OMHR CHECKLIST – YOUTH VERSION
A: This statement describes me.
B: This statement describes me a little.
1. I have made a plan to commit suicide.
2. I have attempted suicide at least once in my life.
3. I feel like killing somebody.
4. I have had hallucinations (seen or heard things that weren’t there when Dot on drugs or alcohol).
5. I have a strong belief that something is true when most people say it isn’t (e.g.‚ someone is out to get me).
6. While not on drugs or alcohol‚ have you lost touch with reality (felt “crazy”)?
7. Have you intentionally harmed or injured an animal?
8. Have you started a fire that was dangerous or could have done harm or damage?
9. Have you sexually assaulted another or taken sexual advantage of another in the past 6 months?
10.I have used drugs or alcohol in the past 6 months.
11.Have you had frequent sex with people‚ or used sex to start a relationship?
12.I have physically harmed myself (such as cutting yourself‚ or putting a cigarette out on your skin)?
13.Have you ever been abused sexually or forced into a sexual activity?
14.Have you seen horrible/traumatic things or severe violence‚ including domestic violence?
15.I have threatened or intentionally harmed others.
16.I have explosive outbursts or sometimes throw fits.
17.I have intentionally destroyed someone else’s belongings/property (e.g.‚ vandalism).
18.Have you rum away from your home or residence in the past 6 months?
19.I feel depressed most of the time.
20.I feel a sense of grief or deep loss for no reason at all.
21.I feel out of control of my emotions.
22.I frequently feel confused or get distracted easily and get off task.
23.I feel overactive or hyperactive.
24.I have thoughts I can’t get out of my mind or behavior I can’t stop.
25.On a typical day my moods are extreme and change dramatically (e.g.‚ going quickly from happy to sad).
26.My moods seem extreme or different from others in the same situation.
27.I feel withdrawn or isolated from others.
28.I have difficulty sleeping‚ including nightmares.
29.I have lost/gained a noticeable amount of weight in the past 6 months.
30.I feel anxious or worried most of the time.
31.I feel angry much of the time or argue it lot.
32.Do you need to see a mental health counselor?
OMHR CHECKLIST – PARENT VERSION
A: I know or am fairly certain this item describes this youth.
B: This item is probably describes this youth.
1. He/she seems actively suicidal/suicide risk.
2. Has this youth ever made a suicide attempt?
3. The child expresses a desire to kill another person(s).
4. He/she appears to have hallucinations (acts as if see or hear things when not on drugs or alcohol).
5. The child expresses bizarre ideas/strong beliefs that are not true (e.g.‚ someone is out to get him/her).
6. While not on drugs or alcohol‚ this child seems out of touch with reality/incoherent
7. Has intentionally harmed or injured an animal.
8. Has intentionally set a fire.
9. Sexually assaulted another or has taken sexual advantage of another in the past 6 months?
10.Has used drugs or alcohol in the past 6 months.
11.Sexually acts out‚ such as frequent sex with people or uses sex to start a relationship.
12.Physically harmed him/herself (such as cutting self with razor or burn self with cigarette).
13.Has this child ever been sexually abused or forced into a sexual activity?
14.Has he/she ever witnessed a traumatic event or severe violence (e.g. domestic violence)?
15.He/she threatens others or has intentionally harmed others in the past 6 months.
16.Has explosive outbursts/throw fits.
17.Intentionally destroyed property.
18.Frequently runs away from home.
19.Has seemed depressed most of the time in the past 6 months.
20.Expresses grief/loss for no reason.
21.Has seemed out of control of his or her emotions in the past 6 months.
22.Seems frequently confused.
23.He or she is overactive or hyperactive.
24.Has had repetitive thoughts or repetitive behaviors.
25.He/she has had dramatic mood swings.
26.His/her moods have been inappropriate (e.g. extreme or different from others in the same situation).
27.This child has been detached or withdrawn.
28.He/she is having difficulty sleeping (too much or too little).
29.I’ve observed noticeable weight gain or weight loss.
30.He/she has been very anxious/nervous or worries most of the time.
31.He/she is angry or has argued excessively during the past 6 months
32.In your opinion‚ does this youth need to see a mental health counselor?
OMHR CHECKLIST STAFF VERSION
A: I know or am fairly certain this item describes this youth.
B: This item is probably describes this youth.
1. Actively suicidal/suicide risk
2. Any prior suicide attempts
3. The child has desire to kill another person(s)
4. Appears to have hallucinations
5. Expresses bizarre ideas or delusional
6. Out of touch with realty/incoherent while not on drugs or alcohol
7. Intentionally harms or injures animals
8. Fire setter
9. Sexually offends
10.Substance abuse
11.Sexually acts out
12.Physically harms self
13.Ever sexually abused
14.Ever witnessed traumatic event or severe violence (e.g. domestic violence)
15.Threatens others or intentionally harms others
16.Explosive outbursts/throws fits
17.Destroys property
18.Frequently runs away
19.Depressed
20.Expresses grief/loss
21.Feels out of control
22.Frequently confused
23.Overactive or hyperactive
24.Repetitive thoughts or repetitive behavior
25.Dramatic mood swings
26.Inappropriate moods
27.Detached or withdrawn
28.Difficulty sleeping
29.Noticeable weight gain/loss
30.Anxious
31.Angry or argues excessively
32.Does this youth need a mental health referral?
This instrument can be found at: https://btci.stanford.clockss.org/cgi/reprint/5/1/9.pdf & https://pdxscholar.library.pdx.edu/cgi/viewcontent.cgi?article=1002&context=socwork_fac & Fischer‚ Joel.‚ Corcoran‚ Kevin J. (2007). Measures for Clinical Practice and research: A sourcebook. (4th ed.). NY. Oxford University Pr. Vol. 1‚ Page (s): 572-575.
Corcoran‚ K. (2005). The Oregon Mental Health Referral Checklist: Concept mapping the mental health needs of youth in the juvenile justice system. Brief Treatment and Crisis Intervention‚ 5(10)‚ 9-18.
Corcoran‚ K.‚ Feyerhem‚ W. H. (1998). Oregon Mental Health Referral Checklist (OMHRC). In Fischer‚ Joel.‚ Corcoran‚ Kevin J. (2007). Measures for Clinical Practice and research: A sourcebook. (4th ed.). NY. Oxford University Pr. Vol. 1‚ Page (s): 572-575.