Child and Adolescent Needs and Strengths (CANS) Massachusetts For Children and Youth ages Five through Twenty This document contains: Form for Identifying Children / Adolescents with Serious Emotional Disturbances (SED) Item rating anchor definitions (guidelines for each section) CANS items (all items with space to record responses) You should also refer to this document: Item glossary for ages Five through Twenty (a detailed guide to coding each item) Instructions: . To complete the CANS, you must be CANS certified by Massachusetts. For more information on training and certification, visit https://masscans.ehs.state.ma.us . Complete all items (except Transition to Adulthood items if child is under 14 ½). If you know that it will not be possible to obtain data to complete all items, see below (“Incomplete but Final”) for instructions. . Use the Comment field that follows each section to clarify any item responses where appropriate (for example, when conflicting information comes from different sources, or when none of the available responses conveys the clinical reality) and to add essential contextual information. (Each comment field must contain some response, even if “n/a”.) . Complete and sign the form titled “Identifying Children / Adolescents with Serious Emotional Disturbances”. . When the CANS is complete (response to all items), check it as “Complete” and sign and date it on the final page. . If completion of the CANS will not be possible, (for example, if client did not return to complete the behavioral health assessment) check it as “Incomplete but Final”, give the reason for inability to complete, and sign and date it on the final page. . When final, all the data in “Identifying Children / Adolescents with Serious Emotional Disturbances” and in the CANS become part of the client’s medical record. . CANS information should be updated at the time of each treatment plan review. For more information and frequently asked questions visit: www.mass.gov/MassHealth/ChildBehavioralHealth More questions? Email CBHI at: cbhi@state.ma.us Praed Foundation Copyright 1999 John S. Lyons, Ph.D. Praed Foundation jlyons@ouotta.ca www.buddinpraed.org praedfoundation@yahoo.com MassHealth ID: Name (Last, First) DOB (mm/dd/yyyy) Gender M F O RACE: Check up to three races that the client identifies as White Black or African American Native Hawaiian or other Pacific Islander American Indian/Alaska Native (Wampanoag) Hispanic/Latino/Black Chooses not to Self-Identify American Indian/Alaska Native (Other Tribal Nation) Hispanic/Latino/White Other Asian Hispanic/Latino/other ETHNICITY: Check up to three ethnicities that the client identifies as Afghan African American Albanian American Arab Argentinean Armenian Asian Indian Austrian Belgian Bhutanese Brazilian British Bulgarian Cambodian Canadian Cape Verdean Chilean Chinese Chooses not to self-identify Columbian Costa Rican Cuban Czech Danish Dominican Dutch Ecuadorian Egyptian English Ethiopian Filipino Finnish French French Canadian German Ghanian Greek Guatemalan Haitian Hmong Honduran Hungarian Indonesian Iranian Iraqi Irish Israeli Italian Jamaican Japanese Kenyan Korean Laotian Latvian Lebanese Liberian Lithuanian Mexican Moldovian Moroccan Myanmar/Burmese Nigerian Norwegian Other Other – African Other – Asian Other – Caribbean Other – European Other – Latin America Pakistani Panamanian Peruvian Polish Portuguese Puerto Rican Romanian Russian Salvadoran Scandinavian Scottish Scottish Irish Sierra Leonean Somalian Sudanese Swedish Swiss Syrian Thai Turkish Ugandan Ukrainian Venezuelan Vietnamese Welsh West Indian PRIMARY LANGUAGE: Identify one from the list below _______________________________________________________________________ LANGUAGE at HOME: Identify one from the list below _______________________________________________________________________ English Farsi/Iranian/Persian Japanese Spanish Albanian Finnish Khmer/Cambodian Tagalog/Filipino American Sign Language French Korean Tamil Amharic German Lao Thai Arabic Greek Mandarin Tigrigna Armenian Haitian Creole Polish Turkish Bosnian Hebrew Portuguese Urdu Cantonese Hindi Russian Vietnamese Cape Verdean Ibo/Igbo Serbian-Croatian Yiddish Chinese Italian Somali Unknown Other REFERRED by: Check one from the list below Inpatient Behavioral Health Unit DYS Clergy Emergency Services provider Court Managed Care Company CBAT School Other behavioral health provider DMH Primary Care Provider Other DDS Family member DCF Friend Identifying Children /Adolescents with Serious Emotional Disturbances 1 1 SED = “Serious emotional disturbance” 2 The determination that a child meets these clinical criteria is not an evaluation under federal and state laws addressing special education. Serious Emotional Disturbance (SED) is a term that encompasses one or more mental illnesses or conditions. Whether a member has a SED can be determined by applying either Part I or Part II, below, or both. Identifying a child as having SED is one step in the determination of medical necessity for Intensive Care Coordination. In addition, MassHealth will be tracking SED determinations to guide service system improvements for children and families. Accurate identification of children with SED will help MassHealth improve services for this population in the future. A child may have a SED under Part I or Part II or both2. All criteria in part 1 and part 2 must be considered and ruled in or out. Part I: Please answer the following questions according to your current knowledge of the child or adolescent: 1. Does the child currently have, or at any time in the last 12 months has had, a diagnosable DSM-IV or ICD-10 disorder(s)? Developmental disorders, substance abuse disorders or V-codes are not included unless they co-occur with another DSM-IV or ICD-10 diagnosis. Yes No 2. If yes to question 1, please indicate whether those diagnoses resulted in functional impairment which substantially interferes with, or limits, the child’s role or functioning in any of the following areas. (Functional impairment is defined as difficulties which substantially interfere with or limit his or her ability to achieve or maintain one or more developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills. Functional impairments of episodic, recurrent, and continuous duration are included unless they are temporary and expected responses to stressful events in the environment) Family School Community activities No functional impairment as defined. 3. If yes to question 1, and you checked “no functional impairment as defined” in question 2: Would the child have met one or more of the functional impairment criteria in question 2 without the benefit of treatment? (Children who would have met functional impairment criteria during the year without the benefit of treatment or other support services are included.) Yes No Part II: 4. Please indicate if the child has exhibited any of the following over a long period of time and to a marked degree that adversely affects the child’s educational performance: (a) An inability to learn, that cannot be explained due to intellectual, sensory, or health factors. Yes No If yes to (a), is this solely the result of autism, mental retardation, specific learning disability, hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a serious emotional disturbance? Yes No (b) An inability to build or maintain satisfactory interpersonal relationships with peers and teachers. Yes No If yes to (b), is this solely the result of autism, mental retardation, specific learning disability, hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a serious emotional disturbance? Yes No (c) Inappropriate types of behavior or feelings under normal circumstances. . Yes No If yes to (c), is this solely the result of autism, mental retardation, specific learning disability, hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a serious emotional disturbance? Yes No (d) A general pervasive mood of unhappiness or depression.. Yes No If yes to (d), is this solely the result of autism, mental retardation, specific learning disability, hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a serious emotional disturbance? Yes No (e) A tendency to develop physical symptoms or fears associated with personal or school problems. . Yes No If yes to (e), is this solely the result of autism, mental retardation, specific learning disability, hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a serious emotional disturbance? Yes No 5. Please check this box if you identified a functional impairment in question 2 or answered “yes” to question 3. The child /adolescent has SED under Part I. 6. Please check this box if you checked one or more “no” boxes in the right hand column of question 4 . The child /adolescent has SED under Part II. Clinician name, degree (print): Clinician signature: Date: _________________________ For Life Domain Functioning, Behavioral/Emotional Needs, Risk Behaviors, Cultural Considerations, Transition to Adulthood, Caregiver Needs and Strengths the following categories and action levels are used: 0 - Indicates a dimension where there is no evidence of any needs. 