Today’s Date:

Child First Name:

Child Last Name:

First & Last Name of person filling out this form:

Relationship to Child:

SECTION A: Education/School

1. Is the child attending school right now?
   Yes
   No
   No, it's summer time
   
   
   
2. If no, why isn’t the child in school right now?
    a - Too Young
    b - Dropped out
    c - Suspended
    d - Expelled
    e - Home Schooling
    f - Other/Don't Know
   
    
   (If it’s summer, answer about the most recent school year?)
   
   

3. What grade is the child in now (or last grade, if it is summer)?
   
   

4. What’s the name of the child’s current school?
   
   

5. What type of school does the child attend? If summer, last school attended. Please select one:

    Public School - Mainstream Classroom
    Public School - Contained Classroom
    Private School
    Alternative to Public School (Riverfront, Willamette, Leadership, A3, LLC)
    Residential Treatment In-House School or Training Program
    Detention / State Training School
    Homeschool
    Other (specify):
   
   
   
    Don't Know
   
   
   

   Has the child EVER received any of the following Education Related Services?

6. Special Education (resource room, class aid, etc) NoYes

       IF YES, currently in service? YesNo
    

7. Chapter I/Title 1 NoYes

       IF YES, currently in service? YesNo
    

8. IEP (Individualized Educational Plan) NoYes

       IF YES, currently in service? YesNo
    

9. Services for disabilities (504 Plan) NoYes

       IF YES, currently in service? YesNo
    

10. In-school counseling NoYes

        IF YES, currently in service? YesNo
     

11. After school tutoring NoYes

         IF YES, currently in service? YesNo
     
    
    

12. Currently, how is the child’s school attendance (or “Last Month Attended” if summer)   

     1: Not Attending (0%)
     2: Attending Very Infrequently (1-25%)
     3: Attending Infrequently (26-50%)
     4: Attending More Than Not (51-75%)
     5: Attending Regularly (76-99%)
     6: Attending Always (100%)
     7: N/A Don't Know

13. Currently, how is the child’s behavior at school (or “Last Month Attended” if summer)? Very PoorPoorO.K.GoodVery GoodDon't Know 

14. How is the child doing with schoolwork (or “Last Month Attended” if summer)? Very PoorPoorO.K.GoodVery GoodDon't Know 

15. Has the child ever: (SELECT ALL THAT APPLY)

          a. Been suspended from school

          b. Been expelled from school

          c. Been in trouble with teachers, parents have been contacted

          d. Been in trouble with the principal, parents have been contacted

          e. Been in other significant trouble at school

SECTION B. Mental Health History

1. Has the child ever had a psychiatric evaluation?
   1: Yes
   2: No
   3: Don't Know
2. Has a doctor or mental health professional ever determined that the child has a mental health diagnosis?
   1: Yes
   2: No - SKIP TO SECTION 3
   3: Don't Know - SKIP TO SECTION C
3. Please list Diagnoses: Mark fields with NA if unknown or does not apply.

a)  

b)  

c)  

d)  

4. Has the child ever been prescribed medication for “emotional,” “nervous,” “hyperactive behavior,” “depression,” “anxiety,” or other problems?
   1: Yes
   2: No - SKIP TO SECTION C
   3: Don't Know - SKIP TO SECTION C

5. Is the child currently taking any of these medications?
   1: Yes
   2: No - SKIP TO SECTION C
   3: Don't Know - SKIP TO SECTION C
6. How many mental health medications is the child currently taking?
   
   

Please tell us about the child’s current mental health medications:

a) Medication #1 name

b) What is the medication prescribed for?

c) Child’s age when 1^st prescribed this medication?

a) Medication #2 name

b) What is the medication prescribed for?

c) Child’s age when 1^st prescribed this medication?

a) Medication #3 name

b) What is the medication prescribed for?

c) Child’s age when 1^st prescribed this medication?

a) Medication #4 name

b) What is the medication prescribed for?

c) Child’s age when 1^st prescribed this medication?  

5. Has the child ever spent time in an Inpatient Mental Health Hospital or facility?
   1: Yes
   2: No - SKIP TO SECTION C
   3: Don't Know - SKIP TO SECTION C
6. How many times?
7. Start date of most recent stay:  
8. For the most recent stay - Total # days spent as an Inpatient?

SECTION C. Foster Home Placement

1. Has the child ever been placed in foster care?
   1: Yes
   2: No - SKIP TO SECTION D
   3: Don't Know - SKIP TO SECTION D
2. Is the child currently in foster care?
   1: Yes
   2: No
3. If yes, Number of days in the current foster home?
   
   If child has been in Foster Care at least once, continue.  IF NOT, SKIP TO SECTION D
   
   
4. Does the child have any siblings (bio/adopted/step)?
   1: Yes
   2: No
   3: Don't Know
    
5. Was the child placed with any siblings in foster care?
   1: Yes
   2: No
   3: Don't Know
6. While in foster care, did the child have contact with one or more sibling(s) at least once a month?
   1: Yes
   2: No
   3: Don't Know
7. How old was the child when first placed in foster care?
8. How many foster home placements has the child had? (# of transitions between foster homes)
9. What is the total amount of time spent in all foster care?

SECTION D. Involvement With Criminal Justice

1. Has the child ever been arrested?
   1: Yes
   2: No - SKIP TO SECTION E
   3: Don't Know - SKIP TO SECTION E
   
   
   
2. How many times has the child been arrested?
   
   
3. Has the child spent time in lockup/juvenile detention?
   1: Yes
   2: No - SKIP TO SECTION E
   3: Don't Know - SKIP TO SECTION E
   
   
   
4. How many days has the child spent in lockup/juvenile detention?

SECTION E. Volunteering/Working (For clients 14 or older ONLY)

Check all that apply

1. Has the youth:
    a: Participated in Volunteer Activities
    b: Participated in Community Service
    c: Worked Part-Time
    d: Worked Full-Time
    

(Parent/Guardian Phone Number)

(Date)