MARION COUNTY HEALTH DEPARTMENT
Marion County Health & Human ServicesChildren’s Behavioral Health Services/Transition Age Youth ServicesINITIAL MENTAL HEALTH ASSESSMENTNAME : FORMTEXT ????? FORMTEXT ID # : FORMTEXT ?????DATE : FORMTEXT ?????DOB : FORMTEXT ?????AGE : FORMTEXT ?????CLINICIAN: Choose an item.PRESENT AT TIME OF ASSESSMENT: FORMTEXT ????? Conducted in Spanish? FORMCHECKBOX Yes FORMCHECKBOX No Conducted with interpreter? FORMCHECKBOX Yes FORMCHECKBOX No If yes, name: FORMTEXT ?????OTHER SOURCES OF INFORMATION (In person, by phone, review of written documentation, etc.): FORMTEXT ?????PRESENTING PROBLEM: FORMCHECKBOX AGGRESSION FORMCHECKBOX ANGER FORMCHECKBOX ANXIETY FORMCHECKBOX ATTENTION/FOCUS FORMCHECKBOX DEPRESSION FORMCHECKBOX DEVELOPMENTAL FORMCHECKBOX EATING FORMCHECKBOX GRIEF/LOSS FORMCHECKBOX IMPULSIVITY FORMCHECKBOX IRRITABILITY FORMCHECKBOX MOOD FORMCHECKBOX OPPOSITION/DEFIANCE FORMCHECKBOX PSYCHOSIS FORMCHECKBOX RELATIONAL FORMCHECKBOX SELF-HARM FORMCHECKBOX SEXUAL FORMCHECKBOX SLEEP ISSUES FORMCHECKBOX SUBSTANCE USE FORMCHECKBOX SUICIDE IDEATION FORMCHECKBOX TRAUMA FORMCHECKBOX OTHER: FORMTEXT ?????History of the problem(s), onset, precipitating factors, duration, intensity/frequency: FORMTEXT ???????AGENCIES / SERVICE PROVIDERS CURRENTLY INVOLVED WITH CHILD / FAMILY : FORMCHECKBOX DHS FORMCHECKBOX JUVENILE DEPARTMENT FORMCHECKBOX OREGON YOUTH AUTHORITY FORMCHECKBOX MEDICAL PROVIDER FORMCHECKBOX A&D PROVIDER FORMCHECKBOX OTHER MENTAL HEALTH PROVIDER FORMCHECKBOX OTHER : FORMTEXT ?????COMMENTS: FORMTEXT ?????CLIENT/FAMILY STRENGTHS: FORMTEXT ?????FAMILY MENTAL HEALTH HISTORY: FORMTEXT ?????FAMILY RELATIONSHIPS (parent/child, marital, sibling relationships): FORMTEXT ?????DEVELOPMENTAL: FORMCHECKBOX DEVELOPMENTAL DELAYS FORMCHECKBOX GROSS MOTOR PROBLEMS FORMCHECKBOX FINE MOTOR PROBLEMS FORMCHECKBOX SPEECH/LANGUAGE DELAYS FORMCHECKBOX AUTISM SPECTRUM FORMCHECKBOX FETAL ALCOHOL/DRUG EFFECTS FORMCHECKBOX LEARNING DISABILITIES FORMCHECKBOX PRENATAL/BIRTH PROBLEMS FORMCHECKBOX PROBLEMS MEETING MILESTONES FORMCHECKBOX MILESTONES MET ON TIME FORMCHECKBOX DD SERVICES – If yes, name of Case Manager FORMTEXT ?????COMMENTS: FORMTEXT ?????CURRENT MEDICAL/PHYSICAL: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ALLERGIESASTHMAHEADACHESHEAD INJURY/TRAUMASEIZURESACCIDENTS/MAJOR INJURIESCHRONIC ILLNESS/DISEASE FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX SURGERIESHOSPITALIZATIONSPREGNANCIESSLEEPING PROBLEMSENURESISENCOPRESISOVERACTIVE FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX LACK OF ENERGYVISION PROBLEMSHEARING PROBLEMSRECURRING INFECTIONSSOMATIC COMPLAINTSTAKES MEDICATIONSOTHER : FORMTEXT ?????CURRENT MEDICATIONS: FORMTEXT ????COMMENTS: FORMTEXT ?????NUTRITION: (Check all that apply): FORMCHECKBOX NUTRITIONAL DEFICIENCIES FORMCHECKBOX EATING NON-FOODS FORMCHECKBOX EXCESSIVE EXERCISE FORMCHECKBOX EXCESSIVE DIETING/FASTING FORMCHECKBOX COMPULSIVE EATING FORMCHECKBOX BINGING FORMCHECKBOX PURGING FORMCHECKBOX OVERWEIGHT FORMCHECKBOX UNDERWEIGHT FORMCHECKBOX OTHER : FORMTEXT ?????COMMENTS: FORMTEXT ????? FORMTEXT ?????LEGAL: FORMCHECKBOX CUSTODY OF PARENT/GUARDIAN FORMCHECKBOX CUSTODY OF DHS If yes, name/contact for Caseworker: FORMTEXT ????? FORMCHECKBOX JUVENILE DEPARTMENT FORMCHECKBOX OREGON YOUTH ATHORITY If yes, name/contact for P.O. FORMTEXT ????? FORMCHECKBOX DD SHARED GUARDIANSHIPIf yes, name/contact for DD worker: FORMTEXT ?????CURRENT LEGAL INVOLVEMENT/DIFFICULTIES? FORMCHECKBOX YES FORMCHECKBOX NO FORMTEXT ????? FORMCHECKBOX FATC Caseworker: FORMTEXT ????? P.O. FORMTEXT ????? FORMCHECKBOX WOODMANSEE Adult? FORMCHECKBOX Child? FORMCHECKBOX Caseworker: FORMTEXT ????? P.O. FORMTEXT ?????EDUCATION/VOCATIONAL:Current Grade: FORMTEXT ????? Current School: FORMTEXT ????? Name of School Contact Person: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ATTENTION PROBLEMSLOW GRADESFALLING GRADESUNDERACHIEVEMENTOVERACHIEVEMENT FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX SKIPPING / POOR ATTENDANCE SUSPENSIONS / EXPULSIONSSOCIAL/BEHAVIORAL PROBLEMSON AN IEPON A 504 PLANCOMMENTS: FORMTEXT ?????SOCIAL/COMMUNITY: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX UNABLE TO KEEP FRIENDSISOLATES SELF/WITHDRAWNARGUMENTATIVE/DEFIANTACTS YOUNG FOR AGEACTS MATURE FOR AGELYINGRUNNING AWAYSTEALINGHURTS ANIMALS FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FIRE SETTINGBULLIESGANG INTEREST/INVOLVEMENTAGGRESSIVE/ASSAULTIVE BEHAVIORSEXUALLY REACTIVE BEHAVIORSSEXUAL OFFENDING BEHAVIORSEXPOSURE TO WEAPONSVANDALISMOTHER: FORMTEXT ?????CULTURE: (Consider ethnic background, language, sexual orientation, gender identity and expression, religion, socioeconomic status, family traditions and rituals): FORMTEXT ?????TRAUMA HISTORY:TRAUMA SYMPTOMS: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NEGLECTEMOTIONAL ABUSESEXUAL ABUSEPHYSICAL ABUSEWITNESSED DOMESTIC VIOLENCEFREQUENT MOVESMULTIPLE CAREGIVERSGRIEF AND LOSSACCIDENTOTHER: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NIGHTMARESPROBLEMS SLEEPINGDIFFICULTY CONCENTRATINGSTARTLES EASILY/HYPERVIGILANTCHANGE IN BEHAVIORREGRESSION IN MILESTONESISOLATION/WITHDRAWLINCREASE IN ANGER/AGGRESSIONCOMMENTS: FORMTEXT ?????SUBSTANCE USE: FORMCHECKBOX ALCOHOL FORMCHECKBOX CANNABIS FORMCHECKBOX PRESCRIPTION OPIATES FORMCHECKBOX HEROIN FORMCHECKBOX STIMULANTS Specify: FORMTEXT ????? FORMCHECKBOX HALLUCINOGENS FORMCHECKBOX Other: FORMTEXT ?????Age of first use: FORMTEXT ????? Duration of use: FORMTEXT ????? Frequency of use: FORMTEXT ????? Amount: FORMTEXT ?????History of treatment? FORMTEXT ????? Currently in treatment? FORMCHECKBOX Yes FORMCHECKBOX No If yes, where? FORMTEXT ?????COMMENTS: FORMTEXT ?????TOBACCO USE: FORMCHECKBOX Yes FORMCHECKBOX No If yes, referral for Tobacco Cessation GAMBLING: FORMCHECKBOX Yes FORMCHECKBOX No If yes, have you ever received treatment? FORMTEXT ?????CURRENT MENTAL STATUS:APPEARANCE: FORMDROPDOWN COMMENTS: FORMTEXT ?????PSYCHOMOTOR: Posture: FORMDROPDOWN Coordination: FORMDROPDOWN Gait: FORMDROPDOWN Manner: FORMDROPDOWN Eye Contact: FORMDROPDOWN INTELLECT: Attention/Concentration: FORMDROPDOWN Fund of Knowledge: FORMDROPDOWN Judgment: FORMDROPDOWN Insight: FORMDROPDOWN Memory: FORMDROPDOWN Abstraction: FORMDROPDOWN SPEECH: Volume: FORMDROPDOWN Rate: FORMDROPDOWN Clarity: FORMDROPDOWN Rhythm: FORMDROPDOWN THOUGHT: Clarity: FORMDROPDOWN Flow: FORMDROPDOWN Content: FORMDROPDOWN Orientation: FORMDROPDOWN AFFECT: Expression: FORMDROPDOWN Attitude: FORMDROPDOWN Mood: FORMDROPDOWN Range: FORMDROPDOWN SLEEP: FORMDROPDOWN APPETITE: FORMDROPDOWN ACTIVITY: FORMDROPDOWN SOCIAL CONTACT: FORMDROPDOWN RISK OF HARM:Suicidal/Self-injurious ideation or behavior: Describe ideation, plans, level of intent, history of past attempts and outcome. FORMTEXT ????? Harm to Others: Describe ideation, plans, level of intent and history of violence. FORMTEXT ?????Discussed Safety Plan with Client/Family: FORMCHECKBOX Yes FORMCHECKBOX No COMMENTS: FORMTEXT ?????Completed CAMS? FORMCHECKBOX Yes FORMCHECKBOX NoPSYCHIATRIC TREATMENT HISTORY: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX PSYCHIATRIC EVALUATIONMEDICATION MANAGEMENTINDIVIDUAL THERAPYFAMILY THERAPYGROUP TREATMENTALCOHOL & DRUG TREATMENT FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX PSYCHOLOGICAL TESTINGDAY TREATMENTRESIDENTIAL TREATMENTSUBACUTE ACUTE HOSPITALIZATIONOTHER : FORMTEXT ?????COMMENTS: FORMTEXT ?????CURRENT DIAGNOSTIC IMPRESSIONS:Primary Diagnosis (F Codes): FORMTEXT ?????Other factors that may be a focus of Clinical Attention: (Z/T Codes) : FORMTEXT ?????Medical Conditions: FORMTEXT ?????ACE Score: FORMTEXT ?????Parent 1 ACE Score: FORMTEXT ????? Parent 2 ACE Score: FORMTEXT ????? CLINICAL FORMULATION: (Include summary of client, family & environmental factors that support current diagnostic impressions and treatment plan) : FORMTEXT ?????TREATMENT RECOMMENDATIONS: FORMCHECKBOX INDIVIDUAL THERAPY FORMCHECKBOX FAMILY THERAPY FORMCHECKBOX PSYCH EVAL/MED MANAGEMENT FORMCHECKBOX CASE MANAGEMENT FORMCHECKBOX SKILLS TRAINING FORMCHECKBOX GROUP SKILLS TRAINING FORMCHECKBOX DBT FORMCHECKBOX YOGACALM FORMCHECKBOX SUPERFLEX FORMCHECKBOX AUTISM 101 FORMCHECKBOX PARENTING FORMCHECKBOX PCIT/PCAT FORMCHECKBOX STRENGTHENING FAMILIES FORMCHECKBOX CPS FORMCHECKBOX MISSION:TRANSITION REFERRAL FORMCHECKBOX EASA REFERRAL FORMCHECKBOX A&D REFERRAL FORMCHECKBOX NEW SOLUTIONS REFERRAL FORMCHECKBOX DD SERVICES REFERRAL FORMCHECKBOX PCP REFERRALCOMMENTS: FORMTEXT ?????EVALUATOR SIGNATURE:__________________________________________ DATE: ___________________EVALUATOR PRINTED NAME/CREDENTIALS: FORMTEXT ?????LMP SIGNATURE: ___________________________________________________ DATE: __________________LMP DESIGNEE SIGNATURE: ________________________________________ DATE: __________________Child and Adolescent Needs and StrengthsCANS 2.0 (Ages 0-5)Individual’s Name: FORMTEXT ?????Birth Date: FORMTEXT ?????CANS Screener: FORMTEXT ?????Screening Date: FORMTEXT ?????CANS Update Type: FORMCHECKBOX Initial FORMCHECKBOX 90 Day FORMCHECKBOX Placement change FORMCHECKBOX Change in Clinical Circumstance FORMCHECKBOX Closing FORMCHECKBOX Other: FORMTEXT ?????SAFETY SECTION0: No concerns1: Watchful waiting2: Action3: Immediate action/safety planningChild Risk Factors/BehaviorsElement01231. Birth Weight FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Prenatal Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Substance Exposure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Parent or Sibling Challenges FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Self-Harm FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Aggressive Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Sexual Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????STRENGTHS SECTION0: Centerpiece strength1: Strength exists2: Identified potential strength3: No strengths currentlyChild StrengthsElement01238. Family Strengths FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Interpersonal Skills FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10. Adaptability FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Persistence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. Curiosity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13. Playfulness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14. Relationship Permanence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????WELL-BEING0: No concerns1: Watchful waiting2: Action3: Immediate action/safety planningExposure to Potentially Traumatic/Adverse Childhood ExperiencesElementNoYes15. Sexual Abuse FORMCHECKBOX FORMCHECKBOX 16. Physical Abuse FORMCHECKBOX FORMCHECKBOX 17. Emotional/Verbal Abuse FORMCHECKBOX FORMCHECKBOX 18. Neglect FORMCHECKBOX FORMCHECKBOX 19. Medical Trauma FORMCHECKBOX FORMCHECKBOX 20. Witness to Family Violence FORMCHECKBOX FORMCHECKBOX 21. Witness to Community/School Violence FORMCHECKBOX FORMCHECKBOX 22. War Affected FORMCHECKBOX FORMCHECKBOX 23.Terrorism Affected FORMCHECKBOX FORMCHECKBOX 24. Witness/Victim of Criminal Activity FORMCHECKBOX FORMCHECKBOX 25. Parental Criminal Behavior FORMCHECKBOX FORMCHECKBOX 26. Disruptions in Caregiving/Attachment Losses FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????Traumatic Stress SymptomsElement 0 1 2 327. Reaction to Traumatic Life Experiences FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 28. Traumatic Grief & Separation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 29. Intrusions/Re-Experiencing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 30. Hyperarousal FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 31. Attempts to Avoid Stimuli FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 32. Numbing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 33. Dissociation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 34. Emotional and/or Physical Regulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????Life FunctioningElement012335. Family Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 36. Living Situation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 37. Preschool/Daycare Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 38. Preschool/Daycare Achievement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 39. Social Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 40. Recreation/Play FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 41. Developmental/Intellectual FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 42. Sensory FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 43. Self-Care/Daily Living Skills FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 44. Motor FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 45. Communication (Receptive/Expressive) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 46. Sleep FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 47. Medical FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 48. Physical FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????Cultural ConsiderationsElement012349. Language FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 50. Cultural Identity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 51. Cultural Events and Activities FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 52. Cultural Stress FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????Behavioral/Emotional NeedsElement012353. Attachment Difficulties FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 54. Impulsive/Hyperactive FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 55. Temperament FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 56. Failure to Thrive FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 57. Eating/Elimination FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 58. Depression FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 59. Anxiety FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 60. Atypical Behaviors FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 61. Service Permanence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????Child and Adolescent Needs and StrengthsCANS 2.0 (Ages 6-20)Individual’s Name: FORMTEXT ?????Birth Date: FORMTEXT ?????CANS Screener: FORMTEXT ?????Screening Date: FORMTEXT ?????CANS Update Type: FORMCHECKBOX Initial FORMCHECKBOX 90 Day FORMCHECKBOX Placement change FORMCHECKBOX Change in Clinical Circumstance FORMCHECKBOX Closing FORMCHECKBOX Other: FORMTEXT ?????SAFETY SECTION0: No concerns1: Watchful waiting2: Action3: Immediate action/safety planningYouth Risk BehaviorsElement01231. Suicide Risk FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2. Non-Suicidal Self-Injurious Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3. Other Self-Harm/Recklessness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4. Danger to Others FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5. Runaway FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6. Delinquent Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. Decision Making FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8. Fire-Setting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9. Sexually Aggressive Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????STRENGTHS SECTION0: Centerpiece strength1: Strength exists2: Identified potential strength3: No strengths currentlyYouth StrengthsElement012310. Family Strengths FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 11. Interpersonal Skills FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 