1 - Indicates a dimension that requires monitoring, watchful waiting, or preventive activities. 2 - Indicates a dimension that requires action to ensure that this identified need or risk behavior is addressed. 3 - Indicates a dimension that requires immediate or intensive action. For Child Strengths the following categories and action levels are used: 0 - Indicates a domain where strengths exist that can be used as a centerpiece for a strength-based plan. 1 - Indicates a domain where strengths exist but require some strength building efforts in order for them to serve as a focus of a strength-based plan. 2 - Indicates a domain where strengths have been identified but they require significant strength building efforts before they can be effectively utilized as a focus of a strength-based plan. 3 - Indicates a domain in which efforts are needed in order to identify potential strengths for strength building efforts. LIFE DOMAIN FUNCTIONING Please rate the highest level of need in the past 30 days (unless otherwise specified). Circle one 1. FAMILY - It is recommended that the definition of family should come from the child’s perspective (i.e. who the child describes as his/her family). 0 No evidence of problems in relationships with family members and/or child is doing well in relationships with family members. 1 Child is doing adequately in relationships with family members, although some problems may exist. For example, some family members may have problems in their relationships with child. Arguing may be common but does not result in major problems. 2 Child is having significant problems with parents, siblings and/or other family members. Frequent arguing, difficulty maintaining positive relationships may be observed. 3 Child is having severe problems with parents, siblings, and/or other family members. This would include problems of domestic violence, absence of any positive relationships, etc. Circle one 2. SOCIAL FUNCTIONING - This item rates any difficulties a child may have with social skills and relationships. 0 No evidence of problems and/or child has developmentally appropriate social functioning. 1 Child has some minor problems with his/her social relationships. 2 Child has problems with social functioning that interfere with other life domains. 3 Child is experiencing severe disruptions in his/her social functioning. Child may have no friends or have constant conflict in relations with others. Circle one 3. MEDICAL/PHYSICAL - This item rates the child’s current health status or any physical limitations. 0 No evidence of health problems and/or child is healthy. 1 Child has some medical/physical problems that require treatment. 2 Child has chronic illness that requires ongoing medical intervention. 3 Child has life threatening illness or physical condition. Circle one 4. DEVELOPMENTAL DELAY - This item rates only the presence of any Developmental Disabilities. It does not refer to broader issues of healthy development. 0 No evidence of developmental delay and/or child has no developmental problems. 1 Child has some problems with immaturity, or there are concerns about possible developmental delay. Child may have low IQ. 2 Child has developmental delays or mild mental retardation. 3 Child has severe and pervasive developmental delays or profound mental retardation. Circle one 5. LEARNING DISABILITY - This item rates the limitations that impact academic learning. 0 No evidence of learning disability. 1 History, suspicion or mild learning disability. 2 Moderate learning disability. Child is struggling to learn, and unless challenges are addressed learning will remain impaired. 3 Severe learning disability. Child is currently unable to learn. Current challenges are preventing any learning. Circle one 6. SEXUALITY - This item refers to concerns with sexual development, sexual behavior and concerns with sexual identity. 0 No evidence of issues with the child’s sexual development, sexual behavioral and/or concerns with sexual identity. 1 Child has some issues with sexual development, but these do not interfere with his/her functioning in other life domains. 2 Child has problems with sexual development that interfere with his/her functioning in other life domains. 3 Child has severe problems with his/her sexual developmental. Circle one 7. SELF CARE - This rating describes the child's ability to perform developmentally appropriate activities of daily living and hygiene tasks. 0 No evidence that the child has any problems performing activities of daily living and/or child’s self-care and daily living skills appear developmentally appropriate. 1 Child requires verbal prompting on self-care tasks or daily living skills. 2 Child requires assistance (physical prompting) on self-care tasks, or attendant care on one self-care task (e.g. eating, bathing, dressing, and toileting). 3 Child requires attendant care on more than one of the self-care tasks - eating, bathing, dressing, or toileting. Circle one 8. COMMUNITY - This rating describes problems with following rules in the community. Please note: school is not considered part of the definition of community in the rating of this item, as school is rated in its own items. 0 No evidence of problems with functioning in the community. 1 Mild problems with functioning in the community. Child’s behavior has raised the concerns of some community members and/or institutions. 2 Moderate problems functioning in the community. Child has difficulty maintaining his/her behavior in order to avoid sanctions from community members and/or institutions. 3 Profound problems functioning in the community. Child is at immediate risk of being removed from the community. Circle one 9. SCHOOL BEHAVIOR - This item rates the child’s behavior in school. 0 No evidence of behavioral issues while in school and/or child is behaving well in school. 1 Child is behaving adequately in school, although some behavior problems exist. 2 Child is having moderate behavioral problems at school. He/she is disruptive and may have received sanctions including suspensions. 3 Child is having severe problems with behavior in school. He/she is frequently disruptive or severely disruptive. School placement may be in jeopardy due to the child’s behaviors. Circle one 10. SCHOOL ACHIEVEMENT - This item rates the child’s grades or level of academic achievement. 0 No evidence of issues in school achievement and/or child is doing well in school. 1 Child is doing adequately in school although some problems with achievement exist. 2 Child is having moderate problems with school achievement. He/she may be failing some subjects. 3 Child is having severe achievement problems. He/she has failed most subjects, or is more than one year behind same age peers in school achievement. Circle one 11. SCHOOL ATTENDANCE - This items rates issues of tardiness and/or truancy. 0 Child attends school regularly. 1 Child has some problems attending school but generally goes to school. May miss up to one day per week on average, or may have had moderate to severe problem during the past six months, but has been attending school regularly during the past month. 2 Child is having problems with school attendance. He/she is missing at least two days each week on average. 