Form D - DxInt.Ser Form D - DxInt.Ser Form D - DxInt.Service Provided After Diag.

SAMHSA FASD Center for Excellence

Form D

Diagnosis and Intervention Programs: FASD Services Planned and Provided based on Diagnostic Evaluation

This form is used in the SAMHSA FASD Center for Excellence Diagnosis and Intervention Programs to record services planned and received based on the diagnostic evaluation. 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 planned and received by the child; however, participation is voluntary.

Child ID: ____________ Anticipated Date of Service Planned: ________________ Date of Birth: _______________ Date of Completion: ___________________

Instructions: Indicate all services planned and provided based on the FASD diagnostic evaluation.

Service Component: A service that is to be provided based on the FASD diagnostic evaluation.

Services Planned: (to be recorded after being identified by service provider. If the service provider determines that the service is not required due to assessment/intake criteria or other eligibility results, complete only the “Reason Service was not Provided as Planned.”)

Based on FASD Diagnostic Evaluation: Services specifically recommended based on the FASD diagnostic evaluation

Amount of Service Units Planned: Amount of service recommended for client per service delivery interval

Service Delivery Interval Planned: Required service delivery interval (daily, weekly, monthly, quarterly) identified by service provider

Services Provided: (to be recorded upon completion of each recommended service component-using details from Form E)

Start Date: Date of first appointment for the service

Amount of Service Units Provided: Total amount of service provided to the child/family (based on cumulative number of hours reported in Form E for each service component)

Service Delivery Interval Provided: Actual service delivery interval (daily, weekly, monthly)

End Date: Date this service stopped being provided.

Reason Service Was Not Provided as Planned: If a service could not be provided as planned, check all applicable reasons for this.

Service Component (Based on FASD Dx Evaluation)	Services Planned		Services Provided (Cumulative)			Reason Service Was Not Provided As Planned	Assessment of Improvement provided by Service Provider to the Case Manager
	Amount of Service Units Planned (in hours) per interval	Service Delivery Interval Planned (daily/weekly/monthly/quarterly)	Start Date (Date service begins)	Amount of Service Units Provided (in hours)	End Date (Date service ended)	Check all that apply.	0 Significant decline (in functionality) 1 Moderate decline 2 No change 3 Moderate improvement 4 Significant improvement
Example	2	weekly	10/1/08	6	10/15/08	□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □   Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________	3

Anger Management						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □   Provider screening or eligibility criteria not met □ Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Behavioral management skills (Family/Child)						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Case Management						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Chemical dependency treatment services						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Educational Support						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________

Family Support						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Family Therapy						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Home Visiting						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Individual Therapy						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Intensive Family Services						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________

Life Skills Training						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Medication management						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Money Management						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Nursing Services						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Nutritional Services						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________

Occupational Therapy						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Parenting Skills						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Physical Therapy						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Play Therapy						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Psychological Services						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________

Respite						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Sensory Integration						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Social Skills Training						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Speech and Language Therapy						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Supervised Visitation						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________

Therapeutic foster care						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Therapeutic nurseries and preschool						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Vocational Training						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Health or Medical Services (please specify below)						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________
Other (please specify below)						□   Lack of access - transportation □   Lack of access - child care □  Lack of access- language barriers □   Waiting list for services □   Identified service not available □ Provider screening or eligibility criteria not met □   Financial cost of service □   Parent/caregiver refused to participate □   Other (specify) _________

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

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 20 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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