Free Collaborative Systems of Care (CSOC) Summary of Strengths and Needs Assessment - Wisconsin


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Date: July 30, 2008
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State: Wisconsin
Category: Health Care
Author: DHS
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http://dhs.wisconsin.gov/forms1/f2/f22685.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-22685 (Rev. 07/2008)

STATE OF WISCONSIN Completion of this form meets the requirements of Chapter 46.56, Section 14(c) of the Wis. Stats.

COLLABORATIVE SYSTEMS OF CARE (CSOC) SUMMARY OF STRENGTHS AND NEEDS ASSESSMENT
Personally identifiable information is collected for monitoring the development of CSOC projects. All information gathered is confidential

Instructions: Complete the Summary of Strengths and Needs Assessment within 30 days of enrollment Name Child (Last, First, Middle Initial) Telephone Number Date of Birth Address Home

Social Security Number County of Residence

PLEASE LIST OTHER PEOPLE WHO LIVE IN THE HOME OF THE CHILD
Relationship to Child Name Race* Ethnicity* Date of Birth Gender Marital Status* Education Level* Mailing Address (If different from above information)

*List of Codes: Race: AI = American Indian, A = Asian, B = Black or African American, H = Native Hawaiian or Other Pacific Islander, W = White Ethnicity: H = Hispanic/Latino, NH = Not Hispanic/Latino Marital Status: Sg = Single, M = Married, Sp = Separated, D = Divorced, W = Widowed, LT = Living Together Educational Level: 01 = Elementary, 02 = Junior High, 03 = Some High School, 04 = High School Diploma/GED, 05 = Some College, 06 = College Degree 07 = Some Graduate School, 08 = Masters, 09 = Ph.D., 10 = Business/Trade School Name Service Coordinator (Case Manager) Dates Updated Date Initial Assessment Started Date Assessment Completed Funding Source 01 = Medicaid 04 = Katie Beckett

02 = SSI 05 = Parents

03 = Private Insurance 06 = Other:

CRISIS / SAFETY
"A crisis occurs when adults don't know what to do." Carl Shick Is this an Area of Strength? Yes No Level of Need (1 = No need, 5 = Great need) Crisis Response Plan for Home 1 2 3 4 5

Have there been any crisis situations at home or in the community?

Name(s) Person(s) in Need

F-22685 What was done in response to the situation(s)? Yes No

Page 2 Crisis Response Plan for Community 1 2 3 4 5

Name(s) Person(s) in Need

Have there been any crisis situations at school?

Yes No

Crisis Response Plan for School 1 2 3 4 5

Name(s) Person(s) in Need

What was done in response to the situation(s)?

Yes No

Other Strengths

Other Needs

LIVING SITUATION
Is this an Area of Strength? Yes No Level of Need (1 = No need, 5 = Great need) Living Arrangement 1 2 3 4 5

1.

Describe your family's current living situation (Do all family members live at home?)

Name(s) Person(s) in Need

2.

Does your home provide enough space, privacy, and comfort? Describe:

Yes No

Space, Privacy and Comfort 1 2 3 4 5

Name(s) Person(s) in Need

3.

Are there barriers to living in your current home long-term? Describe:

Yes No

Stability of Living Arrangement 1 2 3 4 5

Name(s) Person(s) in Need

F-22685 4. Are there any safety concerns? Describe: Yes No Safety of Physical Environment 1 2 3 4 5

Page 3

Name(s) Person(s) in Need

Other Strengths

Other Needs

RESTRICTIVENESS OF LIVING ENVIRONMENT
Living Location Dates (List Start & End Dates) Start Date End Date Only report living locations within past three months Level of Restrictiveness Living Environment and Level of Restrictiveness (Use corresponding codes at right) Jail 9.8 Individual Emergency Shelter Correctional Center 9.0 Home State Mental Hospital 9.0 Specialized Foster Care County Detention Center 8.9 Regular Foster Care Intensive Treatment Unit 8.4 Supervised Independent Living AODA Inpatient Rehab 7.8 Home of Family Friend Inpatient Hospital 7.5 Home of Adoptive Parent
Wilderness Camp 24-hour Year Round Residential Treatment Center Group Emergency Shelter Residential Job Corps Center Group Home Treatment Family Foster Home

Living Location (See choices at right)

4.9 4.6 3.8 3.6 2.6 2.6 2.5 2.0 2.0 1.9 1.4 0.5

7.2 6.5 6.0 5.7 5.7 5.1

Home of Relative School Dormitory Home of Natural Parent (Child) Home of Natural Parent (18 yrs) Independent Living with Friend Independent Living on Own

NOTE: Adopted from Hawkins, R.P.; Almelda, M.C.; Fabry, B.; & Reltz, A.C. (1991) Hospital & Community Psychiatry.

FAMILY
Is this an Area Level of Need of Strength? (1 = No need, 5 = Great need) Family Relationships Yes No 1 2 3 4 5 Name(s) Person(s) in Need

1.

Describe relationships among family members

F-22685 2. Describe relationships with your extended family--are they a resource to your family?

Page 4

Yes Extended Family Resource No 1 2 3 4 5 Name(s) Person(s) in Need

3.

Who (other than family members) offers support to you and your family?

Social Support Network 1 2 3 4 5 Name(s) Person(s) in Need

Yes No

Other Strengths

Other Needs

BASIC NEEDS / FINANCIAL
Is this an Area Level of Need of Strength? (1 = No need, 5 = Great need) Basic Needs Yes 1 2 3 4 5 No Name(s) Person(s) in Need

1.

Are your family's housing, food, and clothing needs met?

2.

Are your family's transportation needs met?

Transportation Yes 1 2 3 4 No Name(s) Person(s) in Need

5

3.

Please indicate your family's gross year income: ________________ What are your family's sources of income? Is there enough income to meet the family's needs?

Financial Resources Yes 1 2 3 4 No Name(s) Person(s) in Need

5

4.

Please describe family members' money management skills

Yes No

Money Management Skills 1 2 3 4 5

Name(s) Person(s) in Need

F-22685 5. Do family members have access to child care when needed--while adults are at work and when family members "just need a break"? Yes No Child Care and/or Respite 1 2 3 4 5

Page 5

Name(s) Person(s) in Need

Other Strengths

Other Needs

MENTAL HEALTH
1. Describe any significant psychological/psychiatric child and family history (past and current providers, medication, hospitalization, etc.)

2.

Describe behavioral strengths and needs of your child and family members:

Is this an Area Level of Need of Strength? (1 = No need, 5 = Great need) Behavioral Functioning Yes 1 2 3 4 5 No Name(s) Person(s) in Need

3.

Describe cognitive strengths and needs (learning ability, problem solving & thinking skills) of your child and family members:

Cognitive Functioning Yes 1 2 3 4 No Name(s) Person(s) in Need

5

4.

Describe emotional strengths and needs (reaction to stress, stability of mood) of your child and family members:

Emotional Functioning Yes 1 2 3 4 5 No Name(s) Person(s) in Need

5.

Do you have access to the mental health service providers your family needs or wants?

Access to Mental Health Providers Yes 1 2 3 4 5 No Name(s) Person(s) in Need

F-22685 Other Strengths Other Needs

Page 6

AODA (Alcohol and Other Drug Abuse)
Is this an Area Level of Need of Strength? (1 = No need, 5 = Great need) Current AODA Abuse or Addiction Yes 1 2 3 4 5 No Name(s) Person(s) in Need

1.

Describe any current AODA abuse or addiction concerns regarding your child or other family members:

2.

Describe past AODA abuse or addiction concerns regarding your child or other family members:

Past AODA Abuse or Addiction Yes 1 2 3 4 5 No Name(s) Person(s) in Need

3.

Do family members have access to needed AODA treatment and support?

Access to AODA Treatment & Support Yes 1 2 3 4 5 No Name(s) Person(s) in Need

4.

Describe the impact AODA issues have had on yourself and family members, both currently and in the past (include impact on social/community and family relationships, as well as on financial, legal, and employment situations):

Impact of AODA Issues Yes 1 2 3 4 5 No Name(s) Person(s) in Need

Other Strengths

Other Needs

F-22685

Page 7

MENTAL HEALTH / AODA (Continued)
Please complete the following Mental Health DSM IV Diagnosis information and Child Adolescent Functioning Scale (CAFAS) information.

DSM IV DIAGNOSIS
Axis Number Name of Diagnosis

CHILD ADOLESCENT FUNCTIONING ASSESSMENT SCALE
Role Performance: School/Work Role Performance: Home

Axis I Role Performance: Community Behavior Toward Others Axis II Moods/Emotions Axis III Axis IV Social Stressors Axis V GAF at Intake Name Author of Diagnosis On Medication at start date of services? Yes No Date Diagnosed If yes, specify medication(s) and daily dosage: Yes No 1 2 3 4 5 6 Self-Harmful Behavior Substance Use Thinking Youth Score Caregiver Resources: Material Needs Caregiver Resources: Family/Social Support Caregiver Resources Score: Notes/Comments Date Administered Name Administered By Notes/Comments

(1 = mild, 6 = severe)

SOCIAL & RECREATIONAL
Is this an Area Level of Need of Strength? (1 = No need, 5 = Great need) Social Interactive Skills Yes 1 2 3 4 5 No Name(s) Person(s) in Need

1.

Social Interactive Skills: Do family members have friends? Why or why not? Do they get along well with others?

F-22685 2. Describe activities family members currently do together or would like to do together: Family Activities Yes 1 2 3 4 No Name(s) Person(s) in Need 5

Page 8

3.

Describe activities your child or family members are involved in, or would like to be involved in, as individuals:

Yes Individual Social & Recreational Activities 1 2 3 4 5 No Name(s) Person(s) in Need

4.

Describe social relationships--do family members spend time with people outside their immediate family?

Social Relationships Yes 1 2 3 4 No Name(s) Person(s) in Need

5

Other Strengths

Other Needs

CULTURAL
Is this an Area Level of Need of Strength? (1 = No need, 5 = Great need) Affiliation with Ethnic Group Yes 1 2 3 4 5 No Name(s) Person(s) in Need

1.

Describe ethnic or national traditions/holidays your family observes.

2.

How do family members participate in these traditions? Are there any barriers to participating in those traditions?

Access to Ethnic Traditions Yes 1 2 3 4 5 No Name(s) Person(s) in Need

Other Strengths

Other Needs

F-22685

Page 9

SPIRITUAL
Is this an Area Level of Need of Strength? (1 = No need, 5 = Great need) Yes Affiliation with Religious or Spiritual Group 1 2 3 4 5 No Name(s) Person(s) in Need

1.

Describe your family's religious or spiritual practices, values, and support network.

2.

Does your family have access to desire spiritual practices and support?

Access to Desire Practices & Support Yes 1 2 3 4 5 No Name(s) Person(s) in Need

Other Strengths

Other Needs

EDUCATIONAL
*Please attach a copy of the child's most recent school report card 1. Describe your child's current educational status--include grade level, placement (LD-Learning Disabled, CD-Cognitively Disabled, ED-Emotionally Disturbed), and attendance.

2.

Describe how your child is doing in his/her school work.

Is this an Area Level of Need of Strength? (1 = No need, 5 = Great need) Academic Skills Yes 1 2 3 4 5 No Name(s) Person(s) in Need

3.

Describe how your child is doing behaviorally in school.

Behavior in School Yes 1 2 3 4 No Name(s) Person(s) in Need

5

F-22685 4 Do family members have age-appropriate independent living skills?

Page 10 Independent Living Skills Yes 1 2 3 4 5 No Name(s) Person(s) in Need

5

If applicable, describe your child's work experience, pre-employment skills and interests.

Pre-employment Skills Yes 1 2 3 4 5 No Name(s) Person(s) in Need

6.

Describe any educational or vocational strengths and needs of adult family members.

Parent Education or Vocational Skills Yes 1 2 3 4 5 No Name(s) Person(s) in Need

Other Strengths

Other Needs

LEGAL
Is this an Area Level of Need of Strength? (1 = No need, 5 = Great need) Need for Legal Services Yes 1 2 3 4 5 No Name(s) Person(s) in Need

1.

Describe significant involvement with legal system and current status.

Other Strengths

Other Needs

CONTACT WITH POLICE AND/OR JUVENILE JUSTICE
(Only report offenses in the past six months) Month/Year Type of Violation Taken into Custody? Yes Yes Yes No No No Adjudicated? Yes Yes Yes No No No Disposition (Use Codes Below)

F-22685 Month/Year Type of Violation Taken into Custody? Yes Yes Yes DISPOSITION CODES: 01 Supervision 02 Fine 03 Restitution 04 Secure Detention 05 Non-Secure Detention 06 Hospitalization 07 CCI 08 Group Home 09 Foster Home No No No Adjudicated? Yes Yes Yes No No No 13 No Contact

Page 11 Disposition (Use Codes Below)

10 Community Service 11 Pending 12 Informal Arrangements

MEDICAL
Is this an Area Level of Need of Strength? (1 = No need, 5 = Great need) Physical Health Yes 1 2 3 4 5 No Name(s) Person(s) in Need

1.

Describe the physical health of family members.

2.

Describe the dental health of family members.

Dental Health Yes 1 2 3 4 No Name(s) Person(s) in Need

5

3.

Do family members have access to needed health equipment or supplies?

Access to Special Equipment Yes 1 2 3 4 5 No Name(s) Person(s) in Need

4.

Do family members have access to needed dental and health care providers?

Yes Access to Dental & Health Care Providers 1 2 3 4 5 No Name(s) Person(s) in Need

Other Strengths

Other Needs