12. Educational Setting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 13. Vocational FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14. Coping and Savoring Skills FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15. Optimism FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16. Talent/Interests FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 17. Community Connections FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 18. Natural Supports FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 19. Relationship Permanence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 20. Resilience FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????WELL-BEING0: No concerns1: Watchful waiting2: Action3: Immediate action/safety planningExposure to Traumatic/Adverse Childhood ExperiencesElementNoYes21. Sexual Abuse FORMCHECKBOX FORMCHECKBOX 22. Physical Abuse FORMCHECKBOX FORMCHECKBOX 23. Emotional/Verbal Abuse FORMCHECKBOX FORMCHECKBOX 24. Neglect FORMCHECKBOX FORMCHECKBOX 25. Medical Trauma FORMCHECKBOX FORMCHECKBOX 26. Witness to Family Violence FORMCHECKBOX FORMCHECKBOX 27. Witness to Community/School Violence FORMCHECKBOX FORMCHECKBOX 28. War Affected FORMCHECKBOX FORMCHECKBOX 29.Terrorism Affected FORMCHECKBOX FORMCHECKBOX 30. Witness/Victim of Criminal Activity FORMCHECKBOX FORMCHECKBOX 31. Parental Criminal Behavior FORMCHECKBOX FORMCHECKBOX 32. Disruptions in Caregiving/Attachment Losses FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????Traumatic Stress SymptomsElement012333. Reaction to Traumatic Life Experiences FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 34. Traumatic Grief & Separation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 35. Intrusions/Re-Experience FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 36. Hyperarousal FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 37. Attempts to Avoid Stimuli FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 38. Numbing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 39. Dissociation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 40. Emotional and/or Physical Regulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????Life FunctioningElement012341. Family Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 42. Living Situation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 43. Social Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 44. Developmental/Intellectual FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 45. Sensory FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 46. Self-care/Daily Living Skills FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 47. Recreational FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 48. Legal FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 49. Medical/Physical FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 50. Sleep FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 51. Sexual Development FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 52. School Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 53. School Attendance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 54. School Achievement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????Cultural ConsiderationsElement012355. Language FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 56. Cultural Identity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 57. Cultural Events and Activities FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 58. Cultural Stress FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????Behavioral/Emotional NeedsElement Elements012359. Impulsivity/Hyperactivity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 60. Depression and Anxiety FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 61. Psychosis (Thought Disorder) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 62. Oppositional (Non-Compliance with Authority) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 63. Substance Use FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 64. Attachment Difficulties FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 65. Eating Disturbances FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 66. Anger Control FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 67. Situational Consistency of Challenges FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 68. Duration of Mental Health Challenges FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 69. Service Permanence FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Updates: FORMTEXT ?????Combined MHA/CANSIntensive Services & SupportsMENTAL HEALTH ASSESSMENTwith CANS 0-5Individual’s legal name: FORMTEXT ?????Raintree ID: FORMTEXT ?????Date of Assessment: FORMTEXT ?????Name in Use: FORMTEXT ?????DOB: FORMTEXT ?????Age: FORMTEXT ?????Clinician: FORMDROPDOWN Pronouns: FORMTEXT ?????Who was present at session: FORMTEXT ?????Other sources of information: FORMTEXT ?????Conducted in individual’s preferred language: FORMCHECKBOX Yes FORMCHECKBOX NoPreferred Language: FORMTEXT ?????Conducted with interpreter? FORMCHECKBOX Yes FORMCHECKBOX No Language interpreted: FORMTEXT ?????Strengths of Individual and FamilyCANS Strengths0: Centerpiece strength1: Strength exists2: Identified potential strengths3: No strengths currentlyCANS ScoreCANS Score FORMTEXT ?????Family Strengths (8) FORMTEXT ?????Interpersonal Skills (9) FORMTEXT ?????Adaptability (10) FORMTEXT ?????Persistence (11) FORMTEXT ?????Curiosity (12) FORMTEXT ?????Playfulness (13) FORMTEXT ?????Relationship Permanence (14)Comments: (document resilience strategies) FORMTEXT ?????Presenting Problems (For suicide and homicide, include recommendations/safety plan in the Risk of Harm Section) CANS Needs0: No Concerns1: Watchful Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Self-harm (5) FORMTEXT ?????Aggressive Behavior (6) FORMTEXT ?????Sexual Behavior (7) FORMTEXT ?????Sleep (46) FORMTEXT ?????Impulsivity/Hyperactivity (54) FORMTEXT ?????Eating/Elimination (57) FORMTEXT ?????Depression (58) FORMTEXT ?????Anxiety (59) FORMTEXT ?????Atypical Behaviors (60)Comments: (onset, precipitating factors, duration, intensity & frequency) FORMTEXT ?????Risk of Harm FORMCHECKBOX None ReportedHarm to Self: (Describe ideation, plans, level of intent, history of past attempts and outcome.) FORMTEXT ?????Harm to Others: (Describe ideation, plans, level of intent and history of violence.) FORMTEXT ?????Level of Risk Identified: (what evidence based tool was used) FORMTEXT ?????Created Safety Plan with Client/Family: FORMCHECKBOX Yes FORMCHECKBOX NoProvided counseling on access to lethal means: FORMCHECKBOX Yes FORMCHECKBOX NoComments: FORMTEXT ?????Psychiatric Treatment History FORMCHECKBOX Acute Hospitalization FORMCHECKBOX Psychiatric Evaluation FORMCHECKBOX Subacute Treatment FORMCHECKBOX Medication Management FORMCHECKBOX Psychiatric Residential Treatment FORMCHECKBOX Group Therapy FORMCHECKBOX Psychiatric Day Treatment FORMCHECKBOX Psychological Evaluation/Testing FORMCHECKBOX Outpatient Individual Therapy FORMCHECKBOX Alcohol and Drug Treatment FORMCHECKBOX Outpatient Family Therapy FORMCHECKBOX Other (See Comments)Comments: (list specific interventions used, including school contact) FORMTEXT ?????Family CANS Needs0: No Concerns1: Watchful Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Parent or Sibling Challenges (4) FORMTEXT ?????Family Functioning (35) FORMTEXT ?????Living Situation (36) FORMTEXT ?????Attachment Difficulties (53)Comments: (Family mental health history, family relationships, family/natural supports, financial stressors) FORMTEXT ?????Developmental FORMCHECKBOX No Concerns Identified FORMCHECKBOX Speech/Language Delays FORMCHECKBOX