Department of Family & Children’s Services

Katie A. Screening Form –Quick Guide

B. MEDICAL/MENTAL HEALTH INFORMATION
To determine full-scope Medi-CAL eligibility contact Foster Care Eligibility Hotline at (408)271-7400
E. BEHAVIORAL / MENTAL HEALTH SERVICES
  1. Is the child/youth receiving or has been assessed as needing any of the following:

In-home/placement behavioral or mental health services
  • Therapeutic Behavioral Services (TBS)
/
  • EMQ Mobile Crisis Team

  • Intensive Mental Health Services (System of Care [SOC], Full Service Partnership [FSP], etc.)
  • Wraparound/Intensive Targeted Wraparound Services (ITWS) [ie Uplift, Compadres, Odyessy, Connections, Teammates, Matrix and Seneca Plus]
  • Crisis Stabilization (Placement Services and Crisis Stabilization Response Team(PSCSRT)

Therapeutic Foster Care or Residential/group home placement
  • Intensive Treatment Foster Care Services (ITFCS)
/
  • Professional Parent Home (PP)

  • Residential/Group Home Placement - RCL 10 or above (any group home)

Psychiatric Hospitalization or 24-hr mental health treatment facility (including EMQ Crisis Services Unit (CSU) or Emergency Psychiatric Services [EPS])
Specialized Care Rate due to behavior health needs
  1. Mark any behaviors exhibited by the child/youth within the last 24 hours or last 30 days. If information is unknown, please indicate.

Questions – for Every Child/Youth
  1. Has the child/youth been a victim of general neglect, emotional abuse, exploitation or significant loss?

  • Poorly groomed,
  • Inadequately clothed,
  • Hungry, or appears malnourished.
/
  • Experienced or witnessed emotional or verbal abuse.
  • Experienced the death of a close friend or family member.
  • Exploited for the personal gain of the parent/caregiver

  1. Did this child/youth reside with a parent/caregiver with a known recent mental health, drug, and/or alcohol problem?

Might include a parent/caregiver with:
  • Might include a parent/caregiver with:
  • Severe depression,
  • Bizarre behavior,
  • Emotional instability,
/
  • History of psychiatric hospitalization,
  • Current drug and/or alcohol abuse,
  • Other mental health issue(s) of concern to you or to the parent/caregiver.

  1. Has this child/youth been a danger to himself/herself or to others?

Has harmed or has a clear desire to harm self or others. Examples of such behaviors may include:
  • Suicidal thoughts or actions;
  • Threatening to harm or actively hurting other people;
  • Attempted suicide;
  • Made suicidal gestures;
  • Expressed suicidal thoughts
/
  • Engages in play, drawing, fantasy, or storytelling with suicidal or homicidal themes.
  • Assaultive to other children or adults;
  • Reckless and puts self in dangerous situations;
  • Attempts to or has sexually assaulted or molested other children, etc.

  1. Does this child/youth exhibit unusual, uncontrollable or bizarre behaviors?
(for children/youth over 5 years consider if effect the child/youth’s current living situation or educational situation)
0 – 18 months:
  • Frequent inconsolable crying;
  • Persistent arching,
  • “Floppiness” or stiffening when held or touched;
/
  • Difficult for caregiver to console;
  • Pattern of difficulty getting to sleep or sleeping through the night (after 1 year of age).

18 – 36 months: Any of the behaviors above and/or:
  • Extremely destructive, disruptive, dangerous or violent behavior;
  • Inconsolable tantrums;
  • Persistent and intentional aggression despite reasonable adult intervention;
  • Excessive or repetitive self-stimulating behavior (e.g. rocking, masturbation, spinning in circles, finger flicking, hand flapping);
/
  • Appears to have an absence of fear, awareness of danger, or pain;
  • Prolonged crying when caregiver leaves the room or the home;
  • Rigidly focused on unusual objects, routines, or rituals;
  • Is willing to walk away to a stranger, has no selective preference for caregiver.

3 –5 years: Any of the above and/or:
  • Does not use sentences of 3 or more words; speech is unintelligible;
  • Does not play or interact with peers and/or adults;
  • Persistent, extremely poor coordination of movement (e.g. extremely clumsy);
/
  • Unusual eating patterns (e.g. refuses to eat, overeats, repetitive ingestion of nonfood items);
  • Clear and significant loss of previously attained skills (e.g. no longer talks or no longer toilet trained).

6-Adult: Observed, reported or disclosed that the child/youth has:
  • Threatened or engaged in physical or sexual assault against others;
  • Persistent chaotic, impulsive or disruptive behaviors so severe that placement is imminently threatened;
  • History or pattern of fire-setting;
  • Cruelty to animals; excessive, compulsive or public masturbation;
/
  • Hears voices, see things, or feels things that others do not (including alcohol or drug induced);
  • Repetitive body motions (e.g. head banging);
  • Involuntary repetition of words, phrases or sounds;
  • Smears feces;
  • Cutting, burning, or deep scratching of self, etc.

  1. Has the child/youth experienced physical or sexual abuse, severe neglect, been abducted or exposed to violent behavior?

  • Experienced or witnessed physical or sexual abuse or was physically injured;
  • Abducted by stranger or family members;
  • Witnessed domestic abuse, including sexual abuse or physical assault or observed torture or murder.
/
  • Parents willfully endangered child/youth’s health and well-being, intentionally failed to provide adequate food, clothing, shelter, general medical treatment, or supervision, including abandonment.

  1. Does the child/youth seem to be disconnected, depressed, excessively passive or withdrawn?

0 – 18 months:
  • Does not vocalize (e.g. “coo”), cry or smiles;
  • Does not respond to caregiver (e.g. turns away from his/her face;
  • Makes or maintains no eye contact;
/
  • Interaction with others does not appear to be pleasing); Does not respond to environment (e.g. motion, sound, light, activity, etc.);
  • Persistent and excessive feeding problems;
  • Predominantly sad, anxious or fearful mood.

18 – 36 months: any of the above and/or:
  • Fails to initiate interaction or share attention with others with whom s/he is familiar;
  • Unaware or uninvolved with surroundings; does not explore environment or play;
/
  • Does not seek caretaker/adult to meet needs (e.g. solace, play, assistance);
  • Few or no words; fails to respond to verbal cues.

3 –5 years: Any of the above and/or:
  • Does not use sentences of 3 or more words;
  • Speech is unintelligible;
  • Does not play or interact with peers and/or adults; persistent.
  • Extremely poor coordination of movement (e.g. extremely clumsy);
/
  • Unusual eating patterns (e.g. refuses to eat, overeats, repetitive ingestion of nonfood items);
  • Clear and significant loss of previously attained skills (e.g. no longer talks or no longer toilet tainted.).

Child/Youth over the age of 5 years
  1. Has the child returned from a runaway episode?

  1. Does the child/youth have problems with social adjustment?

  • Regularly involved in physical fights with other children or adults;
  • Verbally threatens people.
  • Damages possessions of self or others;
  • Runs away;
  • Truant;
/
  • Steals;
  • Regularly lies;
  • Mute;
  • History of law violations;
  • Does not seem to feel guilt after misbehavior, etc.

  1. Does this child/youth have problems making and maintaining healthy relationships?

  • Unable to form positive relationships with peers;
  • Provokes and victimizes other children;
  • Gang involvement;
/
  • Does not form bond with caregiver;
  • Has no friends, etc.

  1. Does this child/youth have problems with personal care?

  • Eats or drinks substances that are not food;
  • Regularly wets or soils self (subject to age of child);
  • Extremely poor personal hygiene;
/
  • Shows evidence of an eating disturbance (refuses to eat, binging and purging, significant weight gain or loss in short period of time).

  1. Does this child/youth have significant functional impairment?

  • Behavior interferes with ability to learn at school;
  • “Not socialized” and incapable of managing basic age appropriate skills;
/
  • Significantly delayed in language;
  • Selectively mute, etc. and no known history of developmental disorder.

  1. Does this child/youth have significant problems managing his/her feelings?

  • Severe temper tantrums;
  • Screams uncontrollably;
  • Cries often; significant and regular nightmares;
  • Difficult to console;
  • Withdrawn and uninvolved with others;
  • Whines or pouts excessively;
/
  • Regularly expresses the feeling that others are out to get him/her;
  • Worries excessively and preoccupied compulsively with minor annoyances;
  • Regularly expresses feelings of worthlessness or inferiority;
  • Frequently appears sad or depressed;
  • Constantly restless or overactive

  1. Does this child/youth have a history of psychiatric hospitalization, psychiatric care and/or prescribed psychotropic medication?

  • Has a history of psychiatric care, either inpatient or outpatient such as EPS or EMQ-CSU, or is taking prescribed psychotropic medication.

  1. Is this child/youth known to abuse alcohol and/or drugs?

  • Has this child/youth been told by friends or family that they were concerned about his/her use of alcohol and/or drugs?
  • Has this child/youth gotten into trouble (family, school, police) because of his/her use of alcohol and/or drugs?
  • Has this child/youth every physically injured himself/herself or others while under the influence of alcohol and/or drugs?

Quick Guide for Katie A. Screening/Referral Form for Mental Health Services

7/14/2014

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