Child Safety and Risk Screening Form
Child's Name
Date of Birth
Parent/Guardian Name
Contact Information
Screening Questions
Are there any known safety risks or concerns regarding the child’s living environment?
Yes
No
Unsure
If yes, please describe:
Has the child been exposed to any form of abuse, neglect, or violence?
Yes
No
Unsure
If yes, please provide details:
Are there any individuals the child should not have contact with?
Yes
No
Unsure
If yes, please specify:
Are there any medical, mental health, or behavioral concerns we should be aware of?
Yes
No
If yes, please explain:
Any other safety or risk concerns:
Screened By
Date