PSYCHOLOGICAL EVALUATION SERVICES

SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE
YOUTH CLINICAL INTERVIEW
Name______________________________________ Date____________
Criminal History
Youth's Account of the Offense(s) Youth's version of current charges (includes why, what led up to it)
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FAMILY FUNCTIONING
Youth's Report of Family Functioning
*(Designate current legal guardian/s)
Father's name: _________________________________________________________________
Mother's name: ________________________________________________________________
Stepfather's name: ______________________________________________________________
Stepmother's name: _____________________________________________________________
Grandmother's name: ____________________________________________________________
Grandfather's name: _____________________________________________________________
Were mother and father ever married?
When Separated/Divorced?
How long did you live with both?
How long did you live with mother/father?
Does either parent have a live-in partner?
Brothers:
Sisters:
Half-brothers/Stepbrothers:
Half-sisters/Stepsisters:
Any out of home placements? (Dates, durations, reasons)
Group homes:
Foster care:
Relatives:
Who lived with you at the time of your offense? Who lives with you now?
Quality of Relationships:
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How do your parents get along?
How does your mom/dad get along with her/his (boyfriend/girlfriend)?
How do you get along with your siblings? Is there a sibling you get along with the best/worst?
How do you get along with your parents?
Discipline/Structure:
Who makes the rules for you at home and what are they?
Curfew: Weekend: Weekday:
Chores:
Do you obey curfew and complete chores?
What happens if you break a rule? (Ask about response of each caretaker if more than one)
ADOLESCENT FUNCTIONING
Relevant History
Previous counseling (when and for how long? Thoughts about counseling? Likes/Dislikes?):
Previous anger management counseling:
Previous substance abuse counseling
Previous diagnoses:
Previous medications (when started, duration, why stopped):
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Currently taking medication? If yes, what medications:
Have you ever been hospitalized for psychological reasons?
History of physical abuse:
History of sexual abuse:
DSS involvement:
History of trauma (family, school, community):
History of head/brain injuries:
Recent major stressors or life changes:
CURRENT SYMPTOMATOLOGY
Substance Use
Tobacco First Used: Last Used:
Frequency of Use:
__Used more than intended __Desire to cut down alcohol use __lot of time spent obtaining, using, recovering from __Cravings __failure to fulfill
obligations __Social or Interpersonal Problems __Give up social or recreational activities __use in hazardous situations __Continued use despite
physical or psychological problems __Tolerance __Withdrawals (must have two)
Alcohol First Used: Last Used:
Frequency of Use:
__Used more than intended __Desire to cut down alcohol use __lot of time spent obtaining, using, recovering from __Cravings __failure to fulfill
obligations __Social or Interpersonal Problems __Give up social or recreational activities __use in hazardous situations __Continued use despite
physical or psychological problems __Tolerance __Withdrawals (must have two)
Marijuana First Used: Last Used:
Frequency of Use:
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__Used more than intended __Desire to cut down alcohol use __lot of time spent obtaining, using, recovering from __Cravings __failure to fulfill
obligations __Social or Interpersonal Problems __Give up social or recreational activities __use in hazardous situations __Continued use despite
physical or psychological problems __Tolerance __Withdrawals (must have two)
Cocaine First Used: Last Used:
Frequency of Use:
__Used more than intended __Desire to cut down alcohol use __lot of time spent obtaining, using, recovering from __Cravings __failure to fulfill
obligations __Social or Interpersonal Problems __Give up social or recreational activities __use in hazardous situations __Continued use despite
physical or psychological problems __Tolerance __Withdrawals (must have two)
Crack First Used: Last Used:
Frequency of Use:
__Used more than intended __Desire to cut down alcohol use __lot of time spent obtaining, using, recovering from __Cravings __failure to fulfill
obligations __Social or Interpersonal Problems __Give up social or recreational activities __use in hazardous situations __Continued use despite
physical or psychological problems __Tolerance __Withdrawals (must have two)
Heroin First Used: Last Used:
Frequency of Use:
__Used more than intended __Desire to cut down alcohol use __lot of time spent obtaining, using, recovering from __Cravings __failure to fulfill
obligations __Social or Interpersonal Problems __Give up social or recreational activities __use in hazardous situations __Continued use despite
physical or psychological problems __Tolerance __Withdrawals (must have two)
Meth First Used: Last Used:
Frequency of Use:
__Used more than intended __Desire to cut down alcohol use __lot of time spent obtaining, using, recovering from __Cravings __failure to fulfill
obligations __Social or Interpersonal Problems __Give up social or recreational activities __use in hazardous situations __Continued use despite
physical or psychological problems __Tolerance __Withdrawals (must have two)
Pills First Used: Last Used:
Frequency of Use:
__Used more than intended __Desire to cut down alcohol use __lot of time spent obtaining, using, recovering from __Cravings __failure to fulfill
obligations __Social or Interpersonal Problems __Give up social or recreational activities __use in hazardous situations __Continued use despite
physical or psychological problems __Tolerance __Withdrawals (must have two)
Ecstasy First Used: Last Used:
Frequency of Use:
__Used more than intended __Desire to cut down alcohol use __lot of time spent obtaining, using, recovering from __Cravings __failure to fulfill
obligations __Social or Interpersonal Problems __Give up social or recreational activities __use in hazardous situations __Continued use despite
physical or psychological problems __Tolerance __Withdrawals (must have two)
Shrooms First Used: Last Used:
Frequency of Use:
__Used more than intended __Desire to cut down alcohol use __lot of time spent obtaining, using, recovering from __Cravings __failure to fulfill
obligations __Social or Interpersonal Problems __Give up social or recreational activities __use in hazardous situations __Continued use despite
physical or psychological problems __Tolerance __Withdrawals (must have two)
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Other First Used: Last Used:
Frequency of Use:
__Used more than intended __Desire to cut down alcohol use __lot of time spent obtaining, using, recovering from __Cravings __failure to fulfill
obligations __Social or Interpersonal Problems __Give up social or recreational activities __use in hazardous situations __Continued use despite
physical or psychological problems __Tolerance __Withdrawals (must have two)
Ever sold drugs?
Mental Health Symptoms
The following is a list of questions to assist in making a diagnosis. Before making a diagnosis, factors such as
number of symptoms, frequency, age of onset, how recently the symptoms occurred, and context in which the
symptoms occur, all must be taken into consideration. It is important to remember that information from the
parent, available records, and the juvenile's presentation should also be considered. If a juvenile seems to have
symptoms of a particular disorder, but not enough for a full diagnosis, consider another/unspecified disorder.
Also keep in mind whether the juvenile may have a disorder that is less common among the DJJ population (for
example, Autism Spectrum Disorder or a neurocognitive disorder) or whether the juvenile's symptoms may be
substance-induced or related to withdrawal.
ADHD
(Be sure to include level of severity when making diagnosis)
Inattention
Do you often have trouble paying attention or staying focused?
Are you easily distracted? Easily sidetracked?
If yes:
Are you forgetful? Do you forget to do things you're supposed to do, have trouble remembering
things?
Are you able to talk to somebody without getting sidetracked, going off-topic, changing the
subject?
Do you tend to lose things easily or forget where you put them?
Do you tend to give up easily on things that seem hard or complicated? Avoid?
When you start something, do you usually finish it?
Do you daydream a lot?
Are you messy/disorganized?
Do you get in trouble for these things at school or at home?
*Do these things happen most days, or only once in a while?
*How long has this been a problem for you? (Onset)
Impulsivity/Hyperactivity
Do you ever feel like you have too much energy, or that you get "hyper"?
Do you hate sitting still? Do you have trouble sitting still for long periods of time?
Do you often do things without thinking about it first? Act first, think later?
If yes:
Do you get in trouble for interrupting others, blurting out answers, giving answers without raising
your hand?
Has anyone ever told you that you're restless/fidgety/move around too much?
Do you get in trouble for talking a lot?
Do you get in trouble for being loud or noisy?
Are you impatient? Do you have trouble waiting your turn?