3 Child is generally truant, or refuses to go to school. 12. Comments on LIFE DOMAIN FUNCTIONING CHILD BEHAVIORAL/EMOTIONAL NEEDS Please rate the highest level of need in the past 30 days (unless otherwise specified). Circle one 13. PSYCHOSIS - The primary symptoms of psychosis include hallucinations, delusions, or bizarre behavior. 0 No evidence of psychotic symptoms. 1 History or suspicion of hallucinations, delusions or bizarre behavior that might be associated with some form of psychotic disorder. 2 Clear evidence of hallucinations, delusions or bizarre behavior that might be associated with some form of psychotic disorder. 3 Clear evidence of dangerous hallucinations, delusions, or bizarre behavior that might be associated with some form of psychotic disorder which places the child or others at risk of physical harm. Circle one 14. HYPERACTIVITY/IMPULSIVITY - This item rates behavioral symptoms associated with hyperactivity and/or impulsiveness, i.e. loss of control of behaviors, which includes, but is not limited to, Attention Deficit/ Hyperactivity Disorder (ADHD) and disorders of impulse control. 0 No evidence of symptoms of hyperactivity or impulse control. 1 Some problems with hyperactive, impulsive or distracted behavior place the child at risk of future difficulty in functioning. 2 Clear evidence of problems with hyperactive, impulsive or distracted behavior interfere with the child’s ability to function in at least one life domain. 3 Clear evidence of a dangerous level of hyperactivity and/or impulsive behavior places the child at risk of physical harm. Circle one 15. DEPRESSION – This item rates displayed symptoms of a change in emotional state and can include sadness, irritability and diminished interest in previously enjoyed activities. 0 No evidence of depressive symptoms. 1 History, suspicion, or mild depression associated with a recent negative life event with minimal impact on life domain functioning. 2 Clear evidence of depression associated with either depressed mood or significant irritability. Depression has interfered with the child’s ability to function in at least one life domain. 3 Clear evidence of depression that is disabling for the child in multiple life domains. Circle one 16. ANXIETY – This item rates evidence of symptoms associated with Anxiety Disorders characterized by either worry, dread, or panic attacks. 0 No evidence of anxiety symptoms. 1 History, suspicion, or mild anxiety associated with a recent negative life event. 2 Clear evidence of anxiety associated with either anxious mood or significant fearfulness. Anxiety has interfered in the child’s ability to function in at least one life domain. 3 Clear evidence of a debilitating level of anxiety that is disabling in multiple life domains. Circle one 17. OPPOSITIONAL – This item rates the child or adolescent’s relationship with authority figures. 0 No evidence of oppositional behaviors. 1 History or recent onset (within the past 6 months) of defiance towards authority figures has not yet begun to cause functional impairment. 2 Clear evidence of oppositional and/or defiant behavior towards authority figures which is currently interfering with the child’s functioning in at least one life domain. 3 Clear evidence of a dangerous level of oppositional behavior involving the threat of physical harm to others. Circle one 18. CONDUCT - This item is used to describe the degree to which a child or adolescent engages in behavior that is consistent with the presence of a Conduct Disorder. 0 No evidence of serious violations of others or laws. 1 History or suspicion of problems associated with antisocial behavior including but not limited to pathological lying, stealing, manipulation of others, acts of sexual aggression, or violence towards people, property or animals. 2 Clear evidence of antisocial behavior including but not limited to lying, stealing, manipulating others, sexual aggression, violence towards people, property, or animals. 3 Evidence of a severe level of aggressive or antisocial behavior, as described above, that places the child or community at significant risk of physical harm due to these behaviors. Circle one 19. ADJUSTMENT TO TRAUMA - This item is used to describe the child or adolescent who is having difficulties adjusting to a traumatic experience. Please note that to rate this item a traumatic event is not required to meet the DSM-IV TR definition of trauma, but rather an event defined as traumatic by the child or youth. There should be an inferred link between the trauma and behavior. 0 No evidence of problems associated with traumatic life events. 1 History or suspicion of, or mild problems associated with traumatic life event/s. 2 Clear evidence of symptoms of Adjustment Disorder associated with traumatic life event/s. Adjustment is interfering with the child’s functioning in at least one life domain. 3 Clear evidence of symptoms of Post Traumatic Stress Disorder, which may include flashbacks, nightmares, significant anxiety, and intrusive thoughts of the trauma experience. Circle one 20. EMOTIONAL CONTROL - This item describes the child or adolescent’s ability to manage his/her emotions. It describes symptoms of affect dysregulation. 0 No evidence of any emotional control problems. 1 History or suspicion of, or mild problems controlling emotions. Peers and family may be aware of and may attempt to avoid stimulating outbursts. 2 Moderate emotional control problems. Child’s labile mood and/or extreme mood swings have gotten him/her in significant trouble with peers, family and/or school. Others are likely quite aware of unstable emotions. 3 Severe emotional control problems. Child is unable to regulate his/her emotions. Others likely fear him/her. Circle one 21. SUBSTANCE USE – This item rates the severity of the child’s substance use which includes alcohol, illegal drugs and inappropriate use of prescription medications. 0 No evidence of substance use. 1 History or suspicion of, or mild use of substances. 2 Clear evidence of substance abuse that interferes with functioning in any life domain. 3 Child requires detoxification, is dependant or addicted to alcohol and/or drugs. Include here a child/youth who is intoxicated at the time of the assessment (i.e., currently under the influence). Circle one 22. EATING DISTURBANCE – This item rates symptoms including problems with eating such as disturbances in body image, refusal to maintain normal body weight, recurrent episodes of binge eating and hoarding food. These ratings are consistent with DSM-IV TR Eating Disorders. 0 No evidence of eating disturbances. 1 History, suspicion or mild level of eating disturbance. This could include some preoccupation with weight, calorie intake, or body size or type when of normal weight or below weight. This could also include some binge eating patterns. 2 Moderate level of eating disturbance. This could include a more intense preoccupation with weight gain or becoming fat when underweight, restrictive eating habits or excessive exercising in order to maintain below normal weight, and/or emaciated body appearance. This level could also include more notable binge eating episodes that are followed by compensatory behaviors in order to prevent weight gain (e.g., vomiting, use of laxatives, excessive exercising). This child may meet criteria for a DSM-IV Eating Disorder (Anorexia or Bulimia Nervosa). 3 More severe form of eating disturbance. This could include significantly low weight where hospitalization is required or excessive binge-purge behaviors (at least once per day). 23. Comments on CHILD BEHAVIORAL/EMOTIONAL NEEDS CHILD RISK BEHAVIORS Please rate the highest level of need in the past 30 days (unless otherwise specified). Circle one 24. SUICIDE RISK - This item is intended to describe the presence of thoughts or behaviors aimed at taking one’s life. 0 No evidence of suicide ideation. 1 History or suspicion of, but no recent ideation or gesture. 2 Recent ideation or gesture but not in past 24 hours. 