Youth Safety Assessment Form
Use this form to assess youth safety risks and support needs in a general, non-medical context.
First Name
*
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Environment/Setting
*
Please Select
School
Home
Community Center
Online/Virtual
Other
How safe do you currently feel in your environment?
*
1
2
3
4
5
Please rate your agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I have someone I trust to talk to about my concerns.
1
2
3
4
5
I know how to ask for help if I need it.
6
7
8
9
10
I feel supported by adults in my environment.
11
12
13
14
15
I know what to do if I feel unsafe.
16
17
18
19
20
Are there any risks or challenges you are currently experiencing?
Bullying or harassment
Isolation or loneliness
Unsafe physical environment
Lack of adult support
None of the above
Other
What type of support would be most helpful to you right now?
More trusted adults to talk to
Peer support groups
Workshops or training
Safe spaces to spend time
Other
Please share any additional comments or suggestions.
Submit Assessment
Should be Empty: