5-18

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

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 concern about my child having suicidal thoughts (wording?)

Psychosis - e.g. seeing or hearing things that are not real, "bizarre" beliefs or behaviors and/or has had multiple psychiatric hospitalizations

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 before?

Yes

My child is displaying:

Drug and/or Alcohol Use

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

Psychosis - e.g. seeing or hearing things that are not real, "bizarre" beliefs or behaviors and/or multiple psychiatric hospitalizations

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