3 Current ideation and/or intent, or command hallucinations that involve self-harm. Circle one 25. SELF MUTILATION - This item is used to describe repetitive behavior that results in physical injury to the child or adolescent, e.g. cutting, head banging, etc. 0 No evidence of self-mutilating behavior. 1 History, suspicion or mild degree of self-mutilation. 2 Engaged in self mutilation that does not require medical attention. 3 Engaged in self mutilation that requires medical attention. Circle one 26. OTHER SELF HARM - This item is used to describe and rate behavior, not covered by either Suicide Risk or Self-Mutilation, in which the child engages in something that has significant potential to result in physical harm or in intentional risk taking behaviors. 0 No evidence of behaviors (other than suicide or self-mutilation) that place the child at risk of physical harm. 1 History, suspicion or mild behavior (other than suicide or self-mutilation) that places child at risk of physical harm such as reckless and risk-taking behavior that may endanger the child. 2 Engaged in reckless or intentional risk-taking behavior (other than suicide or self-mutilation) that places him/her in danger of physical harm. 3 Engaged in reckless or intentional risk-taking behavior (other than suicide or self-mutilation) that places him/her at immediate risk of death. Circle one 27. DANGER TO OTHERS - This item rates the child or adolescent’s violent or aggressive behavior. The intention of this behavior is to cause significant bodily harm to others. 0 No evidence of behavior that could be dangerous to others. 1 History or suspicion of, or acts of mildly aggressive or threatening behavior. 2 Recent aggressive or threatening behavior: e.g. homicidal ideation, physically harmful aggression, or dangerous fire setting, but not within past 24 hours. 3 Acute homicidal ideation with a plan, physically harmful aggression, command hallucinations that involve harm to others, or the child set a fire that placed others at significant risk of harm. Circle one 28. SEXUAL AGGRESSION - This item is intended to describe both aggressive sexual behavior and sexual behavior in which the child or adolescent takes advantage of a younger or less powerful child. 0 No evidence of sexually aggressive behavior. 1 History or suspicion of sexually aggressive behavior (but not within past year) and/or sexually inappropriate behavior within the past year that troubles others such as harassing talk or public excessive masturbation. 2 Child is engaged in sexually aggressive behavior within the past year but not in the past 30 days. 3 Child has engaged in sexually aggressive behavior within the past 30 days. Circle one 29. RUNAWAY - This item describes the risk of running away or actual runaway behavior. 0 No evidence of runaway ideation or behavior. 1 Suspicion or history of running away from home, or other settings, involving at least one overnight absence more than 30 days ago. 2 Recent runaway behavior or ideation but not within the past 7 days. 3 Acute threat to run away, as manifest by either recent attempts or significant ideation about running away, or the child is currently a runaway. Circle one 30. DELINQUENT BEHAVIOR - This item refers to criminal behavior issues for which the youth may or may not have been caught. 0 No evidence of delinquency. 1 Suspicion or history of delinquency, but no acts of delinquency within past 30 days. This may include status offenses and/or CHINS (Child in Need of Services). 2 Recent acts of delinquency. 3 Severe recent acts of delinquency which place others at risk of significant loss or injury, or place child at risk of adult sanctions. Circle one 31. JUDGMENT - This item is intended to describe the youth’s ability to make decisions. 0 No evidence of problems with judgment or poor decision making that result in harm to development and/or well-being. 1 Suspicion or history of problems with judgment in which the child makes decisions that are in some way harmful to his/her development and/or well-being. 2 Problems with judgment in which the child makes decisions that are in some way harmful to his/her development and/or well-being. 3 Problems with judgment that place the child at risk of significant physical harm. Circle one 32. FIRE SETTING - This item describes whether the child intentionally starts fires. 0 No evidence of fire setting. 1 Suspicion or history of fire setting but not within the past six months. 2 Recent fire setting behavior (during the past six months) but not of the type that endangered the lives of others, or repeated fire-setting behavior over a period of at least two years, even if not within the past six months. 3 Acute threat of fire setting. Has set fire that endangered the lives of others (e.g. attempting to burn down a house). Circle one 33. SANCTION SEEKING BEHAVIOR - This item refers to instigating behaviors with the intention of being sanctioned by adults. 0 No evidence of problematic instigating behavior and/or child does not engage in behavior that forces adults to sanction him/her. 1 History, suspicion or mild level of problematic instigating behavior with the intention of being sanctioned. This might include occasional inappropriate behaviors that force adults to sanction the child. Infrequent inappropriate comments to strangers or unusual behavior in social settings might be included in this level. 2 Moderate level of problematic instigating behavior with the intention of being sanctioned. This behavior causes problems in the child’s life. Child may be intentionally getting in trouble in school or at home. 3 Severe level of problematic instigating behavior with the intention of being sanctioned. This level would be indicated by frequent serious instigating behavior that forces adults to seriously and/or repeatedly sanction the child. These behaviors are sufficiently severe that they place the child at risk of significant sanctions (e.g. expulsion from school, removal from the community). Circle one 34. BULLYING - This item describes behavior that involves intimidation (either verbal or physical, or both) of peers and younger children; threatening others with harm if they do not comply with the child or youth’s demands is rated here. 0 No evidence that the child or youth has ever engaged in bullying at school or in the community. 1 History or suspicion of bullying, or youth has engaged in bullying behavior or associated with groups that have bullied other youth. 2 Youth has bullied other youth in school or in the community. Youth has either bullied the other youth individually or led a group that bullied other youth. 3 Youth has repeatedly utilized threats or actual violence when bullying others in school and/or in the community. Circle one 35. EXPLOITED - This item is used to examine a history and pattern of being the object of abuse, and/or includes a level of current risk for re-victimization. This can include parentification of children, being bullied, prostituted, or taken advantage of by others. 0 No evidence of a history of exploitation OR no evidence of recent exploitation and no significant history of victimization within the past year. The person may have been robbed or burglarized on one or more occasions in the past, but no pattern of victimization exists. Person is not presently at risk for re-victimization. 1 Suspicion or history of exploitation, but a person has not been exploited to any significant degree during the past year. Person is not presently at risk for re-victimization. 2 This level indicates a person who has been recently exploited (within the past year) but is not at acute risk of re- exploitation. This might include experiences of physical or sexual abuse, significant psychological abuse by family or friends, extortion or violent crime. 3 This level indicates a person who has been recently exploited and has an acute risk of re-exploitation. Examples include working as a prostitute, living in an abusive relationship, or constantly being forced to take on a parent’s responsibilities. 