Autism Spectrum FORMCHECKBOX Problem Meeting Milestones FORMCHECKBOX Fetal Alcohol/Drug Effects FORMCHECKBOX Gender Dysphoria FORMCHECKBOX Fine Motor Problems FORMCHECKBOX Other (see comments) FORMCHECKBOX Gross Motor Problems FORMCHECKBOX IDD Services (Case Manager: FORMTEXT ?????) FORMCHECKBOX Learning DisabilityCANS Needs0: No Concerns1: Watchful Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Birth Weight (1) FORMTEXT ?????Prenatal Care (2) FORMTEXT ?????Substance Exposure (3) FORMTEXT ?????Developmental/Intellectual (41) FORMTEXT ?????Sensory (42) FORMTEXT ?????Self-Care/Daily Living (43) FORMTEXT ?????Motor (44) FORMTEXT ?????Communication (45)Comments: FORMTEXT ?????Medical/Physical FORMCHECKBOX No Concerns Identified FORMCHECKBOX Accidents/Major Injuries FORMCHECKBOX Allergies FORMCHECKBOX Asthma FORMCHECKBOX Chronic Illness/Disease FORMCHECKBOX Encopresis FORMCHECKBOX Enuresis FORMCHECKBOX Vision Problems FORMCHECKBOX Headaches FORMCHECKBOX Head Injury/Trauma Brain Injury FORMCHECKBOX Hearing Problems FORMCHECKBOX Hospitalizations FORMCHECKBOX Lack of Energy FORMCHECKBOX Nutrition/Food Issues FORMCHECKBOX Overactive FORMCHECKBOX Other (see comments) FORMCHECKBOX Pregnancies FORMCHECKBOX Recurring Infections FORMCHECKBOX Seizures FORMCHECKBOX Sleep Problems FORMCHECKBOX Somatic Complaints FORMCHECKBOX Surgeries FORMCHECKBOX Takes MedicationsCANS Needs0: No Concerns1: Watchful Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Medical (47) FORMTEXT ?????Medical (48)Current Medications: FORMTEXT ?????Comments: (note any past negative medication reactions) FORMTEXT ?????EducationalCurrent Grade: FORMTEXT ????? Current School: FORMTEXT ????? IEP/504 Plan: FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX No Concerns Identified FORMCHECKBOX Skipping/Poor Attendance FORMCHECKBOX Attention Problems FORMCHECKBOX Social/Behavioral Problems FORMCHECKBOX Falling/Low Grades FORMCHECKBOX Suspensions/Expulsions FORMCHECKBOX Overachievement FORMCHECKBOX Underachievement FORMCHECKBOX Other (see comments)CANS Needs0: No Concerns1: Watching Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Preschool/Daycare Behavior (37) FORMTEXT ?????Preschool/Daycare Achievement (38)Comments: (school contact person) FORMTEXT ?????Social FORMCHECKBOX No Concerns Identified FORMCHECKBOX Hurts Animals FORMCHECKBOX Unable to keep friends FORMCHECKBOX Acts young for age FORMCHECKBOX Isolates Self/Withdrawn FORMCHECKBOX Vandalism FORMCHECKBOX Acts mature for age FORMCHECKBOX Lying FORMCHECKBOX Other (see comments) FORMCHECKBOX Exposure to weapons FORMCHECKBOX Argumentative/Defiant FORMCHECKBOX Stealing FORMCHECKBOX Gang Interest/Involvement CANS Needs0: No Concerns1: Watching Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Social Functioning (39) FORMTEXT ?????Recreation/Play (40)Comments: (Peer relational difficulties, adult relational difficulties, early social deficits) FORMTEXT ?????Cultural ConsiderationsCANS Needs0: No Concerns1: Watching Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Language (49) FORMTEXT ?????Cultural Identity (50) FORMTEXT ?????Cultural Events and Activities (51) FORMTEXT ?????Cultural Stress (52)Comments: (Language/Ethnic/Cultural/Religion/Spirituality/family traditions/sexual identity/gender identity) FORMTEXT ?????Legal FORMCHECKBOX No Concerns Identified FORMCHECKBOX Custody of DHS FORMCHECKBOX Juvenile Department FORMCHECKBOX Custody of OYAComments: FORMTEXT ?????Exposure to Traumatic/Adverse Childhood ExperiencesYes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Yes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sexual Abuse (15)Physical Abuse (16)Emotional/Verbal Abuse (17)Neglect (18)Medical Trauma (19)Witness to Family Violence (20)Witness to Community/School Violence (21)War Affected (22)Terrorism Affected (23)Witness/Victim of Criminal Activity (24)Parental Criminal Behavior (25)Disruption in Caregiving/Attachment Losses (26)Comments: (additional trauma not captured on the CANS would be listed here) FORMTEXT ?????Traumatic Stress SymptomsCANS Needs0: No Concerns1: Watching Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Reaction to Traumatic Life Experiences (27) FORMTEXT ?????Traumatic Grief and Separation (28) FORMTEXT ?????Intrusion/Re-Experience (29) FORMTEXT ?????Hyperarousal (30) FORMTEXT ?????Attempts to Avoid Stimuli (31) FORMTEXT ?????Numbing (32) FORMTEXT ?????Dissociation (33) FORMTEXT ?????Emotional and/or Physical Regulation (34)Comments: (onset, precipitating factors, duration, intensity & frequency) FORMTEXT ?????Agencies and Service Providers Currently Involved with Individual and Family FORMCHECKBOX No Concerns Identified FORMCHECKBOX Oregon Youth Authority FORMCHECKBOX A&D Provider FORMCHECKBOX Juvenile Department FORMCHECKBOX Medical Provider FORMCHECKBOX Other Mental Health Provider FORMCHECKBOX Wraparound FORMCHECKBOX Other (See Comments) FORMCHECKBOX DHS CANS Needs0: No Concerns1: Watchful Waiting2: Action3: Immediate Action/Safety PlanningCANS Score FORMTEXT ?????Service Permanence (61)Comments: (names & contact information) FORMTEXT ?????Current Mental Status:Appearance: Choose an item.Psychomotor: Posture: Choose an item. Coordination: Choose an item. Gait: Choose an item. Manner: Choose an item. Eye Contact: Choose an item.Intellect:Attention/Concentration: Choose an item. Fund of Knowledge: Choose an item. Judgment: Choose an item. Insight: Choose an item. Memory: Choose an item. Abstraction: Choose an item.Speech:Volume: Choose an item. Rate: Choose an item. Clarity: Choose an item. Rhythm: Choose an item.Thought:Clarity: Choose an item. Flow: Choose an item. Content: Choose an item. Orientation: Choose an item.Affect:Expression: Choose an item. Attitude: Choose an item. Mood: Choose an item. Range: Choose an item.Sleep: Choose an item. Appetite: Choose an item. Activity: Choose an item. Social Contact: Choose an ments: FORMTEXT ?????Clinical Formulation: (must include strengths, diagnostic justification with DSM criteria and prognosis) FORMTEXT ?????Diagnostic Impression (DSMV & ICD-10)Primary Diagnosis (F code and Diagnosis): FORMTEXT ?????Problem in Functioning (Z code and Diagnosis): FORMTEXT ?????Medical Conditions: FORMTEXT ?????ACE Score for Client: FORMTEXT ????? ACE Score for Parent 1: FORMTEXT ????? ACE Score for Parent 2: FORMTEXT ?????Level of Care FORMCHECKBOX Level 1 – 120 days FORMCHECKBOX Level 2 – 270 days FORMCHECKBOX Level 3 – 364 daysTreatment Recommendations:Services:Referrals: FORMCHECKBOX Individual Therapy FORMCHECKBOX DD Services Referral FORMCHECKBOX Family Therapy FORMCHECKBOX MVWRAP Referral FORMCHECKBOX Group Therapy FORMCHECKBOX Psychological Evaluation/Testing FORMCHECKBOX Psychiatric Evaluation/Medication Management FORMCHECKBOX Other (See comments section) FORMCHECKBOX Skills TrainingComments: FORMTEXT ?????Clinician Signature: ____________________________________________ Date: FORMTEXT ????? Clinician Printed Name/Credentials: FORMTEXT ?????LMP Signature: _______________________________________________ Date: FORMTEXT ?????LMP Designee Signature: _______________________________________ Date: FORMTEXT ????? Combined MHA/CANS-274320-414655Intensive Services & SupportsMENTAL HEALTH ASSESSMENTwith CANS 6-20Individual’s legal name: FORMTEXT ?????Raintree ID: FORMTEXT ?????Date of Assessment: FORMTEXT ?????Name in Use: FORMTEXT ?????DOB: FORMTEXT ?????Age: FORMTEXT ?????Clinician: FORMDROPDOWN Pronouns: FORMTEXT ?????Who was present at session: FORMTEXT ?????Other sources of information: FORMTEXT ?????Conducted in individual’s preferred language: FORMCHECKBOX Yes FORMCHECKBOX NoPreferred Language: FORMTEXT ?????Conducted with interpreter? FORMCHECKBOX Yes FORMCHECKBOX No Language interpreted: FORMTEXT ?????Strengths