*Does this happen most days, or only once in a while?
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If not most days: Does this usually happen when you're feeling really happy (manic symptoms)?
Does this happen when you're feeling sad or angry too? Are you like this at night too? (Insomnia,
sleep disturbance)
*How long has this been doing on? (Onset)
ODD
include specifiers - mild (1 setting), moderate (2 settings), severe (3 settings)
Angry/Irritable
Do you have a quick temper?
Do you get mad/annoyed easily? Do other people get on your nerves?
If yes:
Do you feel angry most of the time?
Do you only feel this way at school/at home/both?
What happens when you get mad?
*How long has this been going on? (Onset)
Argumentative/Defiant
Do you hate it when people tell you what to do?
Do you sometimes do stuff just to annoy other people or get a reaction from them?
Do you get in trouble for not doing what you're told, or talking back to teachers/your parents?
If yes:
Do you argue with your parents/teachers a lot?
Do you feel like you get blamed for things you didn't do, or that other people are too hard on you?
Do you break the rules a lot?
Is this a problem at school/at home/both?
*When did this start? How long has this been going on?
Vindictive
Do you like to get back at people who have made you mad?
Do you hold grudges? Is it hard for you to forgive people?
Conduct Disorder
(Specify childhood-onset, adolescent-onset, or unspecified onset)
Have you been a bully toward others?
Do you start fights a lot?
Have you ever used a weapon in fight?
Have you ever hurt animals?
Have you ever approached someone and stolen something from them?
Have you ever forced someone to have sex with you?
Have you ever intentionally set something on fire?
Have you ever destroyed someone's property on purpose?
Have you ever broken into someone's house, building, or car?
Have you ever stolen something valuable?
Do you lie to get things from people or to get out of something?
Do you stay out at night against your parent's wishes? When did you start doing that?
Have you ever run away overnight? Did your parent(s) know where you were?
Do you skip school often?
Depression
Have you ever thought you might be depressed?
Do you feel sad often?
Do you often feel irritable?
Do you feel like nothing makes you happy anymore?
Have you stopped doing things that you used to really like doing?
If yes:
Do you have crying spells?
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Have you gained or lost a lot of weight lately?
Eating too much or too little?
Sleeping a lot more or a lot less than usual?
Trouble concentrating? (if no ADHD)
Do you feel tired a lot, like you don't have much energy?
Are you pretty hard on yourself if you do something wrong? Has anyone ever told you that you're
too hard on yourself?
Are there a lot of things that you don't like about yourself, or that you wish you could change?
Do you feel like nothing makes you feel happy or sad? Just "blah"? (Apathy)
Are you easily annoyed/irritated? Short temper? People get on your nerves?
Do you ever feel like things are never going to get better?
*How long have you been feeling this way?
*Do you feel like this nearly every day?
Have you ever hurt yourself on purpose? Cutting, burning, or scratching?
If yes:
When did this start?
When is the last time you did this?
Do you think you will do it again? Soon?
If no:
Have you ever thought about hurting yourself?
If yes: What stopped you?
Have you ever thought about suicide?
If yes:
When?
Are you thinking about it now? When's the last time?
Have you ever thought about how you would go about doing it? (Means, opportunity)
What kept you from doing it? (reasons for living)
Do you think you might feel that way again soon?
What will you do if that happens?
Have you ever tried to commit suicide?
If yes:
When?
What happened?
Do you think you'll feel that way again someday? Soon?
What will you do if that happens?
Disruptive Mood Dysregulation Disorder *(cannot co-occur w/ ODD, Bipolar, IED)
Do you feel irritable most of the time?
If yes:
Do you feel angry/irritable almost every day? Do others notice it?
Does the feeling of anger/irritability last all day?
Do you have major/severe verbal or physical outbursts of anger? (get example)
How long do they usually last?
How many times per week? (at least 3x)
In what settings? (irritability & outbursts in at least 2 settings, severe
in at least 1 of these)
How long has this been happening? (12+ months, no more than 3
consecutive months without)
How old were you when it started? (onset between ages 6-10)
Persistent Depressive Disorder
Do you feel depressed more often than you feel happy? (in adolescents, mood can be irritable)
If yes:
How long have you felt this way?
