EXPANDED VERSION DRAFT ::PROVIDER “8/21”

How old is your child?

0-5

5-18

18-22

What best describes your main concern for your child?

Development (physical, cognitive, social)

Emotional Distress - (grief/loss, trauma, regression to former behaviors, significant changes in sleep/eating, high irritability, inactive or hyperactive, more afraid of things, clinging to adults, increased/frequent crying, angry outbursts)

Behavior Problems: (acting out behaviors, not following rules for safety, destroying things, hitting or threatening)

Severity of Concern

MILD - My child does not have prior treatment history and/or their symptoms have limited impact on daily life

MODERATE - My child has symptoms that negatively impact their daily functioning at home and/or school

SEVERE

Severity of Concern:

MILD -My child does not have prior treatment history and/or their symptoms have limited impact on daily life

MODERATE -My child has symptoms that negatively impact their daily functioning at home and/or school

SEVERE -My child's emotional/behavioral difficulties are highly disruptive at home, in school and/or in the community; my child has a significant psychiatric diagnosis and/or is at risk of out-of-home placement/hospitalization or is being discharged from a hospital or out-of-home placement and we will need a high level of therapeutic support

What best describes your main concern for your child?

Crisis - You feel your child is in IMMEDIATE danger; talking about hurting themselves or someone else

Trauma - my child has recently (within the past 6 months) experienced something traumatic and needs help processing the event (wording?)

Emotional Distress (depression, anxiety, tearfulness, excessive worry, irritability, not enjoying things they used to, grief/loss, trauma)

Behavioral Problems: (acting out behaviors, not following rules for safety, destroying things, angry outbursts, hitting or threatening, running away)

Drug and/or Alcohol Use

Both emotional/behavioral health concern(s) AND drug and/or alcohol use

Eating Problems

Developmental disability and/or concerns about Autism

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Severity of Concern (trauma symptoms may include: avoiding certain places/people, sleep difficulties, difficulty with concentration, physical symptoms like sweating, heart racing, feeling sick without medical reasons, feeling isolate or not connected to others)

MILD ( one or two of above symptoms)

MODERATE (two to three of above symptoms)

SEVERE (four or more of the above, or symptoms are getting in the way of typical daily activities)

Severity of Concern

MILD - My child does not have prior treatment history and/or their symptoms have limited impact on daily life

MODERATE - My child has symptoms that are negatively impacting their daily life in at least one area (school, home, relationships).

SEVERE - My child's emotional difficulties are highly disruptive at home, in school and/or in the community; my child has a significant psychiatric diagnosis and/or is at risk of out-of-home placement/hospitalization or is being discharged from a hospital or out-of-home placement and we will need a high level of therapeutic support

Has your child received services before?

Yes

My child is displaying:

Severe Depression - I am concerned about my child having suicidal thoughts (wording?)

Psychosis - For example.: Confused thinking, odd/false beliefs that seem real to them, seeing/hearing/smelling things that are not there, high level of suspicion or mistrust.

Neither of the above.

Severity of Concern

MILD - My child does not have prior treatment history and/or their symptoms have limited impact on daily life

MODERATE - My child has symptoms that are negatively impacting their daily life in at least one area (school, home, relationships).

SEVERE - My child's behavioral difficulties are highly disruptive at home, in school and/or in the community; my child has a significant psychiatric diagnosis and/or is at risk of out-of-home placement/hospitalization or is being discharged from a hospital or out-of-home placement and we will need a high level of theraputic support

Has your child received treatment (therapy?) before?

Yes

My child is displaying:

Drug and/or Alcohol Use

Problem Sexual Behavior - Taking advantage of or assaulting others sexually.

Psychosis - For example.: Confused thinking, odd/false beliefs that seem real to them, seeing/hearing/smelling things that are not there, high level of suspicion or mistrust.

Getting into trouble with the law

Other

Is there any Opioid use?

Yes

Is your child currently on probation?

Yes

Is there any Opioid use?

Yes

Severity of Concern

MILD - My child is using drugs or alcohol, but the use is not frequent and/or there have not been any serious consequences.

MODERATE- My child's use of drugs or alcohol is causing problems in at least one area (at school, with peers, at home).

SEVERE - My child is using drugs or alcohol frequently and this is creating problems in multiple areas such as: school attendance/performance; relationships with peers or family; illegal activities; high risk behaviors; or I am concerned that my child would not be able to stop using drugs or alcohol even if they wanted to.

Have you attempted treatment before?

Yes

Is there any Opioid use?

Yes

Severity of Concern:

MILD

MODERATE My child's drug and/or alcohol use and other problem behaviors have been increasing; there is quite a bit of tension at home.

SEVERE My child is at high risk for negative outcomes including injury, criminal justice involvement , school drop out, risk of drug overdose event, any opioid use; high risk of out-of-home placement or returning to community from placement

Consider either: Multi-Systemic Therapy (MST) or Multi-Dimensional Family Therapy (MDFT)

Substance use primary, behavioral acting out secondary

Behavioral acting out primary, substance use secondary

Severity of Concern

Mild

Moderate

Severe

Does your child currently have a diagnosis? (needs defining)

Yes

What best describes your main concern?

Crisis My child is in IMMEDIATE danger; talking about hurting themselves or someone

Psychosis - For example: Confused thinking, odd/false beliefs that seem real to them, seeing/hearing/smelling things that are not there, high level of suspicion or mistrust.

Emotional Distress and/or Behavioral Problems - Depression, anxiety, tearfulness, excessive worry, irritability, not enjoying things they used to, acting out behaviors, not following rules for safety, destroying things, angry outbursts, hitting or threatening

Substance use

Both emotional/behavioral health concern(s) AND drug/alcohol use

Eating Problems

Severity of Concern

MILD- No prior therapy and/or a new concern that I'm noticing: the symptoms have limited impact on daily life

MODERATE- Symptoms are negatively impacting daily functioning(activities?) at home, school, and/or work

SEVERE - My child's behavior or emotional distress is highly disruptive at home, school, work and/or in the community; my child has a significant psychiatric diagnosis and/or is at risk of or has had multiple hospitalizations or is being discharged from a hospital and will need a high level of therapeutic support

Has your child been diagnosed with an intellectual disability and/or autism?

Yes

Select that option that best describes your child's diagnosis

Intellectual Disability

Autism Spectrum Disorder

Both Intellectual Disability and Autism spectrum disorder

Is there any Opioid use?

Yes

Severity of Concern

MILD - My child is using drugs or alcohol, but the use is not frequent and/or there have not been any serious consequences.

MODERATE- Use of drugs and/or alcohol is causing problems in at least one area of life (school, work, home, relationships)

SEVERE - Use of drugs and/or alcohol is frequent and is creating problems in multiple areas such as: school or work attendance/performance; relationships with peers or family; illegal activities; high risk behaviors; or I am concerned that my child would not be able to stop using even if they wanted to

Is there any Opioid use?

Yes

Severity of concern

MILD

MODERATE - The drug and/or alcohol use and other problem behaviors have been increasing; (draw language from ASAM)

SEVERE - high risk for negative outcomes including injury, criminal justice involvement, school drop out, risk of drug overdose event, any opioid use; high risk of out-of-home placement or is just returning to community from placement and is need of a high level of support

Severity of Concern

MILD

MODERATE

SEVERE

EXPANDED VERSION DRAFT ::PROVIDER “8/21”

How old is your child?

What best describes your main concern for your child?

My child has been diagnosed with a developmental disability or has an Autism diagnosis.

Severity of Concern

Severity of Concern:

What best describes your main concern for your child?

Severity of Concern (trauma symptoms may include: avoiding certain places/people, sleep difficulties, difficulty with concentration, physical symptoms like sweating, heart racing, feeling sick without medical reasons, feeling isolate or not connected to others)

Severity of Concern

Has your child received services before?

My child is displaying:

Severity of Concern

Has your child received treatment (therapy?) before?

My child is displaying:

Is there any Opioid use?

Is your child currently on probation?

Is there any Opioid use?

Severity of Concern

Have you attempted treatment before?

Is there any Opioid use?

Severity of Concern:

Consider either: Multi-Systemic Therapy (MST) or Multi-Dimensional Family Therapy (MDFT)

Severity of Concern

Does your child currently have a diagnosis? (needs defining)

What best describes your main concern?

Severity of Concern

Has your child been diagnosed with an intellectual disability and/or autism?

Select that option that best describes your child's diagnosis

Is there any Opioid use?

Severity of Concern

Is there any Opioid use?

Severity of concern

Severity of Concern