Family Services of Plano



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Threat Assessment Incident Report: Complete Online

This is the minimum information required in order to schedule and complete a threat assessment. Please be as specific as possible. Responses are needed for each item below. The assessment will be scheduled with the family only after this information is received in our office. Thank you!

Referring School
Name of Student
Age
Grade Level
Special Education	Yes No
Parent / Guardian Name
Work Phone
Home Phone
Date of Incident
Where Incident Occurred
Description of Incident

Behavioral History (Please check all that apply & describe when necessary)

Fighting	Bullying
Arguing / Talking back to Teachers	ADD / ADHD
Verbal Threats	Mood Disorder:
Possession / Use of Weapons	Sexual Misconduct:
Gang Involvement / Affiliation	Other:
Vandalism	Other:

Other Information that would be helpful for us to know for this assessment:

Date student is scheduled to return to school:

Name of person to Receive Report:

Phone Number:

Fax Number:

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