36. Comments on CHILD RISK BEHAVIORS CULTURAL CONSIDERATIONS Please rate the highest level of need in the past 30 days (unless otherwise specified). Circle one 37. LANGUAGE - This item looks at whether the child and family need help to communicate with you or others in English. This item includes spoken, written, and sign language, as well as addresses issues of literacy. This item should be rated without considering the child as an adequate interpreter. Interpreting for a parent may place a burden on a child and/or negatively impact the quality of care the child or family receives. If another adult family member serves as an interpreter in a behavioral health setting, the quality of this interpretation and confidentiality of the patient cannot be assured. Interpreting and written translation are complex skills. Trained and accredited interpreters and translators are impartial, confidential, and accountable to a code of ethics. Some families may have difficulty communicating due to issues beyond language difference, such as hearing issues or difficulty reading written English language. In addition, families may have difficulty understanding mental/behavioral health terminology. Issues such as these should be rated here. If there are language differences between family members, this would also be rated in the Cultural Differences Within a Family item. 0 No evidence that there is a need or preference for an interpreter or bilingual services and/or child and family speak, hear and read English. 1 Child and/or family speak or read English, but potential communication problems exist because of limited vocabulary or comprehension of the nuances of the language. 2 Child and/or significant family members possess only limited ability to speak and/or read English. While basic communication may be possible, a bilingual provider or interpreter is needed to assure that adequate communication is possible for extensive work. 3 Child and/or significant family members do not speak English. A bilingual provider or interpreter is needed for all communications. Circle one 38. DISCRIMINATION/BIAS - This item refers to any experience of discrimination or bias that is purposeful or accidental, direct or indirect. Discrimination may be based on gender, race, ethnicity, socioeconomic status, religion, sexual orientation, skin shade/color/complexion, linguistic ability, body shape/size, etc. Any statement of discrimination by a client should be acknowledged and respected. Children, youth and families’ feelings are what matter. These feelings can impact how a child or family function and creates stress for the child and/or family which can correlate with depression and/or poor health outcomes. The presence of such discrimination or experiences may present a barrier to accessing supports or services that may be helpful to the child or family. When families report feelings of discrimination providers can discuss those feelings and how they impact functioning, create an advocacy statement in the treatment plan, or assist the family in finding a better fit for necessary services. 0 No report of experiences of discrimination that impacts the child or family’s ability to function and/or creates stress 1 Child or family reports experiences of discrimination that occurred recently or in the past, but it is not currently causing any stress or difficulties for the child or family. 2 Child or family reports experiences of discrimination which is currently interfering with the child or family’s functioning 3 Child or family reports experiences of discrimination that substantially and immediately interferes with the child or family’s functioning on a daily basis and requires immediate action. Circle one 39. CULTURAL IDENTITY - This item refers to a child’s feelings about her/his cultural identity. Research shows a strong and positive cultural identity may help protect children from mental/behavioral health problems. However, in some cases, because of pressure to identify with a particular group or sub-group, negative societal messages about their group, or previous discrimination, children may be conflicted about their identity, feel caught between several cultural identities, or struggle with the dominant responses to their preferred identity. This item measures the extent to which those feelings may cause stress for or influence the behavior of the child. 0 No evidence of an issue with the child’s cultural identity or child has a strong and positive racial/ethnic/cultural identity. 1 Child has struggled in the past with her/his group or sub group membership, but is presently comfortable with her/his identity or there are mild issues related to identity. 2 Child expresses some distress or conflict about her/his racial/ethnic/cultural identity which interferes with the child or family’s functioning. 3 Child expresses significant distress or conflict about her/his racial/ethnic/cultural identity. Child may reject her/his cultural group identity, which severely interferes with the child or family’s functioning and/or requires immediate action. Circle one 40. CULTURAL DIFFERENCES WITHIN A FAMILY - Sometimes individual members within a family have different backgrounds, values and/or perspectives. In many cases, this may not cause any difficulties in the family as they are able to communicate about their differences, but for others it may cause conflict, stress, or disengagement between family members and impact the child’s functioning. This might occur in a family where a child is adopted from a different race, culture, ethnicity, or socioeconomic status. The parent may struggle to understand or lack awareness of the child’s experience of discrimination. Additionally this may occur in families where the parents are first generation immigrants to the United States. The youth may refuse to adhere to certain cultural practices, choosing instead to participate more in popular US culture. . 0 No evidence of conflict, stress or disengagement within the family due to cultural differences or family is able to communicate effectively in this area. 1 Child and family have struggled with cultural differences in the past, but are currently managing them well or there are mild issues of disagreement. 2 Child and family have struggled with cultural differences in the past, but are currently managing them well or there are mild issues of disagreement. 3 Child and family experience such significant difficulty managing cultural differences within the family that it interferes with the child’s functioning and/or requires immediate action. Circle one 41. YOUTH/FAMILY RELATIONSHIP TO SYSTEM - There are situations and instances when people may be apprehensive to engage with the formal behavioral health care or helping system. Clients, as well as providers, bring their cultural experiences to the treatment relationship. Members of some cultural groups may be accustomed to the use of traditional healers or self-management of behavioral health issues or are simply distrustful of Western medicine. Undocumented individuals may be fearful of interaction with the health care system because of their legal status. These complicated factors may translate into generalized discomfort with the formal behavioral health care system. This item rates the degree to which the family’s apprehension to engage with the formal health care system creates a barrier for receipt of care. Additionally, the professionals’ relationship with the family may require the clinician to reconsider their approach. For example a family who refuses to see a psychiatrist due to their belief that medications are over-prescribed for children in their community. A clinician must consider this experience and understand its impact on the family’s choices.. 0 The caregiver/child expresses no concerns about engaging with the formal helping system. 1 The caregiver/child expresses little or mild hesitancy to engage with the formal helping system that is easily rectified with clear communication about intentions or past issues engaging with formal helping system. 2 The caregiver/child expresses moderate hesitancy to engage with the formal helping system that requires significant discussions and possible revisions to the treatment plan. 3 The caregiver/child expresses significant hesitancy to engage with the formal helping system that prohibits the family’s engagement with the treatment team at this time. When this occurs, the development of an alternate treatment plan may be required. Circle one 42. AGREEMENT ABOUT STRENGTHS AND NEEDS - (Between provider and family) This item refers to the agreement between the family’s explanation and the treatment team’s understanding of the child’s presenting issues and treatment. The treatment planning process is more effective when the family and the provider understand each other’s perspectives and can agree on the issue and subsequent course of action. Typically, disagreement is present at some point during this process, however when it becomes problematic and children/youth are not getting their needs met it requires that the provider validate the feelings of the family and work with them towards agreement, or the provider can help the family find a provider who might be a better match for them. . 0 Treatment team and family have a shared understanding of the presenting needs and strengths of the child. 1 Small or mild disagreement between the clinician and the family with regard to the child’s presenting needs and strengths that are easily rectified or past issues of disagreement between clinician and family. 2 Moderate disagreement between the clinician and the family with regard to the child’s presenting needs and strengths that require consideration in treatment planning in order to create a therapeutic alliance. 3 Significant disagreement about the child’s needs and strengths that is currently preventing a successful alliance between the family and provider. 43. Comments on CULTURAL CONSIDERATIONS TRANSITION TO ADULTHOOD Please rate the highest level of need in the past 30 days (unless otherwise specified). The following items are required for youth 14 years, 6 months and older. However, any of these items can be rated regardless of age if they represent a need for a specific youth. Circle one 44. INDEPENDENT LIVING SKILLS - This item is used to describe the youth’s ability to take responsibility for and also manage him/herself in an age appropriate way. 0 No evidence of any deficits or barriers in demonstrating developmentally appropriate responsibility or anything that could impede the development of skills to maintain one’s own home and/or this level indicates a person who is fully capable of independent living. 1 This level indicates a person with mild impairment of independent living skills. These problems are generally addressable with training or supervision. 2 This level indicates a person with moderate impairment of independent living skills. Notable problems completing tasks necessary for independent living and/or managing him- or herself when unsupervised would be common at this level. Problems are generally addressable with in-home services and supports. 3 This level indicates a person with profound impairment of independent living skills. This individual would be expected to be unable to live independently given their current status. Problems require a structured living environment. N/A Youth is under age 14 years, 6 months. Circle one 45. TRANSPORTATION - This item is used to rate the level of transportation required to ensure that the individual could effectively participate in his/her own treatment and in other life activities. Only unmet transportation needs should be rated here. 0 No evidence of an unmet transportation need. 1 The individual has occasional unmet transportation needs (e.g., appointments). These needs would be no more than weekly and do not require a special vehicle. 2 The individual has occasional transportation needs that require a special vehicle, or frequent transportation needs (e.g., daily to work or therapy) that do not require a special vehicle. 3 The individual requires frequent (e.g., daily to work or therapy) transportation in a special vehicle. N/A Youth is under age 14 years, 6 months. Circle one 46. PERSONALITY DISORDER - This rating identifies the presence of any DSM-IV Axis II personality disorder for youth 18 years old and older. 0 No evidence of symptoms of a personality disorder. 1 Evidence of a mild degree, probably sub-threshold, for the diagnosis of a personality disorder. For example, mild but consistent dependency in relationships might be noted here, or, there is some evidence of antisocial or narcissistic behavior. An unconfirmed suspicion of the presence of a diagnosable personality disorder would be rated here. 2 Personality issues interfere with the individual’s functioning in multiple life domains. Evidence of sufficient degree of impact to warrant a DSM-IV Axis II diagnosis. 3 Evidence of a severe personality disorder that has significant implications for the individual’s long-term functioning. Personality disorder dramatically interferes with the individual’s ability to function independently. N/A Youth is under 18 years of age. Circle one 47. PARENTING ROLES - This item is intended to rate the individual in any caregiver roles. For example, an individual with a son or daughter or an individual responsible for a younger sibling, parent , or grandparent would be rated here. Include pregnancy as a parenting role. 0 Individual is not a parent or in any other care-giving role and/or no evidence that the individual functions inappropriately in a parenting role. 1 The individual has responsibilities as a parent but occasionally experiences difficulties with this role. 2 The individual has responsibilities as a parent, and either the individual is struggling with these responsibilities, or, these issues are currently interfering with the individual’s functioning in other life domains. 3 The individual has responsibilities as a parent and is currently unable to meet these responsibilities. Or, these responsibilities make it impossible for the individual to function in other life domains. The individual has the potential to abuse or be neglectful in his/her parenting. N/A Youth is under age 14 years, 6 months. Circle one 48. MEDICATION ADHERENCE - This item focuses on the individual’s level of willingness or ability to collaborate and participate in taking prescribed medications. 0 This level indicates a person who is not currently on any medication and/or there is no evidence of unwillingness or noncompliance to taking medications as prescribed and without reminders and/or the youth collaborates in taking medication as prescribed. 1 This level indicates a person who usually collaborates and will take prescribed medications routinely, but who sometimes needs reminders to take medication regularly. Also, a history of inability or unwillingness to take medication as prescribed, but no current problems would be noted here. 2 This level indicates a person who is periodically unable or unwilling to collaborate or take medication as prescribed. This person may be resistant to taking prescribed medications, or this person may tend to overuse his or her medications. He/she might adhere to prescription plans for periods of time (1-2 weeks) but generally does not sustain taking medication following the prescribed dose or protocol. 3 This level indicates a person who does not collaborate and has refused to take prescribed medications during the past 30-day period. A person who has abused his or her medications to a significant degree (i.e., overdosing or over using medications to a dangerous degree) would be noted here. N/A Youth is under age 14 years, 6 months. Circle one 49. EDUCATIONAL ATTAINMENT - This rates the degree to which the individual is making progress toward or has completed his/her planned education. 0 No evidence of need in working towards completing youth’s planned educational goal and/or individual has achieved all educational goals. 1 Individual has set educational goals and is currently making progress towards achieving them. 2 Individual has set educational goals but is currently not making progress towards achieving them. 3 Individual has no educational goals and lack of educational attainment interferes with individual’s lifetime vocational functioning. N/A Youth is under age 14 years, 6 months. Circle one 50. FINANCIAL RESOURCES - This item is used to evaluate whether the youth has sufficient financial resources to support him/herself with respect to stated goals. 