.
  10. Negative Community Contacts: Creating a disturbance in the community, such as going into other people's houses, urinating in public, creating an atmosphere that results in neighbors not wanting them in their neighborhood.
  11. Other Behavioral Concerns: Laughing or crying without reason, interferes with activities of others, unusual or repetitive behaviors, socially offensive behaviors, uncooperative behavior, stealing, breaking laws.
  12. Medical Non-Compliance:  Lack of cooperation with carrying out recommended steps in a medical treatment plan.
  13. Unexplained Physical Deterioration:  Weight loss, sleep disturbance, loss of use of limb or gait disturbance, falls from chair, change in control of bowel or bladder -- without known cause.  Please indicate frequency of issue. If frequency cannot be quantified, enter 0, see below.
  14. Other medical concerns:  not listed above. Please indicate frequency of issue. If frequency cannot be quantified, enter 0, see below.

Frequency

Frequency # Description
0 Never
1 Less than 1 time per month
2 1 to 3 times per month
3 1 to 6 times per week
4 1 to 10 times per day
5 1 or more times per hour

Severity

Severity # Description
0 Not serious, not a problem
1 Slightly serious, a mild problem
2 Moderately serious, a moderate problem
3 Very serious, a serious problem
4 Extremely serious, a critical problem