Oregon Mental Health Referral Checklist – Youth Version (OMHRC-Y)

I have made a plan to commit suicide.

I have attempted suicide at least once in my life.

I feel like killing somebody.

I have had hallucinations (seen or heard things that weren't there when not on drugs or alcohol).

I have a strong belief that something is true when most people say it isn't (e.g., someone is out to get me).

While not on drugs or alcohol, have you lost touch with reality (felt "crazy")?

Have you intentionally harmed or injured an animal?

Have you started a fire that was dangerous or could have done harm or damage?

Have you sexually assaulted another or taken sexual advantage of another in the past 6 months?

I have used drugs or alcohol in the past 6 months.

Have you had frequent sex with people, or used sex to start a relationship?

I have physically harmed myself (such as cutting yourself, or putting a cigarette out on your skin)?

Have you ever been abused sexually or forced into a sexual activity?

Have you seen horrible/traumatic things or severe violence, including domestic violence?

I have threatened or intentionally harmed others.

I have explosive outbursts or sometimes throw fits.

I have intentionally destroyed someone else's belongings/property (e.g., vandalism).

Have you run away from your home or residence in the past 6 months?

I feel depressed most of the time.

I feel a sense of grief or deep loss for no reason at all.

I feel out of control of my emotions.

I frequently feel confused or get distracted easily and get off task.

I feel overactive or hyperactive.

I have thoughts I can't get out of my mind or behavior I can't stop.

On a typical day my moods are extreme and change dramatically (e.g., going quickly from happy to sad).

My moods seem extreme or different from others in the same situation.

I feel withdrawn or isolated from others.

I have difficulty sleeping, including nightmares.

I have lost/gained a noticeable amount of weight in the past 6 months.

I feel anxious or worried most of the time.

I feel angry much of the time or argue a lot.

Do you need to see a mental health counselor?