Do you eat more or less when you feel this way?
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Do you sleep too little or too much?
Do you feel fatigued or like you have no energy?
Do you feel bad about yourself?
Do you have trouble concentrating or making decisions?
Do you feel as if things are hopeless?
Has the juvenile ever gone longer than two months without experiencing this symptoms?
Has duration been at least 1 year?
Has juvenile ever experienced a manic or hypomanic episode?
Manic/Hypomanic Episodes
Do you ever have times where you are abnormally happy, irritable, or have increased energy or goal-
directed activities?
If yes:
How long do these feelings last?
During these times do you feel you can do things you know are impossible?
Do you believe you are the greatest at something despite never trying it before?
Do you have so much energy that you do not need to sleep, or only need a few hours of
sleep a night?
Do you talk excessively during these times without care for other peoples' thoughts?
Do you feel like your thoughts come and go faster than you can express them?
Do you get distracted easily?
Do you engage in multiple activities, calling people frequently, carrying on multiple
conversations (via texts or emails) at once?
Do you engage in dangerous activities (spending sprees, reckless driving, sexual
promiscuity)?
Do you only notice these symptoms while using drugs or alcohol?
Anxiety:
Phobias
Is there any one thing that you're really afraid of? Much more afraid than most people?
Are you always afraid when you see or experience that thing?
Do you go out of your way to avoid that thing?
Social Anxiety
Do you get really nervous or anxious when you have to do something in front of other
people? Much more nervous than most people?
Are you afraid that you will be embarrassed?
Does this only happen when you have to speak in front of others?
Separation Anxiety (3 or more of following):
Do you feel really scared or anxious when away from your family?
Do you often worry that someone in your family will die or be harmed?
Do you often worry about being kidnapped, or getting into a serious accident that will
take you away from your family?
Do you avoid going to school because you're worried something bad will happen?
(If yes), what are you worried will happen?
Do you avoid sleeping way from home because you're worried?
Do you have nightmares about being away from family?
Do you ever feel sick when you know you're going to be separated from family?
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Obsessions/compulsions
Have you ever had a thought that you think about all the time, but you wish it would go
away?
Have you ever done anything to make that thought go away?
Have you done something over and over again because you were worried something bad
would happen if you didn't do that thing?
Generalized Anxiety Disorder
Do you worry a lot more than most people?
Do you find it hard to stop worrying?
When you worry, do you (one of following):
Feel restless?
Feel easily fatigued?
Have difficulty concentrating?
Feel irritable?
Feel tense?
Have problems sleeping?
Panic attacks (4 or more of the following)
Have you experienced any times when you suddenly:
Felt your heart racing?
Began sweating?
Began shaking?
Felt short of breath?
Felt as if you were choking?
Had chest pain?
Felt nauseous?
Felt dizzy or light-headed?
Had chills or heat sensations?
Felt numbness or tingling sensations?
Felt as though things weren't real or you were outside of your body?
Felt that you might be going crazy?
Felt that you were about to die?
Did these symptoms only occur when you were really angry about something?
Did these symptoms only occur when you had suddenly stopped using drugs/alcohol?
Panic Disorder
Does juvenile have history of panic attacks? If yes,
Do you worry about having another panic attack?
Do you do things to avoid having another panic attack?
(The symptoms do not occur only in response to feared social situations (Social Anxiety Disorder), Specific
Phobias, obsessions (OCD), reminders of traumatic events (PTSD), or in response to separation from attachment
figures (Separation Anxiety Disorder).
Psychosis (hallucinations, delusions, odd beliefs)
Have you ever seen/heard things other people couldn't see/hear?
Have you ever believed something that other people tell you isn't true, but you know it is?
Do believe people are out to get you?
If juvenile seems to have symptoms of psychosis, consider whether disorganized speech or behavior, negative
symptoms (e.g. flattened affect), or mood symptoms are present. Also consider whether symptoms could be
attributable to substance use.
Form 903A
04-2022