Form Soc 837 - Supplement To The Rate Questionnaire Page 3
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DISRUPTIVE or SELF-INJURIOUS BEHAVIOR
9. The child/youth has severe behavioral outbursts or deficits that have occurred in the last twelve months and presents a
significant high-risk of reoccurrence that, due to their severity, require long term intervention (i.e.: attempted suicide, acts
of aggression that result in serious injury or significant property damage, sexually assaultive behavior, and attempted
arson) .
■ ■
■ ■
■ ■
YES (If YES, skip 10 and 11)
NO
DO NOT KNOW
COMMENTS:
10. The child/youth has severe behavioral outbursts or deficits that occur regularly (e.g.: daily or several times a week) that
require behavioral intervention. This includes when caregiver intervention is needed to avoid self-injury or injury to
others, resulting from the behavioral outbursts or deficits. This also includes children/youth who have severe disruptive
behaviors such as: elopement, (running away) feces smearing, public urination, property destruction, severe aggression,
maladaptive sexual behavior, eating disorders, habitual lying and/or theft, and/or sleep disorders.
■ ■
■ ■
■ ■
YES (If YES, skip 11)
NO
DO NOT KNOW
COMMENTS:
11. The child/youth needs monitoring due to severe behavioral outbursts or deficits that are frequent and occur at least once
a week or four times a month and require behavioral intervention. This includes when caregiver intervention is needed
to avoid self-injury or injury to others, resulting from the behavioral outbursts or deficits. This also includes children/youth
who have severe disruptive behaviors such as: elopement (running away) , feces smearing, public urination, property
destruction, severe aggression, maladaptive sexual behavior, eating disorders, habitual lying, theft and/or sleep
disorders.
■ ■
■ ■
■ ■
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a)
YES (two or more behaviors present)
b)
YES (one behavior present)
NO
DO NOT KNOW
COMMENTS:
NAME OF PERSON COMPLETING THE FORM:
DATE:
PHONE NUMBER:
FAX NUMBER:
AGENCY NAME:
Social Services/Adoption/Probation
(circle one)
ADDRESS:
SIGNATURE:
NAME OF PERSON REVIEWING INFORMATION:
PHONE NUMBER:
DATE:
AGENCY NAME:
FAX NUMBER:
ADDRESS
SIGNATURE:
PAGE 3 OF 3
SOC 837 (11/08)
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