of Individual and FamilyCANS Strengths0: Centerpiece strength1: Strength exists2: Identified potential strengths3: No strengths currentlyCANS ScoreCANS Score FORMTEXT ?????Family Strengths (10) FORMTEXT ?????Interpersonal Skills (11) FORMTEXT ?????Educational Setting (12) FORMTEXT ?????Vocational (13) FORMTEXT ?????Coping & Savoring Skills (14) FORMTEXT ?????Optimism (15) FORMTEXT ?????Talents/Interests (16) FORMTEXT ?????Community Connection (17) FORMTEXT ?????Natural Supports (18) FORMTEXT ?????Relationship Permanence (19) FORMTEXT ?????Resilience (20)Comments: (document resilience strategies) FORMTEXT ?????Presenting Problems (For suicide and homicide, include recommendations/safety plan in the Risk of Harm Section) CANS Needs0: No Concerns1: Watchful Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Suicide Risk (1) FORMTEXT ?????Non-Suicidal Self-Injurious Behavior (2) FORMTEXT ?????Other Self-Harm/Recklessness (3) FORMTEXT ?????Danger to Others (4) FORMTEXT ?????Runaway (5) FORMTEXT ?????Fire-Setting (8) FORMTEXT ?????Sexually Aggressive Behavior (9) FORMTEXT ?????Sleep (50) FORMTEXT ?????Impulsivity/Hyperactivity (59) FORMTEXT ?????Depression/Anxiety (60) FORMTEXT ?????Psychosis (thought disorder) (61) FORMTEXT ?????Oppositional (non-compliance with authority (62) FORMTEXT ?????Eating Disturbances (65) FORMTEXT ?????Anger Control (66) FORMTEXT ?????Duration of Mental Health Challenges (68)Comments: (onset, precipitating factors, duration, intensity & frequency) FORMTEXT ?????Risk of Harm FORMCHECKBOX None ReportedHarm to Self: (Describe ideation, plans, level of intent, history of past attempts and outcome.) FORMTEXT ?????Harm to Others: (Describe ideation, plans, level of intent and history of violence.) FORMTEXT ?????Level of Risk Identified: (what evidence based tool was used) FORMTEXT ?????Created Safety Plan with Client/Family: FORMCHECKBOX Yes FORMCHECKBOX No Provided counseling on access to lethal means: FORMCHECKBOX Yes FORMCHECKBOX NoComments: FORMTEXT ?????Psychiatric Treatment History FORMCHECKBOX Acute Hospitalization FORMCHECKBOX Psychiatric Evaluation FORMCHECKBOX Subacute Treatment FORMCHECKBOX Medication Management FORMCHECKBOX Psychiatric Residential Treatment FORMCHECKBOX Group Therapy FORMCHECKBOX Psychiatric Day Treatment FORMCHECKBOX Psychological Evaluation/Testing FORMCHECKBOX Outpatient Individual Therapy FORMCHECKBOX Alcohol and Drug Treatment FORMCHECKBOX Outpatient Family Therapy FORMCHECKBOX Other (See Comments)Comments: (list specific interventions used) FORMTEXT ?????Family CANS Needs0: No Concerns1: Watchful Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Family Functioning (41) FORMTEXT ?????Living Situation (42) FORMTEXT ?????Attachment Difficulties (64)Comments: (Family mental health history, family relationships, family/natural supports, financial stressors) FORMTEXT ?????Developmental FORMCHECKBOX No Concerns Identified FORMCHECKBOX Speech/Language Delays FORMCHECKBOX Autism Spectrum FORMCHECKBOX Problem Meeting Milestones FORMCHECKBOX Fetal Alcohol/Drug Effects FORMCHECKBOX Gender Dysphoria FORMCHECKBOX Fine Motor Problems FORMCHECKBOX Other (see comments) FORMCHECKBOX Gross Motor Problems FORMCHECKBOX IDD Services (Case Manager: FORMTEXT ?????) FORMCHECKBOX Learning DisabilityCANS Needs0: No Concerns1: Watchful Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Developmental/Intellectual (44) FORMTEXT ?????Sensory (45) FORMTEXT ?????Self-Care/Daily Living Skills (46)Comments: FORMTEXT ?????Medical/Physical FORMCHECKBOX No Concerns Identified FORMCHECKBOX Accidents/Major Injuries FORMCHECKBOX Allergies FORMCHECKBOX Asthma FORMCHECKBOX Chronic Illness/Disease FORMCHECKBOX Encopresis FORMCHECKBOX Enuresis FORMCHECKBOX Vision Problems FORMCHECKBOX Headaches FORMCHECKBOX Head Injury/Trauma Brain Injury FORMCHECKBOX Hearing Problems FORMCHECKBOX Hospitalizations FORMCHECKBOX Lack of Energy FORMCHECKBOX Nutrition/Food Issues FORMCHECKBOX Overactive FORMCHECKBOX Other (see comments) FORMCHECKBOX Pregnancies FORMCHECKBOX Recurring Infections FORMCHECKBOX Seizures FORMCHECKBOX Sleep Problems FORMCHECKBOX Somatic Complaints FORMCHECKBOX Surgeries FORMCHECKBOX Takes MedicationsCANS Needs0: No Concerns1: Watchful Waiting2: Action3: Immediate Action/Safety PlanningCANS Score FORMTEXT ?????Medical/Physical (49)Current Medications: FORMTEXT ?????Comments: (note any past negative medication reactions) FORMTEXT ?????EducationalCurrent Grade: FORMTEXT ????? Current School: FORMTEXT ????? IEP/504 Plan: FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX No Concerns Identified FORMCHECKBOX Skipping/Poor Attendance FORMCHECKBOX Attention Problems FORMCHECKBOX Social/Behavioral Problems FORMCHECKBOX Falling/Low Grades FORMCHECKBOX Suspensions/Expulsions FORMCHECKBOX Overachievement FORMCHECKBOX Underachievement FORMCHECKBOX Other (see comments)CANS Needs0: No Concerns1: Watching Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS ScoreCANS Score FORMTEXT ?????School Behavior (52) FORMTEXT ?????School Attendance (53) FORMTEXT ?????School Achievement (54)Comments: (school contact person) FORMTEXT ?????Social FORMCHECKBOX No Concerns Identified FORMCHECKBOX Hurts Animals FORMCHECKBOX Unable to keep friends FORMCHECKBOX Acts young for age FORMCHECKBOX Isolates Self/Withdrawn FORMCHECKBOX Vandalism FORMCHECKBOX Acts mature for age FORMCHECKBOX Lying FORMCHECKBOX Other (see comments) FORMCHECKBOX Exposure to weapons FORMCHECKBOX Argumentative/Defiant FORMCHECKBOX Stealing FORMCHECKBOX Gang Interest/Involvement CANS Needs0: No Concerns1: Watching Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Delinquent Behavior (6) FORMTEXT ?????Decision Making (7) FORMTEXT ?????Social Functioning (43) FORMTEXT ?????Recreational (47) FORMTEXT ?????Sexual Development (51) FORMTEXT ?????Situational Consistency of Challenges (67)Comments: (Peer relational difficulties, adult relational difficulties, early social deficits) FORMTEXT ?????Cultural ConsiderationsCANS Needs0: No Concerns1: Watching Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Language (55) FORMTEXT ?????Cultural Identity (56) FORMTEXT ?????Cultural Events and Activities (57) FORMTEXT ?????Cultural Stress (58)Comments: (Language/Ethnic/Cultural/Religion/Spirituality/family traditions/sexual identity/gender identity) FORMTEXT ?????Legal FORMCHECKBOX No Concerns Identified FORMCHECKBOX Custody of DHS FORMCHECKBOX Juvenile Department FORMCHECKBOX Custody of OYACANS Needs0: No Concerns1: Watching Waiting2: Action3: Immediate Action/Safety PlanningCANS Score FORMTEXT ?????Legal (48)Comments: FORMTEXT ?????Exposure to Traumatic/Adverse Childhood ExperiencesYes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Yes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sexual Abuse (21)Physical Abuse (22)Emotional/Verbal Abuse (23)Neglect (24)Medical Trauma (25)Witness to Family Violence (26)Witness to Community/School Violence (27)War Affected (28)Terrorism Affected (29)Witness/Victim of Criminal Activity (30)Parental Criminal Behavior (31)Disruption in Caregiving/Attachment Losses (32)Comments: (Additional trauma not captured on the CANS would be listed here) FORMTEXT ?????Traumatic Stress SymptomsCANS Needs0: No Concerns1: Watching Waiting2: Action3: Immediate Action/Safety PlanningCANS ScoreCANS Score FORMTEXT ?????Reaction to Traumatic Life Experiences (33) FORMTEXT ?????Traumatic Grief and Separation (34) FORMTEXT ?????Intrusion/Re-Experience (35) FORMTEXT ?????Hyperarousal (36) FORMTEXT ?????Attempts to Avoid Stimuli (37) FORMTEXT ?????Numbing (38) FORMTEXT ?????Dissociation (39) FORMTEXT ?????Emotional and/or Physical Regulation (40)Comments: (onset, precipitating factors, duration, intensity & frequency) FORMTEXT ?????Substance UseCANS Needs0: No Concerns1: Watching Waiting2: Action3: Immediate Action/Safety PlanningCANS Score FORMTEXT ?????Substance Use (63)SubstanceFreq. of useAmount of useDuration of PatternRoute of Admin.Date of last use FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Family history of substance use: FORMCHECKBOX YES FORMCHECKBOX NOIf client meets criteria for substance use disorder: Recommend Service Needs: FORMTEXT ?????Risk of Harm: FORMTEXT ?????Referrals to be Made: FORMTEXT ?????Comments: FORMTEXT ????? Agencies and Service Providers Currently Involved with Individual and Family FORMCHECKBOX No Concerns Identified FORMCHECKBOX Oregon Youth Authority FORMCHECKBOX A&D Provider FORMCHECKBOX Juvenile Department FORMCHECKBOX Medical Provider FORMCHECKBOX Other Mental Health Provider FORMCHECKBOX Wraparound FORMCHECKBOX Other (See Comments) FORMCHECKBOX DHS CANS Needs0: No Concerns1: Watchful Waiting2: Action3: Immediate Action/Safety PlanningCANS Score FORMTEXT ?????Service Permanence (69)Comments: (names & contact information including school contact) FORMTEXT ?????Current Mental Status:Appearance: Choose an item.Psychomotor: Posture: Choose an item. Coordination: Choose an item. Gait: Choose an item. Manner: Choose an item. Eye Contact: Choose an item.Intellect:Attention/Concentration: Choose an item. Fund of Knowledge: Choose an item. Judgment: Choose an item. Insight: Choose an item. Memory: Choose an item. Abstraction: Choose an item.Speech:Volume: Choose an item. Rate: Choose an item. Clarity: Choose an item. Rhythm: Choose an item.Thought:Clarity: Choose an item. Flow: Choose an item. Content: Choose an item. Orientation: Choose an item.Affect:Expression: Choose an item. Attitude: Choose an item. Mood: Choose an item. Range: Choose an item.Sleep: Choose an item. Appetite: Choose an item. Activity: Choose an item. Social Contact: Choose an ments: FORMTEXT ?????Clinical Formulation: (must include strengths, diagnostic justification with DSM criteria and prognosis) FORMTEXT ?????Diagnostic Impression (DSMV & ICD-10)Primary Diagnosis (F code and Diagnosis): FORMTEXT ?????Problem in Functioning (Z code and Diagnosis): FORMTEXT ?????Medical Conditions: FORMTEXT ?????ACE Score for Client: FORMTEXT ????? ACE Score for Parent 1: FORMTEXT ????? ACE Score for Parent 2: FORMTEXT ?????Level of Care FORMCHECKBOX Level 1 – 120 days FORMCHECKBOX Level 2 – 270 days FORMCHECKBOX Level 3 – 364 daysTreatment Recommendations:Services:Referrals: FORMCHECKBOX Individual Therapy FORMCHECKBOX Alcohol/Drug Referral FORMCHECKBOX Family Therapy FORMCHECKBOX DD Services Referral FORMCHECKBOX Group Therapy FORMCHECKBOX MVWRAP Referral FORMCHECKBOX Psychiatric Evaluation/Medication Management FORMCHECKBOX Psychological Evaluation/Testing FORMCHECKBOX Skills Training FORMCHECKBOX Other (see comments)Comments: FORMTEXT ?????Clinician Signature: _______________________________________________Date: FORMTEXT ????? Clinician Printed Name/Credentials: FORMTEXT ?????LMP Signature: __________________________________________________ Date: FORMTEXT ?????LMP Designee Signature: __________________________________________ Date: FORMTEXT ????? FORMCHECKBOX Initial InformationDate: FORMTEXT ????? FORMCHECKBOX Change *Date: FORMTEXT ????? FORMCHECKBOX DischargeDate: FORMTEXT ?????Mental Health InformationClient NameDate of BirthOHP IDPCP FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Your patient is receiving services at our agencyIf you have questions or want additional information, including the assessment or treatment plan, please contact:Clinician/Therapist/Case Manager/Service CoordinatorChoose an item.Presenting Issues/Diagnosis FORMTEXT ?????MedicationsPrescriber: FORMTEXT ?????Tel: FORMTEXT ?????Email: FORMTEXT ?????MedicationDosage/FrequencyPrescribed to Address . . . FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????* Describe Change(s) FORMTEXT ?????If you patient is receiving psychiatric medications, we will stabilize them appropriate to their condition. Once your patient is on a stable medication regimen, we will contact you to discuss transitioning them back to you for continued prescribing of their psychotropic medications. We will continue to be available for consultation and support and immediate return to services if you patient’s needs change.Note: Please fax ongoing lab results and/or medication changes to us for coordination of care.-13335-165735Level of Care- Child & YouthAges 0-5Name: FORMTEXT ????? DOB: FORMTEXT ????? Program: Choose an item. Screener: FORMTEXT ????? Date: FORMTEXT ????? LOC Assessed: Choose an item. Authorization Length: Choose an item Explain any deviation from the derived LOC assessed and the determined services being recommended:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________LEVEL 1 - OUTPATIENT SERVICES: FORMCHECKBOX Covered diagnosis on the prioritized list; AND meeting at least one criteria from 1 or 2. FORMCHECKBOX Transition from higher level of care; stepdown to maintain treatment gains; FORMCHECKBOX A rating of “2” or “3” on at least 1 of the following (in any column)SAFETY/RISKFUNCTIONINGENVIRONMENT/RELATIONSHIP FORMCHECKBOX Self Harm (#5) FORMCHECKBOX Reaction to Traumatic Life Experiences (#27) FORMCHECKBOX Parent or Sibling Challenges (#4) FORMCHECKBOX Aggressive Behavior (#6) FORMCHECKBOX Preschool/Daycare Behavior (#37) FORMCHECKBOX Traumatic Grief & Separation (#28) FORMCHECKBOX Sexual Behavior (#7) FORMCHECKBOX Social Functioning (#39) FORMCHECKBOX Family Functioning (#35) FORMCHECKBOX Recreational/Play (#40) FORMCHECKBOX Living Situation (#36) FORMCHECKBOX Sleep (#46) FORMCHECKBOX Cultural Stress (#52) FORMCHECKBOX Impulsivity/Hyperactivity (#54) FORMCHECKBOX Attachment Difficulties (#53) FORMCHECKBOX Temperament (#55) FORMCHECKBOX Depression (#58) FORMCHECKBOX Anxiety (#59) FORMCHECKBOX Atypical Behaviors (#60)LEVEL 2 - INTENSIVE OUTPATIENT SERVICES: FORMCHECKBOX Covered diagnosis on the prioritized list; AND meeting at least one criteria from 1 or 2 FORMCHECKBOX Discharge from an Acute, Subacute or Psychiatric Residential treatment facility within the last 6 months FORMCHECKBOX Meeting criteria for both A & BA rating of “2” or “3” on at least 2 of the following (in any column);SAFETY/RISKENVIRONMENT/RELATIONSHIP FORMCHECKBOX Self Harm (#5) FORMCHECKBOX Parent or Sibling Challenges (#4) FORMCHECKBOX Aggressive Behavior (#6) FORMCHECKBOX Traumatic Grief & Separation (#28) FORMCHECKBOX Sexual Behavior (#7) FORMCHECKBOX Family Functioning (#35) FORMCHECKBOX Living Situation (#36) FORMCHECKBOX Cultural Stress (#52) FORMCHECKBOX Attachment Difficulties (#53) ANDA rating of “2” or “3” on at least 3 of the followingFUNCTIONING FORMCHECKBOX Reaction to Traumatic Life Experiences (#27) FORMCHECKBOX Preschool/Daycare Behavior (#37) FORMCHECKBOX Social Functioning (#39) FORMCHECKBOX Recreational/Play (#40) FORMCHECKBOX Sleep (#46) FORMCHECKBOX Impulsivity/Hyperactivity (#54) FORMCHECKBOX Temperament (#55) FORMCHECKBOX Depression (#58) FORMCHECKBOX Anxiety (#59) FORMCHECKBOX Atypical Behaviors (#60)LEVEL 3 - INTENSIVE INTEGRATED SERVICES: FORMCHECKBOX Covered diagnosis on the prioritized list; AND meeting at least one criteria from 1, 2, or 3 FORMCHECKBOX Discharge from an Acute, Subacute or Psychiatric Residential treatment facility within the last 3 months; FORMCHECKBOX Multiple system involvement requiring care coordination and intensive case management; AND FORMCHECKBOX A rating of “2” or “3” on 2 or more of the following;SAFETY/RISK FORMCHECKBOX Self Harm (#5) FORMCHECKBOX Aggressive Behavior (#6) FORMCHECKBOX Sexual Behavior (#7) FORMCHECKBOX Multiple system involvement requiring care coordination and intensive case management; AND meeting criteria