5-18 | Wrap CT

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

Emotional/Behavioral (Symptoms such as: increased sadness, frequent tearfulness, excessive worry, irritability, not enjoying things they used to, grief/loss, reaction to trauma, acting out behaviors, not following rules, destroying things, angry outbursts, hitting or threatening, running away, high family conflict)

Drug/Alcohol Use (including misuse of prescriptions)

Both emotional/behavioral AND drug/alcohol use (including prescription misuse)

Unusual thoughts (question about disordered thinking/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.

Eating Problems

Concerns about Autism

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/behavioral difficulties are highly disruptive at home, in school and/or in the community. Concerns may include: my child has been arrested and/or is on probation; 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

Is your child currently in treatment?

Yes

Do you have any of the following specific areas of concern:

Increasing SUICIDAL thoughts (but NOT IMMEDIATE threat) NOTE: If immediate threat, call 988 for CRISIS assistance

Disordered thinking/Psychosis - Such as: hallucinations (seeing/hearing/smelling things that are not there); delusions (odd/false beliefs that seem real to them); high level of suspicion or mistrust.

Legal Issues- My child is court involved and/or is on probation.

Problem Sexual Behavior e.g. Taking advantage of others sexually; forcing sexual contact; sexualized threats; repeated engagement in risky sexual behavior/activities on social media or text; receiving money or goods for sex; arrested or at risk of arrest for sexual behavior; voyeurism (exposing self or spying on others)

My child has been diagnosed with autism

My child has been diagnosed with other developmental or intellectual disability

None of the above apply

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 - 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

Have you attempted treatment before?

Yes

Is there any Opioid use?

Yes

Severity of Concern:

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: Multisystemic Therapy (MST) or Multidimensional Family Therapy (MDFT)

Substance use primary, behavioral acting out secondary

Behavioral acting out primary, substance use secondary

Is this a new concern?

Yes

No my child has been diagnosed and/or is/has been in treatment for disordered thinking/psychosis

Does your child currently have a diagnosis of Autism?

Yes

Which best describes current concerns:

Child's behavior is safe, but they need therapy to help with their adjustment at home or school. (wording to make this parent friendly?)

Child is able to be kept safe with increased support, but is showing increasingly challenging behavior that is seriously impacting school or hoe life such as self-injury, aggression, property destruction, and/or school refusal.