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-685803175DEPARTMENT OF CHILDREN, YOUTH, AND FAMILIES Child Health and Education Tracking Screening ReportCompletion Date? Preliminary Report FORMTEXT ?????? Final Report – Complete FORMTEXT ?????? Final Report – Closed FORMTEXT ?????One or more items were not obtainedChild’s Identifying InformationCHILD’S NAME FORMTEXT ?????PREFERRED NAME FORMTEXT ?????DATE OF BIRTH FORMTEXT ?????SEX? Male ? FemaleCHILD’S PERSON ID FORMTEXT ?????STUDENT STATE IDENTIFICATION NUMBER (10 DIGITS) FORMTEXT ?????? N/ACONSENT? Received ? N/APROVIDER ONE NUMBER FORMTEXT ????? ? N/AAPPLE HEALTH CORE CONNECTIONS NUMBER FORMTEXT ????? ? N/ADOES THE CHILD HAVE LIMITED ENGLISH PROFICIENCY?? Yes? NoPRIMARY LANGUAGE FORMTEXT ?????IS THE CHILD NATIVE AMERICAN?? Yes ? No ? Status PendingCHILD’S RACE AND ETHNICITY FORMTEXT ?????DATE OF PLACEMENT FORMTEXT ?????TYPE OF PLACEMENT? Foster Care ? Relative Caregiver ? Other: FORMTEXT ?????SCREENING SPECIALIST FORMTEXT ?????CASEWORKER NAME FORMTEXT ?????TELEPHONE NUMBER FORMTEXT ?????Physical Health DomainDATE WELL CHILD EXAM COMPLETED FORMTEXT ?????DATE WELL CHILD EXAM SCHEDULED FORMTEXT ?????PROVIDER’S NAME FORMTEXT ?????TELEPHONE NUMBER FORMTEXT ?????Well Child Exam Results and Recommendations made by Health Care Provider FORMTEXT ?????Well Child exam was not completed within 30 days of placement. Follow-up needed to obtain well child exam: FORMTEXT ?????Other Significant Physical Health Information FORMTEXT ?????DATE WELL CHILD EXAM COMPLETED FORMTEXT ?????DATE WELL CHILD EXAM SCHEDULED FORMTEXT ?????PROVIDER’S NAME FORMTEXT ?????TELEPHONE NUMBER FORMTEXT ?????Dental Exam Results and Recommendations made by Dental Provider FORMTEXT ?????Dental exam was not completed within the past six months. Follow-up needed to obtain dental exam: FORMTEXT ?????Other Significant Dental Information FORMTEXT ?????Provider and other information found in Medical Management Information System (MMIS)? ? Yes ? NoPlease list most current primary provider(s) below. FORMTEXT ?????Note: MMIS reflects billing information only and is not an official medical history. The purpose of this information is to assist you in gathering health care service history provided to a child eligible for Apple Health in Washington State. MMIS provides billing information only, and may not reflect recent health care encounters or be complete. At present, MMIS is limited to the two most recent years of billing history.Developmental Domain? Developmental screening not applicable due to age, developmental delay or medical complexity? Denver Developmental Screening Test II (Denver II) (birth up to 1 month of age)? Ages and Stages Questionnaires, Third Edition (ASQ-3) (1 to 66 months of age)? Developmental screening results obtained from another source? Child not available for screening. Follow-up needed to obtain developmental screening: FORMTEXT ?????Denver IIThe Denver Developmental Screening Test (Denver II) is administered to infants, birth to one month old. The screen is used to identify potential developmental problems in four areas: gross motor, language, fine motor-adaptive, and personal-social.Date Administered: FORMTEXT ?????Date Scored: FORMTEXT ?????Age at administration: FORMTEXT ????? (in weeks)If adjusted for age (test) check here ?Adjusted age in weeks: FORMTEXT ?????Denver II ResultsDEVELOPMENTAL AREASNORMALCAUTIONDELAYEDNOT APPLICABLEPersonal-Social????Fine Motor-Adaptive????Language????Gross Motor????OVERALL SCORE?Normal – No delays or a maximum of one caution. This child should have routine screenings at future well-child exams.?Suspect – Two or more cautions and/or one delay. Refer to ESIT or appropriate local resource for further assistances.? Untestable – Screen was unable to be completed at this time. See narrative for explanationDenver II Results Summary FORMTEXT ?????Ages and Stages Questionnaires, Third Edition (ASQ-3)Ages and Stages Questionnaires, Third Edition (ASQ-3) is administered to children one to 66 months old. The screen is used to identify young children who may need a developmental evaluation. Ages and Stages are divided into five developmental areas: communication, gross motor, fine motor, problem solving, and personal-social. Each developmental area is scored based on the child’s demonstrated ability compared to a typical child of the same age. Scores below the cutoff indicate a possible concern.Date Administered: FORMTEXT ?????Date Scored: FORMTEXT ?????AGE AT ADMINISTRATION FORMTEXT ?????WHICH ASQ-3 USED FORMTEXT ?????? Corrected for premature birthASQ-3 ResultsDevelopment DomainCommunicationGross motorFine motorProblem solvingPersonal-SocialScore / Cut-off FORMTEXT ????? / FORMTEXT ????? FORMTEXT ????? / FORMTEXT ????? FORMTEXT ????? / FORMTEXT ????? FORMTEXT ????? / FORMTEXT ????? FORMTEXT ????? / FORMTEXT ?????No apparent concern?????Borderline?????Possible concern?????ASQ-3 Results Summary FORMTEXT ?????Developmental