for both A & B A rating of “2” or “3” on at least 2 of the following (in any column); SAFETY/RISKENVIRONMENT/RELATIONSHIP FORMCHECKBOX Self Harm (#5) FORMCHECKBOX Parent or Sibling Challenges (#4) FORMCHECKBOX Aggressive Behavior (#6) FORMCHECKBOX Traumatic Grief & Separation (#28) FORMCHECKBOX Sexual Behavior (#7) FORMCHECKBOX Family Functioning (#35) FORMCHECKBOX Living Situation (#36) FORMCHECKBOX Cultural Stress (#52) FORMCHECKBOX Attachment Difficulties (#53) ANDA rating of “2” or “3” on at least 3 of the followingFUNCTIONING FORMCHECKBOX Reaction to Traumatic Life Experiences (#27) FORMCHECKBOX Preschool/Daycare Behavior (#37) FORMCHECKBOX Social Functioning (#39) FORMCHECKBOX Recreational/Play (#40) FORMCHECKBOX Sleep (#46) FORMCHECKBOX Impulsivity/Hyperactivity (#54) FORMCHECKBOX Temperament (#55) FORMCHECKBOX Depression (#58) FORMCHECKBOX Anxiety (#59) FORMCHECKBOX Atypical Behaviors (#60)Level of Care- Child & YouthAges 6-20Name: FORMTEXT ????? DOB: FORMTEXT ????? Program: Choose an item. Screener: FORMTEXT ????? Date: FORMTEXT ????? LOC Assessed: Choose an item. Authorization Length: Choose an item Explain any deviation from the derived LOC assessed and the determined services being recommended: ___ Youth has been enrolled in ISS services for 11 months and is expected to show improvement in several areas for level of need. Team process will determine when it is appropriate for a successful and mindful transition out of ISS services. _____________________________________________________________________________________________________________________________________________________________________________________LEVEL 1 - OUTPATIENT SERVICES: FORMCHECKBOX Covered diagnosis on the prioritized list; AND meeting at least one criteria from 1, 2, or 3 FORMCHECKBOX Transition from higher level of care; stepdown to maintain treatment gains; FORMCHECKBOX Ongoing medication management needed to maintain treatment gains; FORMCHECKBOX A rating of “2” or “3” on at least 1 of the following (in any column)SAFETY/RISKFUNCTIONINGENVIRONMENT/RELATIONSHIP FORMCHECKBOX Suicide Risk (#1) FORMCHECKBOX Reactions to Traumatic Life Experiences (#33) FORMCHECKBOX Traumatic Grief & Separation (#34) FORMCHECKBOX Non-Suicidal Self-Injurious Behavior (#2) FORMCHECKBOX Emotional and/or Physical Regulation (#40) FORMCHECKBOX Family Functioning (#41) FORMCHECKBOX Other Self Harm/ Recklessness (#3) FORMCHECKBOX Social Functioning (#43) FORMCHECKBOX Living Situation (#42) FORMCHECKBOX Danger to Others (#4) FORMCHECKBOX Self-Care/Daily Living Skills (#46) FORMCHECKBOX Cultural Stress (#58) FORMCHECKBOX Decision Making (#7) FORMCHECKBOX Sleep (#50) FORMCHECKBOX Attachment Difficulties (#64) FORMCHECKBOX Fire-Setting (#8) FORMCHECKBOX Sexual Development (#51) FORMCHECKBOX Sexually Aggressive Behavior (#9) FORMCHECKBOX School Behavior (#52) FORMCHECKBOX Anger Control (#66) FORMCHECKBOX School Achievement (#54) FORMCHECKBOX Impulsivity/Hyperactivity (#59) FORMCHECKBOX Depression and Anxiety (#60) FORMCHECKBOX Psychosis (Thought Disorder) (#61) FORMCHECKBOX Oppositional (Non-Compliance With Authority) (#62) FORMCHECKBOX Eating Disturbances (#65)LEVEL 2 - INTENSIVE OUTPATIENT SERVICES: FORMCHECKBOX Covered diagnosis on the prioritized list; AND meeting at least one criteria from 1 or 2 FORMCHECKBOX Discharge from an Acute, Subacute or Psychiatric Residential treatment facility within the last 6 months; FORMCHECKBOX Meeting criteria for both A & BA rating of “2” or “3” on at least 2 of the following (in any column); SAFETY/RISKENVIRONMENT/RELATIONSHIP FORMCHECKBOX Suicide Risk (#1) FORMCHECKBOX Traumatic Grief & Separation (#34) FORMCHECKBOX Non-Suicidal Self-Injurious Behavior (#2) FORMCHECKBOX Family Functioning (#41) FORMCHECKBOX Other Self Harm/Recklessness (#3) FORMCHECKBOX Living Situation (#42) FORMCHECKBOX Danger to Others (#4) FORMCHECKBOX Cultural Stress (#58) FORMCHECKBOX Decision Making (#7) FORMCHECKBOX Attachment Difficulties (#64) FORMCHECKBOX Fire-Setting (#8) FORMCHECKBOX Sexually Aggressive Behavior (#9) FORMCHECKBOX Anger Control (#66) ANDA rating of “2” or “3” on at least 3 of the followingFUNCTIONING FORMCHECKBOX Reactions to Traumatic Life Experiences (#33) FORMCHECKBOX Emotional and/or Physical Regulation (#40) FORMCHECKBOX Social Functioning (#43) FORMCHECKBOX Self-Care/Daily Living Skills (#46) FORMCHECKBOX Sleep (#50) FORMCHECKBOX Sexual Development (#51) FORMCHECKBOX School Behavior (#52) FORMCHECKBOX School Achievement (#54) FORMCHECKBOX Impulsivity/Hyperactivity (#59) FORMCHECKBOX Depression and Anxiety (#60) FORMCHECKBOX Psychosis (Thought Disorder) (#61) FORMCHECKBOX Oppositional (Non-Compliance with Authority) (#62) FORMCHECKBOX Eating Disturbances (#65)LEVEL 3 - INTENSIVE INTEGRATED SERVICES: FORMCHECKBOX Covered diagnosis on the prioritized list; AND meeting at least one criteria from 1, 2, or 3 FORMCHECKBOX Discharge from an Acute, Subacute or Psychiatric Residential treatment facility within the last 3 months; FORMCHECKBOX Multiple system involvement requiring care coordination and intensive case management; AND FORMCHECKBOX A rating of “2” or “3” on 3 or more of the following; SAFETY/RISK FORMCHECKBOX Suicide Risk (#1) FORMCHECKBOX Non-Suicidal Self-Injurious Behavior (#2) FORMCHECKBOX Other Self Harm/Recklessness (#3) FORMCHECKBOX Danger to Others (#4) FORMCHECKBOX Decision Making (#7) FORMCHECKBOX Fire-Setting (#8) FORMCHECKBOX Sexually Aggressive Behavior (#9) FORMCHECKBOX Anger Control (#66) FORMCHECKBOX Multiple system involvement requiring care coordination and intensive case management; AND meeting criteria for both A & BA rating of “2” or “3” on at least 3 of the following (in any column); SAFETY/RISKENVIRONMENT/RELATIONSHIP FORMCHECKBOX Suicide Risk (#1) FORMCHECKBOX Traumatic Grief & Separation (#34) FORMCHECKBOX Non-Suicidal Self-Injurious Behavior (#2) FORMCHECKBOX Family Functioning (#41) FORMCHECKBOX Other Self Harm/Recklessness (#3) FORMCHECKBOX Living Situation (#42) FORMCHECKBOX Danger To Others (#4) FORMCHECKBOX Cultural Stress (#58) FORMCHECKBOX Decision Making (#7) FORMCHECKBOX Attachment Difficulties (#64) FORMCHECKBOX Fire-Setting (#8) FORMCHECKBOX Sexually Aggressive Behavior (#9) FORMCHECKBOX Anger Control (#66) ANDB- A rating of “2” or “3” on at least 4 of the followingFUNCTIONING FORMCHECKBOX Reactions to Traumatic Life Experiences (#33) FORMCHECKBOX Emotional and/or Physical Regulation (#40) FORMCHECKBOX Social Functioning (#43) FORMCHECKBOX Self-Care/Daily Living Skills (#46) FORMCHECKBOX Sleep (#50) FORMCHECKBOX Sexual Development (#51) FORMCHECKBOX School Behavior (#52) FORMCHECKBOX School Achievement (#54) FORMCHECKBOX Impulsivity/Hyperactivity (#59) FORMCHECKBOX Depression and Anxiety (#60) FORMCHECKBOX Psychosis (Thought Disorder) (#61) FORMCHECKBOX Oppositional (Non-Compliance with Authority) (#62) FORMCHECKBOX Eating Disturbances (#65)CBH TEAM REFERRALSClient Name: FORMTEXT ?????RT#: FORMTEXT ?????DOB: FORMTEXT ?????Level of Care: FORMTEXT ????? INFO Comments \* MERGEFORMAT INFO Comments \* MERGEFORMAT Who should be contacted for scheduling appointments? Name: FORMTEXT ?????Contact phone number: FORMTEXT ?????School Based Services: Yes FORMCHECKBOX No FORMCHECKBOX If yes, which school: FORMDROPDOWN Intake Therapist Keeping the Case: Yes FORMCHECKBOX No FORMCHECKBOX 1st Appointment Already Scheduled? Yes FORMCHECKBOX No FORMCHECKBOX Spanish Speaking? Yes FORMCHECKBOX No FORMCHECKBOX Other Language: FORMTEXT ?????Prescriber Referral Made? Yes FORMCHECKBOX No FORMCHECKBOX Open/Close Assessment Only: Yes FORMCHECKBOX No FORMCHECKBOX YFCS Referral to COP: Yes FORMCHECKBOX No FORMCHECKBOX DHS Referral to COP: Yes FORMCHECKBOX No FORMCHECKBOX Additional Notes: FORMTEXT ????? FORMCHECKBOX Alberto Vazquez, MA, LPCi, QMHP FORMCHECKBOX Lupita Pena-Baltazar, MSW, QMHP FORMCHECKBOX Erin Ahlquist, NCC, LPC FORMCHECKBOX Joel Rosano-Alvarez, MA, QMHP FORMCHECKBOX Eleni Speropulos, MA, QMHP, LMFTi FORMCHECKBOX Micheen Panosh, MSW, QMHP FORMCHECKBOX Jennifer Helms, MA, QMHP FORMCHECKBOX Mariana Barrera, FORMCHECKBOX Keith Irwin, LPC, MA, QMHP FORMCHECKBOX FORMCHECKBOX Margie Braaten, BS, QMHP FORMCHECKBOX FORMCHECKBOX Maria Cardenas, MSW, QMHP FORMCHECKBOX FORMCHECKBOX Christopher David, MS LMFTintern QMHP FORMCHECKBOX FORMCHECKBOX Kiri Horsey, NCC, LPC FORMCHECKBOX Adam Bird FORMCHECKBOX Esthela Mitchell, LMFT, QMHP FORMCHECKBOX FORMCHECKBOX Erica Alonzo-Leon, MSW, QMHP FORMCHECKBOX Intern: FORMTEXT ????? FORMCHECKBOX COP FORMCHECKBOX PCITO FORMCHECKBOX PCITG FORMCHECKBOX FATC FORMCHECKBOX LATG FORMCHECKBOX STAR FORMCHECKBOX Phil Blea FORMCHECKBOX Jason Tate FORMCHECKBOX Viri Pozos FORMCHECKBOX Erin Ahlquist FORMCHECKBOX Mechelle MillmakerDate: FORMTEXT ?????Date of Transfer: FORMTEXT ?????Level of Care Form FORMCHECKBOX By (Initials): FORMTEXT ?????Changes made to: FORMCHECKBOX Raintree FORMCHECKBOX IPA FORMCHECKBOX H:Drive/Client foldersAdverse Childhood Experience (ACE) QuestionnaireName(s): FORMTEXT ?????RT#: FORMTEXT ?????Date: FORMTEXT ?????While you were growing up, during your first 18 years of life:Parent ‘yes’Parent ‘no’Youth ‘yes’Youth ‘no’1. Did a parent or other adult in the household often …Swear at you, insult you, put you down, or humiliate you?orAct in a way that made you afraid that you might be physically hurt?2. Did a parent or other adult in the household often … Push, grab, slap, or throw something at you?orEver hit you so hard that you had marks or were injured?3. Did an adult or person at least 5 years older than you ever…Touch or fondle you or have you touch their body in a sexual way?orTry to or actually have oral, anal, or vaginal sex with you?4. Did you often feel that …No one in your family loved you or thought you were important or special?orYour family didn’t look out for each other, feel close to each other, or support each other?5. Did you often feel that …You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?orYour parents were too drunk or high to take care of you or take you to the doctor if you needed it?6. Were your parents ever separated or divorced?7. Was your mother or stepmother:Often pushed, grabbed, slapped, or had something thrown at her?orSometimes or often kicked, bitten, hit with a fist, or hit with something hard?orEver repeatedly hit over at least a few minutes or threatened with a gun or knife?8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?9. Was a household member depressed or mentally ill or did a household member attempt suicide?10. Did a household member go to prison?Total up the ‘yes’ answers to show your ‘ACE’ scoreCual?es?el?puntuage?de?mi?ACE?(Experiencias?Adversas?Durante?la?Ni?ez)??Nombre:_____________________ RT#:____________________ Fecha:________________Antes?de?tus?18?anos:?Padres "sí"Padres "no"Ni?o[a] "sí"Ni?o[a] "no"1.Alguno?de?tus?padres?o?algun?otro?adulto?en?tu?casa?frequentement?o?muy??frequentemente... ?Te?grito,?insultó,?te?hizo?sentir?menos,?o?te?humillo??O?Se?comporto?de?alguna?manera?que?hizo?que?sintieras?miedo?o?que?te?sintieras?fisicamante?herido??2.Alguno?de?tus?padres?o?algun?otro?adulto?en?tu?hogar?frequentemente?o?muy?frequentemente…? ?Te?empujó,?te?agarro?bruscamente,?te?dio?una?bofetada,?o?te?tiro?con?algo??O?Te?golpeo?tan?fuerte?que?te?dejo?marcas?o?heridas??3.Algun?adulto?u?otra?persona?por?lo?menos?5?a?os?mas?grande?que?tu?alguna?vez….. ?Toco?tu?cuerpo?o?te?obligo?a?tocar?su?cuerpo?de?una?manera?sexual??O?Atentó?o?tuvo?sexo?oral,?anal,?o?vaginal?contigo??4. Sientes?frequentemente?o?muy?frequentemente?…?Que?nadie?en?tu?familia?te?ha?querido?o?que?ha?pensado?que?eres?importante?o?especial??O?En?tu?familia?no?se?protegían?mutuamente,?o?eran?cercanos?unos?a?otros,?o?se?apoyaban?mutuamente??5. Sientes?frequentemente?o?muy?frequentemente?…?Que?no?tienes?suficiente?comida,?que?tienes?que?usar?ropa?sucia,?o?que?no?tienes?quien?te?proteja??O?Que?tus?padres?estaban?muy?tomados?o?drogados?para?cuidarte?or?llevarte?al?doctor?si?fuera?necesario??6.Perdiste?alguno?de?tus?padres?biologicos?como?resultado?de?divorcio,?abandono,?o?alguna?otra?razon??7.Tu?mama?o?madrasta?alguna?vez:?Frequentemente?or?muy?frequentement?la?empujaron,?la?agarraron ?bruscamente,?le?dieron?una?bofetada,?o?le?tiraron?con?algun?objecto??O?De?vez?en?cuando,?frequentemente,?o?muy?frequentemente?la?patearon,?mordieron,?le?pegaron?con?el?puno,?o?le?pegaron?con?algun?objeto?duro??O?Alguna?vez?la?golpearon?repetidamente?for?algunos?minutos?o?amenazaron?con?pistola?o?cuchillo??8.Haz?vivido?con?alguien?que?tiene?problemas?con?el?alcohol,?que?es/fue?alcoholico,?o?que?uso?drogas??9.Algun?miembro?de?tu?hogar,?sufria?de?depression?o?enfermedad?mental,?o?algun?miembro?de?tu?hogar?intentó?suicidarse??10.?Alguien?de?tu?hogar?estuvo?en?prision??Sume el total de las respuestas "sí" para mostrar su puntuación de 'ACE'MARION COUNTY HEALTH & HUMAN SERVICES CHILDREN’S BEHAVIORAL HEALTH SERVICESService Plan FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Client’s NameRaintree ID#Date of BirthAssigned Therapist: FORMTEXT ?????_____________________ If applicable, please refer to the client’s file for current medication(s) prescribed by this agency. Crisis Plan: In case of a mental health crisis, I will call: This agency (Children’s Behavioral Health): 503 981 5851 or (TAY): 503-576-4600 Youth & Family Crisis Services 503-576-4673; 3)Crisis Hotline: 503-581-5535. Refer to the mental health assessment form for client’s status on legal, education, strengths, family, physical health, and social domains/areas, and identified current and natural supports that will occur throughout treatment.Start DateClient’s PresentingIssue / ProblemTreatment GoalObjective/Action Plan FORMTEXT ????? FORMCHECKBOX Adjustment Do FORMCHECKBOX ADHD FORMCHECKBOX Mood Do FORMCHECKBOX Oppositional Do FORMCHECKBOX Anxiety Do FORMCHECKBOX Trauma/PTSD FORMCHECKBOX Alcohol/Drugs FORMCHECKBOX Other_____________________________For the client to engage in treatment, build rapport with therapist, and decrease problematic symptoms.-The client will meet with assigned therapist to assess and establish specific tx goal(s) to be determined within 45 days.If recommended:-Refer client to A & D Srvcs.-Refer client to Intnsv Srvcs.Treatment complete/discharge criteria: The client will be able to maintain personal stability, as well as stability at home with care providers, at school, and in the community without the help of this agency.Services/Activities[Tx issues from above]Person Responsible(Provider)Frequency (Weekly, Monthly)Duration(Minutes)1. FORMCHECKBOX Individual TherapyClient and QMHP1 - 4 x per month 30 - 90 mins FORMCHECKBOX Family TherapyClient and QMHP1 - 4 x per month30 - 90 mins FORMCHECKBOX GroupQMHP, QMHA1 x per week60 - 90 mins FORMCHECKBOX Med Srvcs.Rxer, Client, Guardian1 x per month30 - 90 mins FORMCHECKBOX Case Mgmt. QMHP, QMHA2-4 x per month15-60 mins FORMCHECKBOX Skills Trng.QMHA1-4x per month60-90 mins FORMCHECKBOX A & D Tx RfrlClient and TherapistTBDTBD FORMCHECKBOX Mission Trans RfrlClient and TherapistTBDTBDSIGNATURES: Client: __________________________________________Date: Legal Guardian: ___________________________________________ Date: ___________Therapist: ____________________________________________________Date:Medical Practitioner (LCSW, PMHNP, MD): _________________________Date: ___________Printed Name & Credentials of Therapist: _______________________________________Date: ___________ ................
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