Needs Assessment

Assessment Checklist:

_____ Inappropriate anger?
_____ Had any changes in behavior and/or mood? (I.e. sad, angry, withdrawn, etc.)
_____ Exhibited depressive symptoms? (I.e. sadness, hopelessness,  weight loss, weight gain,  

             excessive sleep, etc.)
_____ Had problems getting along with others?
_____ Had a worrisome change in friends?
_____ Do you have reason to suspect that your child has abused drugs or alcohol?
_____ Has your child disregarded family rules and parental guidance?
_____ Shown hostility toward other family members?
_____ Been physically assaultive toward adults or peers?
_____ Been verbally assaultive toward adults or peers?
_____ Had more frequent violent outbursts at home?
_____ Has your child escaped consequences by manipulating people and situations?
_____ Had problems in school? (I.e. poor grades, challenging authority, detentions

             suspensions, etc.)
_____ Shown a tendency toward reckless behavior?
_____ Intentionally frightened others?
_____ Made threatening statements in writing?
_____ Implied that they might have a plan for violent or suicidal behavior?
_____ Implied that they have identified a target for violence?
_____ Been destructive to property?
_____ Had valuables suddenly appear in their possession?
_____ Shown a loss of interest in healthy activities and/or a general lack of motivation?
_____ Shown no concern about his/her future?
_____ Had gang involvement or is a gang wanna be?
_____ Shown inappropriate sexual behavior with same or opposite sex?
_____ Run away?
_____ Self-injurious acts or threats such as cutting or mutilating self?
_____ Set fires/participated in arson?
_____ Other (specify) _________________________________________________

Please attach a statement telling us of your child’s current problems and the reasons you are seeking placement.

If you would like to contact us, please feel free to:

Call us at: 815-796-4561
Fax us at: 815-796-4565

Mail us at:
The Ranch Program at Salem
15161 N. 400 East Road
Flanagan, IL 61740

Or contact us via e-mail through our contact initiation form.