MWO Program Designation Question Title * 1. Rank the school-based behaviors for your program from most to least challenging. (1 = Most; 8 = Least) 1 2 3 4 5 6 7 8 School attendance is poor, grades are poor, concentration is poor when in school; requires oversight from teachers, family and/or caregiver 1 2 3 4 5 6 7 8 Multiple school suspensions and disciplinary actions 1 2 3 4 5 6 7 8 History of explosive outbursts in school 1 2 3 4 5 6 7 8 Failure and/or inability to learn 1 2 3 4 5 6 7 8 IEP with placement in specialized classes for behavioral or learning disabilities 1 2 3 4 5 6 7 8 May require adaptive learning tools 1 2 3 4 5 6 7 8 Refuses help with school work or tutoring 1 2 3 4 5 6 7 8 Oppositional and defiant in the home and school setting OK Question Title * 2. Rank the mental health behaviors for your program from most to least challenging. (1 = Most; 8 = Least) 1 2 3 4 5 6 7 8 Smearing and/or throwing feces 1 2 3 4 5 6 7 8 Fire setting with intent to destroy property or injure others and/or preoccupation with fire 1 2 3 4 5 6 7 8 Intentionally and/or maliciously cruel to animals 1 2 3 4 5 6 7 8 History of cruelty to animals 1 2 3 4 5 6 7 8 Hearing voices and/or seeing things that are not there 1 2 3 4 5 6 7 8 Withdrawn behavior, attention seeking behaviors that are excessive, constant complaining about physical ailments, nightmares, difficulty going to bed and/or refusal to stay in bedroom 1 2 3 4 5 6 7 8 Fears, worries, and anxieties that affect daily activities; frequent and severe headaches, stomach aches and/or refusal to get out of bed 1 2 3 4 5 6 7 8 Bedwetting - graduating to intentional urination in places other than the toilet OK Question Title * 3. Rank the risky and/or dangerous behaviors for your program from most to least challenging. (1 = Most; 8 = Least) 1 2 3 4 5 6 7 8 Recurrent and/or severe self-injurious behaviors and/or suicidal behaviors that are under control 1 2 3 4 5 6 7 8 Homicidal and/or suicidal threats 1 2 3 4 5 6 7 8 Runs away with involvement in situations where high risk activities are likely to occur 1 2 3 4 5 6 7 8 Drinking and/or drug use which may have resulted in disciplinary actions and/or affect daily function 1 2 3 4 5 6 7 8 Highly sexualized behaviors, promiscuity, seeking inappropriate relationships with older persons, poor physical boundaries, often with history of sexual abuse and poor self esteem 1 2 3 4 5 6 7 8 Sexual acting out with or without aggression that may be opportunistic, situational or planned 1 2 3 4 5 6 7 8 Delinquent behaviors - stealing, burglary, assault and/or battery 1 2 3 4 5 6 7 8 Odd, bizarre or explosive actions, which pose a significant risk of harm to self or others OK Question Title * 4. Rank the inadequate life skills-based behaviors for your program from most to least challenging. (1 = Most; 8 = Least) 1 2 3 4 5 6 7 8 Serious problems with personal hygiene 1 2 3 4 5 6 7 8 Seems unable to form any meaningful friendships, is socially isolated and unable to enjoy activities with peers 1 2 3 4 5 6 7 8 Several years behind in the development of age-appropriate knowledge of self-care of life skills 1 2 3 4 5 6 7 8 Limited ability to perform routine tasks of daily living such as chores or laundry 1 2 3 4 5 6 7 8 Poorly prepared for, and lacking skills necessary for independent living 1 2 3 4 5 6 7 8 Difficulties with social interactions and/or communication (failure to speak, make eye contact, shake hands, hiding, standing too close, revealing personal information inappropriately to strangers, etc.) 1 2 3 4 5 6 7 8 Inflexibly adheres to routines or rituals and has difficulty with transitions, which may lead to serious harm to self or others or extremely aggressive behaviors 1 2 3 4 5 6 7 8 Hiding soiled clothing/bed linens OK Question Title * 5. Rank the conduct-based behaviors for your program from most to least challenging. (1 = Most; 8 = Least) 1 2 3 4 5 6 7 8 Verbal aggression (Use of vulgar and/or provocative language) 1 2 3 4 5 6 7 8 Deliberately or impulsively destroying property while in a structured setting breaking windows, pictures, mirrors, damage to furniture, appliances, clothing, electronics, and vehicles 1 2 3 4 5 6 7 8 Physical aggression and/or assault (hitting, kicking, spitting, attacking may with or without a weapon, throwing objects) toward adults and/or other children with and/or without injuries 1 2 3 4 5 6 7 8 Chaotic and poor control of anger toward self and others with frequency and intensity that needs attention 1 2 3 4 5 6 7 8 Frequent and/or uncontrollable behavioral outbursts and mood swings 1 2 3 4 5 6 7 8 Recurring involvement with Department of Juvenile Justice (DJJ) 1 2 3 4 5 6 7 8 Involvement with gangs and/or gang-like activities 1 2 3 4 5 6 7 8 Impulsive behaviors that present barrier to maintaining physical safety OK Question Title * 6. Rank the moderate medical issues for your program from most to least challenging. (1 = Most; 8 = Least) 1 2 3 4 5 6 7 8 9 Mild Cerebral Palsy 1 2 3 4 5 6 7 8 9 Cancer in remission 1 2 3 4 5 6 7 8 9 Diabetes – managed with insulin and follow up with Endocrinologist 1 2 3 4 5 6 7 8 9 Infant with sucking difficulty and/or on a monitor 1 2 3 4 5 6 7 8 9 Severe visual impairment to include a diagnosis of legal blindness 1 2 3 4 5 6 7 8 9 Seizure disorder requiring medication 1 2 3 4 5 6 7 8 9 HIV exposure with medications 1 2 3 4 5 6 7 8 9 Reflux that is controlled with 1-2 medications 1 2 3 4 5 6 7 8 9 Recovering from head injury OK Question Title * 7. Rank the moderate developmental or psychological issues for your program from most to least challenging. (1 = Most; 8 = Least) 1 2 3 4 5 6 7 8 Global developmental delay as the primary diagnosis 1 2 3 4 5 6 7 8 Fetal Alcohol Syndrome 1 2 3 4 5 6 7 8 Ordered to have physical, occupational, and/or speech therapy 1-2 times weekly 1 2 3 4 5 6 7 8 Episodes of enuresis or encopresis or a history of one or both 1 2 3 4 5 6 7 8 Autism (high functioning) 1 2 3 4 5 6 7 8 Deafness or severe hearing impairment 1 2 3 4 5 6 7 8 May have self-harming behaviors such as cutting or ingesting harmful substances 1 2 3 4 5 6 7 8 Children with mental retardation may not be able to follow simple one and/or two step directions and frequently have difficulty with three step directives OK Question Title * 8. Additional comments OK DONE