Strengths / Concerns FORMTEXT ?????Education Domain? Child is not school aged? Child school aged but not attending school? Education records were not obtained within 30 days of placement.Follow-up recommended to obtain education records: FORMTEXT ?????NAME OF SCHOOL CHILD IS CURRENTLY ATTENDING FORMTEXT ?????GRADE LEVEL FORMTEXT ?????Educational Strengths / Concerns FORMTEXT ?????Educational RecordsRecords Requested from (School Name) FORMTEXT ?????Initial Date Records Requested FORMTEXT ?????Date Records Received FORMTEXT ?????School District Requested from FORMTEXT ?????Initial Date Records Requested FORMTEXT ?????Date Records Received FORMTEXT ?????SPECIAL EDUCATION RECORDS?Not Applicable?Requested Not ObtainedThe following Special Education records were received:?Individual Family Service Plan (IFSP) ?Individual Education Program (IEP)?504 Plan (special accommodations)Emotional / Behavioral Domain? Emotional / Behavioral screening not applicable due to age, developmental delay or medical complexity? ASQ:SE(3 months to 65 months)? PSC-17 (66 months to 17 years)? SCARED(7 years to 17 years)? GAIN-SS(13 years to 17 years)? Emotional/ Behavioral screening results obtained from another sourceAges and Stages Questionnaire: Social-Emotional (ASQ:SE) ? ASQ:SE (3 to 65 months)The Ages and Stages Questionnaire – Social-Emotional (ASQ:SE) screen is administered to children ages 3 to 65 months old. The screen is completed by out-of-home caregivers, parents, and/or child care providers to gather information about a child in the areas of personal-social, self-regulation, compliance, communication, adaptive functioning, autonomy, affect, and interactions with people. Scores above the cutoff indicate a need for a mental health assessment to be completed by a qualified professional. Service needs are then determined by the assessment.AGE AT ADMINISTRATION FORMTEXT ?????WHICH ASQ:SE USED FORMTEXT ?????Check box(es) if possible concern:Date ADMINISTEREDDate ScoredRELATIONSHIP TO CHILDName of Person Providing InformationScore / Cut-offNo apparent concernPossible Concern FORMTEXT ????? FORMTEXT ?????Caregiver FORMTEXT ????? FORMTEXT ????? / FORMTEXT ??????? FORMTEXT ????? FORMTEXT ?????Parent / Guardian #1 FORMTEXT ????? FORMTEXT ????? / FORMTEXT ??????? FORMTEXT ????? FORMTEXT ?????Parent / Guardian #2 FORMTEXT ????? FORMTEXT ????? / FORMTEXT ??????? FORMTEXT ????? FORMTEXT ?????School / Daycare FORMTEXT ????? FORMTEXT ????? / FORMTEXT ??????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? / FORMTEXT ???????ASQ:SE Results Summary FORMTEXT ?????ASQ:SE was not administered during this screening. Follow-up needed to complete emotional / behavioral screen: FORMTEXT ?????Pediatric Symptoms Checklist 17 (PSC-17)? PSC-17(66 months to 17 years)The Pediatric Symptom Checklist (PSC-17) screen is administered for children / youth ages 66 months to 17 years old. The screen is completed by out-of-home caregivers, parents, teachers, and/or youth (11-17 years old) to assess for psychosocial problems. The PSC-17 has scales to identify externalizing, internalizing, and attention problems. Scores equal to or above the cutoff score indicate a need for a mental health assessment to be completed by a qualified professional. Service needs are then determined by the assessment.Check box(es) if possible concern:DateADMINISTEREDDate ScoredRELATIONSHIP TO CHILDName of Person Providing InformationExternalizing Subscale Possible ConcernInternalizingSubscale Possible ConcernATTENTION SUBSCALE POSSIBLE CONCERNToTAL SCORE Possible Concern FORMTEXT ????? FORMTEXT ?????Out-of Home Caregiver FORMTEXT ????????? FORMTEXT ????? FORMTEXT ?????Youth (11-17 years) FORMTEXT ????????? FORMTEXT ????? FORMTEXT ?????Parent / Guardian FORMTEXT ????????? FORMTEXT ????? FORMTEXT ?????School Professional FORMTEXT ????????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????????PSC-17 subscale definitions:Attention Subscale – This subscale reflects problems paying attention, staying focused or on track. Children high on this scale may also have hyperactivity, or trauma related attentional behaviors.Internalizing Subscale – Mainly effects problems the child / adolescent experiences within such as depression, anxiety, sadness and withdrawal from others and social activities.Externalizing Subscale – Children high on the externalizing subscale may be having conflict with others – caregivers, teachers, and/or peers. These children are having behavior problems such as not listening to commands or rules, being argumentative, getting into trouble, and being physically or verbally aggressive.PSC-17 Results Summary FORMTEXT ?????PSC-17 was not completed during screening process by out-of-home caregiver. Follow-up needed to complete emotional / behavioral screening: FORMTEXT ?????Screen for Child Anxiety Related Emotional Disorders (SCARED) Trauma Tool? SCARED (7 years to 17 years)The Screen for Child Anxiety Related Emotional Disorders (SCARED) is a trauma tool that screens for anxiety and post-traumatic stress disorder with two sets of questions. One completed trauma screen is required for each child or youth age 7 to 17 years old by either an out-of-home caregiver, parent(s), the child, or the youth. An attempt must be made to screen children and youth ages 7-17 directly, with documentation if the child or youth refuses or is unable to answer the questions. Scores equal to or above the cutoff score on either subsection indicate a need for a mental health assessment to be completed by a qualified professional. Service needs are then determined by the assessment.Check box(es) if possible concern:DateADMINISTEREDDateScoredName of Person Providing InformationAnxietySubscalePossibleConcernPTS SubScalEPossible Concern FORMTEXT ????? FORMTEXT ????? FORMTEXT ??????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ???????SCARED SCALE DEFINITIONSAnxiety Scale: This subscale reflects potential issues with general anxiety, separation anxiety, panic, and/or social or school phobia.PTSD Scale: This subscale reflects potential issues with general anxiety and/or somatic / panic symptoms.SCARED Summary FORMTEXT ?????SCARED was not completed during screening process by youth or out-of-home caregiver. Follow up needed to complete trauma screening: FORMTEXT ?????Global Assessment of Individual Needs – Short Screen (GAIN-SS)? GAIN-SS not applicable due to age, developmental delay or medical complexity? GAIN-SS (13 through 17 years)?Previously completed by caseworker? Youth currently receiving mental health or substances servicesThe Global Assessment of Individual Needs – Short Screen (GAIN-SS) is a validated screening tool used with youth ages 13 years to 17 years. The tool asks five questions each about internalizing, externalizing, and substance abuse concerns. On the GAIN-SS, attention problems are included among the externalizing concerns. The tool identifies a need for a chemical dependency, mental health, or co-occurring assessment to be completed by a qualified professional. Scores equal to or above the cutoff score of two (2) or “YES” for suicidal thoughts indicate a need for a mental health assessment to be completed by a qualified professional. Service needs are then determined by the assessment.GAIN-SS Results Summary FORMTEXT ?????GAIN-SS was not completed during screening process. Follow-up needed to complete GAIN-SS. FORMTEXT ?????Emotional / Behavioral Strengths / Concerns FORMTEXT ?????CSEC Screening (Ages 11 – 17)CSEC completed: ? Yes ? NoCSEC: ? Indicated ? Confirmed ? N/AConnections DomainThe Connections Domain, administered for children / youth ages birth to 17 years, identifies relationships, to people or things, which the child or caregiver has identified as important to the child. This information may be used to build on the child’s strengths and maintain existing relationships. Considerations for Connections may include, but are not limited to: identifying and recognizing the child’s cultural identity and their affiliations to their culture, tribe, religious and spiritual beliefs, recreational activities personal interests, friends, classmates, siblings, extended family, parents and other significant adults such as teachers, coaches or neighbors. FORMTEXT ?????Referrals made by CHET ScreenerReferral(s) made by screener: Date Referral MadeEarly Support for Infants and Toddler program (ESIT) FORMTEXT ?????Education Advocate FORMTEXT ?????Independent Living Skills (if applicable) FORMTEXT ?????Expedited Referral to Apple Health Core Connections (via FWB) FORMTEXT ?????Supplemental Security Income (SSI) FORMTEXT ?????Wraparound with Intensive Services (WISe) FORMTEXT ?????Other (Identified): FORMTEXT ?????Item Needing Follow-up by Assigned CaseworkerInformed assigned caseworker the following referral(s) need to be made:DateSupplemental Security Income FORMTEXT ?????Mental HealthConcerns were reported to screener FORMTEXT ?????Standardized Tool Scores reported to caseworker FORMTEXT ?????(Based on ASQ:SE, PSC-17, SCARED or GAIN-SS scores)Substance AbuseConcerns were reported to screener FORMTEXT ?????Standardized Tool Scores reported to caseworker FORMTEXT ?????(Based on GAIN-SS)GAIN-SS Co-Occurring FORMTEXT ?????CSEC FORMTEXT ?????Wraparound with Intensive Services (WISe) FORMTEXT ?????Summary of All Follow-up Needed Items FORMTEXT ?????PhotoDATE PICTURE TAKEN FORMTEXT ?????HAIR COLOR FORMTEXT ?????EYE COLOR FORMTEXT ????? FORMTEXT ?????These records are confidential and are disclosed under the limitations of RCW 13.50.100. This disclosure does not constitute a waiver of any confidentiality or privilege attached to the records by operation of any state or federal law or regulation. The recipient of these records must comply with the laws governing confidentiality and must protect the records from unauthorized disclosure. RCW 13.50.100(5). ................
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