0 No evidence of financial difficulties and/or individual has financial resources necessary to meet needs. 1 Mild difficulties. Individual has financial resources necessary to meet most needs; however, some limitations exist. 2 Moderate difficulties. Individual has financial difficulties that limit his/her ability to meet needs. 3 Severe difficulties. Individual is experiencing financial hardship, poverty. N/A Youth is under age 14 years, 6 months. 51. Comments on TRANSITION TO ADULTHOOD CHILD STRENGTHS Please rate the highest level of strength in the past 30 days (unless otherwise specified). Circle one 52. FAMILY - This item refers to the presence of a sense of family identity as well as love and communication among family members. 0 Family has one or more strong relationships where communication is effective. 1 Family has one or more good relationships, and communication is good. 2 Strength building is required to develop stronger relationships and/or strengthen the family’s ability to communicate. 3 There is no evidence of any family relationships as strength at this time or the child has no identified family, or the family requires significant assistance to develop relationships and their ability to communicate. Circle one 53. INTERPERSONAL - This item is used to identify a child’s social and relationship skills. 0 Child has well-developed interpersonal skills and healthy friendships. 1 Child has good interpersonal skills and has shown the ability to develop healthy friendships. 2 Child requires strength building to learn to develop good interpersonal skills and/or healthy friendships. 3 There is no evidence of interpersonal skills or healthy friendships at this time and/or child requires significant help to learn to develop interpersonal skills and healthy friendships. Circle one 54. OPTIMISM - This refers to the child’s positive orientation toward the future. 0 Child has a strong and stable optimistic outlook for his/her future. 1 Child is generally optimistic about his/her future. 2 Child has difficulty maintaining a positive view of him/herself and his/her life. Child’s outlook may vary from overly optimistic to overly pessimistic. 3 There is no evidence of optimism at this time and/or child has difficulties seeing positive aspects about him/herself or his/her future. Circle one 55. EDUCATIONAL SYSTEM - This item is used to evaluate the nature of the school’s relationship with the child and family, as well as, the level of support the child receives from the school. 0 The school is an effective advocate on behalf of the child and family to identify and successfully address the child’s educational needs, or, the child excels in school. 1 The school works with child and family to identify and address the child’s educational needs, or, the child performs adequately in school. 2 The school is currently unable to adequately address the child’s academic or behavioral needs. 3 There is no evidence of the school working to identify or successfully address the child’s needs at this time and/or the school is unable and/or unwilling to work to identify and address the child’s needs and/or there is no school to partner with at this time. Circle one 56. VOCATIONAL – This item rates the development of skills which could be applied to a vocation including prevocational skills and work experience. 0 Child has vocational skills and work experience. 1 Child has some vocational skills or work experience. 2 Child has some prevocational skills. 3 There is no evidence of vocational skills or work experience at this time and/or child requires significant assistance to develop vocational skills. Circle one 57.TALENTS/INTERESTS - This item refers to hobbies, skills, artistic interests and talents that are positive ways that kids can spend their time, and also give them pleasure and a positive sense of self. 0 Child has a talent that provides him/her with pleasure and/or self esteem. 1 Child has a talent, interest, or hobby that has the potential to provide him/her with pleasure and self esteem. 2 Child has identified interests, but needs help to convert those interests into a talent or hobby. 3 There is no evidence of identified talents, interests or hobbies at this time and/or child requires significant assistance to identify and develop talents and interests. Circle one 58. SPIRITUAL/RELIGIOUS - This item refers to the child’s experience of receiving comfort and support from spiritual or religious involvement. 0 Child is involved in and receives comfort and support from spiritual and/or religious beliefs, practices and/or community. 1 Child is involved in and receives some comfort and/or support from spiritual and/or religious beliefs, practices and/or community. 2 Child has expressed some interest in spiritual or religious belief and practices. 3 There is no evidence of identified spiritual or religious beliefs, nor does the child show any interest in these pursuits at this time. Circle one 59. COMMUNITY CONNECTIONS - This item reflects the youth’s connection to people, places or institutions in his or her community. 0 Child is well-integrated into his/her community. He/she is a member of community organizations and has positive ties to the community. 1 Child is somewhat involved with his/her community. 2 Child has an identified community but has only limited, or unhealthy, ties to that community. 3 There is no evidence of an identified community of which he/she is a member at this time. Circle one 60. RESILIENCY. This rating refers to the child or youth’s ability to recognize his or her strengths and use them in times of need or to support his or her own healthy development. 0 Child is able to recognize and use his/her strengths for healthy development and to solve problems. 1 Child’s ability to recognize and use his/her strengths to support healthy development and/or to solve problems is limited. 2 Child recognizes his/her strengths, but is not yet able to use them to support his or her healthy development or to solve problems and/or child is not conscious of the use of their strengths. 3 There is no evidence of resiliency at this time and/or child requires significant assistance to develop the ability to recognize and utilize his/her strengths. 61. Comments on CHILD STRENGTHS CAREGIVER RESOURCES & NEEDS Please rate the highest level of need in the past 30 days (unless otherwise specified). Caregivers are rated by household. The needs and resources of multiple caregivers are combined based on how they affect care giving. These items are non-applicable (N/A) for youth living independently of any caregiver. Caregiver(s) Name(s): Caregiver(s) Relationship(s) to child: Circle one 62. MEDICAL/PHYSICAL - This item refers to medical and/or physical problems that the caregiver(s) may be experiencing that prevent or limit his or her ability to parent the child. 0 No evidence of caregiver medical/physical problems and/or caregiver is generally healthy. 1 History or suspicion of, and/or caregiver is in recovery from medical/physical problems. 2 Caregiver has medical/physical problems that interfere with his or her capacity to parent. 3 Caregiver has medical/physical problems that make parenting impossible at this time. N/A There is no permanent caregiver known at this time. Circle one 63. MENTAL HEALTH - This item refers to any serious mental health issues among caregivers that might limit their capacity to provide care for the child. 0 There is no evidence of caregiver mental health difficulties and/or caregiver has no mental health needs. 1 History or suspicion of, and/or caregiver is in recovery from mental health difficulties. 2 Caregiver has some mental health difficulties that interfere with his or her capacity to parent. 3 Caregiver has mental health difficulties that make parenting impossible at this time. N/A There is no permanent caregiver known at this time. Circle one 64. SUBSTANCE USE - This item describes the impact of any notable substance use by caregivers that might limit their capacity to provide care for the child. 0 No evidence of caregiver substance use issues and/or caregiver has no substance use needs. 