Form C - DxInt. Se Form C - DxInt. Se Form C - DxInt. Services Provided at Diag

OMB # 0930- XXXX

Expiration Date: xx/xx/xxxx

SAMHSA FASD Center for Excellence

Form C

Diagnosis and Intervention Programs: Services Child is Receiving at the time of the FASD Diagnosis

This form is used in the SAMHSA FASD Center for Excellence Diagnosis and Intervention Programs to record services the child is receiving at the time of an FASD diagnosis. To protect privacy, name and any other individually identifying information will not be collected. It is important to us to obtain this information to understand the services the child is currently receiving; however, participation is voluntary.

Child ID: ____________ Date Completed: ________________ Date of Birth: _______________

Instructions: Indicate all services the child is currently receiving and not based on the FASD diagnostic evaluation.

Service Component: A service that the child is currently receiving (not part of the FASD intervention).

Amount of services: Amount of service child is currently receiving.

Service units: Service units – hours.

Service Component	Start Date (Date service began)	Amount of services units provided in hours	Frequency (daily/ weekly/ monthly)	End date (Date service ended)
Example	5/1/08	20	Monthly	11/25/08
Anger Management
Behavioral management skills (Family/Child)
Case Management
Chemical dependency treatment services
Educational Support
Family Support
Family Therapy
Home Visiting
Individual Therapy
Intensive Family Services
Life Skills Training
Medication management
Money Management
Nursing Services
Nutritional Services
Occupational Therapy
Parenting Skills
Physical Therapy
Play Therapy
Psychological Services
Respite
Sensory Integration
Speech and Language Therapy
Social Skills Training
Supervised Visitation
Therapeutic foster care
Therapeutic nurseries and preschool
Vocational Training
Health or Medical Services (please specify below)
Other (please specify below)

List other services not described in hours (e.g., changes in school environment)

_____________________________________________________________________________________________________________

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An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-xxxx. Public reporting burden for this collection of information is estimated to average 10 minutes per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

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