1 History, suspicion or mild use of substances and/or caregiver is in recovery from substance abuse difficulties and/or there is no interference in their ability to parent. 2 Caregiver has some substance abuse difficulties that interfere with his or her capacity to parent. 3 Caregiver has substance abuse difficulties that make parenting impossible at this time. N/A There is no permanent caregiver known at this time. Circle one 65. DEVELOPMENTAL DELAY - This item describes the presence of limited cognitive capacity that challenges his or her ability to parent. 0 No evidence of caregiver developmental delay and/or caregiver has no developmental needs. 1 History or suspicion of, and/or caregiver has developmental delays, but these do not currently interfere with parenting. 2 Caregiver has developmental delays that interfere with his or her capacity to parent. 3 Caregiver has severe developmental delays that make parenting impossible at this time. N/A There is no permanent caregiver known at this time. Circle one 66. FAMILY STRESS - This item is used to describe the impact of the child’s behavioral and emotional needs on the stress level of the family. 0 No evidence of caregiver having difficulty managing the stress of the child’s needs and/or caregiver is able to manage the stress of child/children’s needs. 1 History or suspicion of, and/or caregiver has some problems managing the stress of child/children’s needs. 2 Caregiver has notable problems managing the stress of child/children’s needs. This stress interferes with his or her capacity to provide care. 3 Caregiver is unable to manage the stress associated with child/children’s needs. This stress prevents caregiver from parenting. N/A There is no permanent caregiver known at this time. Circle one 67. HOUSING STABILITY - This item rates the housing stability of the caregiver(s) and does not include the likelihood that the child or youth will be removed from the household. 0 No evidence of instability in the caregiver’s housing and/or caregiver has stable housing for the foreseeable future. 1 History of housing instability and/or caregiver has relatively stable housing, but either has moved within the past three months, or there are indications of housing problems that might force them to move within the next three months. 2 Caregiver has moved multiple times during the past year and/or housing is unstable. 3 Caregiver has experienced periods of homelessness during the past six months. N/A There is no permanent caregiver known at this time. Circle one 68. SUPERVISION - This item refers to the caregiver’s ability to monitor and discipline the child. 0 No evidence caregiver needs help or assistance in monitoring or disciplining the child and/or caregiver has good monitoring and discipline skills. 1 History or suspicion of need for assistance monitoring or disciplining child, but caregiver generally provides adequate supervision. Caregiver may need occasional help or assistance. 2 Caregiver reports difficulties monitoring and/or disciplining the child. Caregiver needs assistance to improve supervision skills. 3 Caregiver is unable to monitor or discipline the child. Caregiver requires immediate and continuing assistance. Child is at risk of harm due to absence of supervision. N/A There is no permanent caregiver known at this time. Circle one 69. INVOLVEMENT – This item is used to rate caregiver knowledge of their child, their child’s rights and options, as well as, participation in services. 0 No evidence of problems with caregiver involvement in services or interventions and/or caregiver is able to act as an effective advocate for child. 1 History or suspicion of need for assistance seeking help, and/or caregiver has history of seeking help for their child. Caregiver is open to receiving support, education, and information. 2 Caregiver does not actively involve him/herself in services and/or interventions intended to assist their child. 3 Caregiver wishes for the child to be removed from his/her care. N/A There is no permanent caregiver known at this time. Circle one 70. ORGANIZATION – This item is used to rate the caregiver’s ability to manage their household within the context of community services. For example, they may be forgetful about appointments or occasionally fail to return case manager calls. 0 No evidence of difficulties the caregiver may have in organizing and maintaining the household to support needed services and/or caregiver is well organized and efficient. 1 History or suspicion of minor difficulty, and/or caregiver has minimal difficulties organizing and maintaining the household to support needed services. 2 Caregiver has moderate difficulty organizing and maintaining household to support needed services. 3 Caregiver is unable to organize household to support needed services. N/A There is no permanent caregiver known at this time. Circle one 71. NATURAL SUPPORTS- This item describes the caregiver’s resources to support caring for their child. 0 No evidence of caregiver needing help to utilize their social network, family or friends to help with child rearing and/or caregiver has significant social network, neighbors, family and friends who actively help with childcare. 1 History or suspicion of use of social network, and/or caregiver has some social network, neighbors, family or friends who actively help with childcare. 2 Evidence that caregiver has some access to a social network, neighbors, family or friends who may be able to help with childcare. 3 Caregiver has no family or social network that may be able to help with childcare. N/A There is no permanent caregiver known at this time. Circle one 72. FINANCIAL RESOURCES – This item refers to the income and other sources of money available to caregivers that can be used to address family need. 0 No evidence of financial issues for the caregiver and/or caregiver has financial resources necessary to meet needs. 1 History or suspicion, or existence of mild difficulties. Caregiver has financial resources necessary to meet most needs; however, some limitations exist. 2 Moderate difficulties. Caregiver has financial difficulties that limit their ability to meet significant family needs. 3 Significant difficulties. Caregiver is experiencing financial hardship, poverty. N/A There is no permanent caregiver known at this time. 73. Comments On CAREGIVER RESOURCES and NEEDS DIAGNOSES 74. AXIS I 75. AXIS II 76. AXIS III 77. AXIS IV 78. AXIS V Circle one 79. DIAGNOSTIC CERTAINTY This item refers to the degree to which the symptoms are clear and consistent with a specific psychiatric diagnosis or diagnoses. Concerns regarding certainty could revolve around issues such as inconsistent symptom presentation, the presence of behavioral health or medical rule outs, etc. 0 The child’s behavioral health (i.e. mental health and substance abuse) diagnoses are clear and there is no doubt as to the correct diagnoses. Symptom presentation is clear. 1 Although there is some confidence in the accuracy of the child’s diagnoses, the child’s symptom presentation is sufficiently complex, raising concerns that the diagnoses may not be accurate. 2 There is substantial concern about the accuracy of the child’s diagnoses due to the complexity of the child’s presentation of symptoms. 3 It is currently not possible to accurately diagnose the child’s behavioral health condition(s) Circle one 80. PROGNOSIS This item refers to the child’s expected trajectory of recovery based on their current diagnosis, symptoms and functioning when compared with children having similar diagnostic, symptomatic, and functioning presentations. 0 Behavioral health problems began during the past six months, and there is a clear stressor to which they can be attributed. 1 Behavioral health problems have been ongoing, but resolution can be anticipated within the next year. 2 Behavioral health problems have been ongoing and are anticipated to continue to be a problem for at least another year. 3 Behavioral health problems have been ongoing and are anticipated to continue through to adulthood. 81. Comments On DIAGNOSES 82. Summary Clinician Name/Degree (print): Clinician Signature: Date: Complete Incomplete but Final, Reason: Client did not return Other: