Followup

Form Approved

OMB NO. 0930-0276

Exp. Date: xx-xx-xxxx

Public Burden Statement: 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 0930-0276.  Public reporting burden for this collection of information is estimated to average 30 minutes per response, 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.

Core Clinical Characteristics
(Follow-up Assessment Form)

Child ID Number:  -  - Child’s Initials:
	Center ID	Subcenter ID	Child ID		First	Middle	Last

Follow-up Information

Follow-up Assessment(s) should be completed in each of the following conditions:

1. Near the end of planned treatment (e.g., approaching the last session for a planned discharge, at the time of termination for children who indicate they are dropping out, or at the last session before transferring to an out-of NCTSN provider)

2. Every three months as long as the child remains in treatment

3. When a child returns to treatment for a new episode of care Every child must have a Follow-up Assessment completed with an “End of Treatment” status. Some follow-up data is expected to be reported for all cases except those “Lost to follow-up”.

1. Date of follow-up:  /  / 

Month Day Year

2. Which type of follow-up is being performed?

1 = Follow-up for ongoing treatment

If “Follow-up for ongoing treatment”: Please indicate the follow-up timeframe:

1 = 3-month

2 = 6-month

3 = 9-month

4 = 12-month

5 = 15-month

6 = 18-month

7 = 21-month

8 = 24-month

98 = Other, please specify: _______________________________________________________

2 = End of treatment

If “End of Treatment”: Please indicate the status of the child at the completion of follow-up:

1 = Treatment is completed as planned.

2 = Case was transferred to another clinic or program.

3 = Child dropped out prior to end of planned treatment (for any reason)

4 = Case is lost, no follow-up assessments performed

98 = Other, please specify: _______________________________________________________

3 = Re-opening case for new episode of care

98 = Other, please specify: ______________________________________________________________

3. Has any new trauma been experienced since last interview?

0 = No

1 = Yes

If Yes: Please update the General Trauma Information form

99 = Unknown

4. Has any previously experienced trauma been revealed since last interview?

0 = No

1 = Yes

If Yes: Please update the General Trauma information form

99 = Unknown

Follow-up Information (continued)

Note: For a child identified as ‘Case is lost, no follow-up assessments performed’, questions 5 and 6 are not required.

5. From whom are you collecting information for this form? (Check all that apply)

Parent

Other adult relative

Foster parent

Agency staff

Child/Adolescent/Self

Other, please specify: _______________________________________________________________

6. Who is currently the legal guardian for this child? (Select only one)

1 = Parent

2 = Other adult relative

3 = State

4 = Emancipated minor (self)

98 = Other, please specify: ______________________________________________________________

99 = Unknown

7. Question 7 is not applicable at this time.

8. Question 8 is not applicable at this time.

9. Please provide an identifier for the health care provider currently caring for this child. __________________

Brief Intervention Services Information

Brief Intervention refers to the number of sessions that a child may receive. If a child is receiving 3 – 6 sessions, then complete the following.

1. Is this child/family receiving brief intervention services?

0 = No

1 = Yes

If Yes: Please press the Add Entry button and complete the requested information for EACH episode of care where the child/family receives brief intervention services. A new entry is required for each type of treatment and each different set of start/stop dates.

1. What treatment component(s) is the child/family receiving for this brief episode of care?
   (Check all that apply)

Screening

Assessment

Case Consultation

Case Management

Child and Family Traumatic Stress Intervention (CFTSI)

Psychological First Aid (PFA)

Skills for Psychological Recovery

Acute Crisis Response and Management

Referral Services

Psycho-education

Safety Planning

Individual Therapy

Family Therapy

Group Therapy

Support Group

Other, Specify: ____________________________________________________________________

2. 2. Date this brief episode of care began:  /  / 

Month Day Year

NOTE: Answer question 3 after the child/family has completed the selected treatment component(s).

3. Did this child/family complete the treatment component(s) offered during this brief episode of care?

0 = No, left treatment before completing

If No: Date left treatment:  /  / 

Month Day Year

1 = Yes, completed treatment

If Yes: Date completed treatment:  /  / 

Month Day Year

NCTSN Breakthrough Series/Learning Collaboratives

Complete the following.

1. Is this child/family receiving a treatment from a therapist participating in a breakthrough series or learning collaborative for that treatment?

0 = No

1 = Yes

If Yes: Please press the Add Entry button and complete the requested information for each treatment the child/family is receiving through a breakthrough series or learning collaborative. A new entry is required for each type of treatment and each different set of start/stop dates.

1. What treatment is this child/family receiving through a therapist participating in a breakthrough series or other learning collaborative? (Select only one)

1 = Trauma-Focused Cognitive Behavior Therapy (TF-CBT)

2 = Life Skills/Life Stories

3 = Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)

4 = Trauma Adaptive Recovery Group Education and Therapy (TARGET)

5 = Trauma Systems Therapy (TST)

6 = Child Parent Psychotherapy (CPP)

7 = Cognitive-Behavioral Intervention for Trauma in Schools (CBITS)

98 = Other, specify name of treatment: ____________________________________________________

2. Date this treatment began:  /  / 

Month Day Year

NOTE: Complete question 3 after the child/family has terminated this treatment.

3. Did this child/family complete this treatment?

0 = No, left this treatment before completing

If No: Date left this treatment:  /  / 

Month Day Year

1 = Yes, completed treatment

If Yes: Date completed this treatment:  /  / 

Month Day Year

Insurance Information and Domestic Environment

Insurance Information

1. Is the child currently covered by any type of public or private health insurance?

0 = No (If no, skip to Question 3)

1 = Yes

If Yes: Specify type below in Question 2

99 = Unknown

2. Type of public or private health insurance currently covering the child (Check all that apply)

Public:

Medicare

Medicaid

Indian health service

Children’s health insurance program (CHIP)

Other public, please specify:___________ ________________________________________________

Private:

HMO

PPO

Fee-for-service

Other private, please specify:___________ _______________________________________________

3. Is the child’s parent/guardian covered by any type of insurance?

0 = No (If no, skip to Question 5)

1 = Yes

If Yes: Specify type below in Question 4

99 = Unknown

4. Type of public or private health insurance currently covering the child’s parent/guardian
   (Check all that apply)

Public:

Medicare

Medicaid

Indian health service

Children’s health insurance program (CHIP)

Other public, please specify: ____________ ______________________________________________

Private:

HMO

PPO

Fee-for-service

Other private, please specify: __________________________________________________________

Domestic Environment

5. Where is the child’s current primary residence? (Select only one)

1 = Independent (alone or with peers)

2 = Home (With parent(s))

3 = With relatives or other family

4 = Regular foster care

5 = Treatment foster care

6 = Residential treatment center

7 = Correctional facility

8 = Homeless

9 = Shelter

99 = Unknown

98 = Other, please specify___________________________________

6. How many months has the child been living in above setting?

_____(Enter number of months or “0” if less than one month)

Or, circle one of the following options:

1 = Entire life

99 = Unknown

Domestic Environment Details

If ‘Home with parent(s)’ or ‘With relatives or other family’ is selected for primary residence on the Insurance Information and Domestic Environment form at Baseline complete the following questions.

1. What types of adults live in the home with the child? (Check all that apply)

Mother (Biological or adopted)

Father (Biological or adopted)

Parent’s partner/significant other

Grandparent

Other adult relative

Other adult non-relative

Unknown

Other, please specify: _______________________________________________________________

2. Total number of adults (18 years of age or older) living in child’s home: _________

Or, circle the following if unknown: 99 = Unknown

3. Total number of children younger than 18 years of age (including client) living in child’s home: __________

Or, circle the following if unknown: 99 = Unknown

4. Please specify ZIP code of child’s current residence:  (5 digit ZIP code)

Or, circle the following if unknown: 99 = Unknown

5. Primary language spoken at home: (Select only one)

1 = English

2 = Spanish

3 = French

4 = Mandarin

5 = Cantonese

6 = Navaho

7 = Japanese

8 = Korean

9 = Russian

99 = Unknown

98 = Other, please specify: ______________________________________________________________

6. What is the total income for the child’s household for the past year, before taxes and including all sources:

$ _________________(US$)

Or, circle the following if unknown: 99 = Unknown

Family Assessment Module – Family APGAR The following 5 questions are designed to be completed by the child’s caregiver. The following questions have been designed to help us better understand you and your family. You should feel free to ask questions about any item in the questionnaire. Answer each question as “almost always”, “sometimes”, or “hardly ever”. Family is defined as the individual(s) with whom you usually live.
I am satisfied with the help that I receive from my family when something is troubling me.	0 = Hardly ever 1 = Some of the time 2 = Almost always 99 = Unknown
I am satisfied with the way my family discusses items of common interest and shares problem solving with me.	0 = Hardly ever 1 = Some of the time 2 = Almost always 99 = Unknown
I find that my family accepts my wishes to take on new activities or make changes in my life-style.	0 = Hardly ever 1 = Some of the time 2 = Almost always 99 = Unknown
I am satisfied with the way my family expresses affection and response to my feelings such as anger, sorrow, and love.	0 = Hardly ever 1 = Some of the time 2 = Almost always 99 = Unknown
I am satisfied with the amount of time my family and I spend together.	0 = Hardly ever 1 = Some of the time 2 = Almost always 99 = Unknown

Indicators of Severity of Problems This section relates to the types of problems and experiences ‘child’ might have displayed. Indicate if the child experienced these types of problems within the past month (within the last 30 days). Please answer each question. This section should be completed for children ages 6 and older.
All responses should be the Indicator of Severity for problems experienced within the past month.
Academic problems (e.g., Problems with school work or grades)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown
Behavior problems in school or daycare (e.g., Getting into trouble, detention, suspension, expulsion)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown
Problems with skipping school or daycare (e.g., Where he/she skipped at least 4 days in the past month, or skipped parts of the day on at least half of the school days)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown
Behavior problems at home or community (e.g., Violent or aggressive behavior; breaking rules, fighting, destroying property, or other dangerous or illegal behavior)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown
Suicidality (e.g., Thinking about killing himself/herself or attempting to do so)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown
Other self-injurious behaviors (e.g., Cutting him/herself, pulling out his/her own hair)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown
Developmentally inappropriate sexualized behaviors (e.g., Saying or doing things about sex that children his/her age do not usually know)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown
Alcohol use (e.g., Use of alcohol)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown
Substance use (e.g., Use of illicit drugs or misuse of prescription medication)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown
Attachment problems (e.g., Difficulty forming and maintaining trusting relationships with other people)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown
Criminal activity (e.g., Activities that have resulted in being stopped by the police or arrested)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown

Indicators of Severity of Problems (continued)
Running away from home (e.g., Staying away for at least one night)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown
Prostitution (e.g., Exchanging sex for money, drugs or other resources)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown
Child has other medical problems or disabilities (e.g., Chronic or recurrent condition that affects the child’s ability to function)	0 = Not a problem 1 = Somewhat/sometimes a problem 2 = Very much/often a problem 99 = Unknown

15. In the past 3 months, has the child talked about committing suicide?

0 = No

1 = Yes

99 = Unknown

16. In the past 3 months, has the child attempted suicide?

0 = No

1 = Yes

99 = Unknown

Young Child Indicators of Severity of Problems

This section relates to the types of problems and experiences ‘child’ might have displayed. Indicate if the child experienced these types of problems within the past month (within the last 30 days). Please answer each question. This section should be completed for children younger than age 6.

All responses should be the Indicator of Severity for problems experienced within the past month.

1. Immediate Risk – Child’s current risk of self-harm

0	No current self injurious behaviors
1	Mild risk of self injury due to dysregulated behaviors (i.e. climbing high furniture, etc.)
2	Moderate problems with dangerous or self injurious behaviors, e.g. running from caregivers, pulls own hair, or head banging.
3	Severe problems with dangerous and self injurious behaviors, e.g. child runs into street, tries to hang or injury self or talks about wanting to kill themselves even though their understanding of death is not complete
99	Unknown/unable to rate

2. Emotional Regulation – Child’s ability: 1) to have developmentally appropriate control over emotions (including joy, excitement, anger, sadness, and fear); 2) to be comforted, and 3) to regulate the intensity of emotional expression particularly when faced with frustration.

0	No evidence of regulatory problems.
1	Mild problems with emotional regulation. Child may be difficult to choose or may require more structure and support than other children. in coping with frustration and difficult emotions.
2	Moderate problems with emotion regulation that may include: 1) difficulties with transitions; 2) severe irritability including extreme or prolonged tantrums; 3) low frustration tolerance; 4) age inappropriate ability to delay gratification. Problems interview with child’s developmental functioning and may require consistent adult intervention.
3	Profound problems with emotional regulation that place the child’s safety, well-being and/or development at risk.
99	Unknown/unable to rate

3. Feeding – Issues with feeding (e.g. difficulty sucking, chewing or swallowing, sensory food aversions,

symptoms of failure to thrive, overeating and/or Pica)

0	No evidence of any feeding problems.
1	Child has minor feeding problems; however, problems have not interfered with the child’s functioning or the parent-child relationship.
2	Child has moderate symptoms of feeding problems
3	Child’s feeding problems have become so significant that the child has had medical problems associated with feeding issues
99	Unknown/unable to rate

4. Child Sleep Problems – Problems with sleep including insomnia, frequent awakening, and nightmares.

0	No evidence of sleep disturbance.
1	Mild sleep disruption, including occasional nightmares or difficulty falling asleep, i.e., mild insomnia of up to 1 hour.
2	Moderate sleep disturbance including frequent (at least once per week to nearly daily) resistance to going to bed, difficulty falling asleep, or nightmares. May include insomnia for up to 2 hours each night or frequent awakening with difficulty falling back asleep.
3	Severe sleep disturbance that could include daily sleep problems, including difficulty falling asleep, awakening in the night. The child has less than 4 hours of sleep per night or has day/night reversal.
99	Unknown/unable to rate

5. Play – Consider child’s developmental age when considering the child’s ability to engage in age appropriate

play.

0	Child demonstrates age appropriate play.
1	Child demonstrates age appropriate play most of the time or is responsive to adult prompts to play.
2	Child demonstrates moderate problems with age appropriate play (e.g. child shows little interest or enjoyment in playing with peers or adults, child does not explore toys for significant length of time).
3	Child does not demonstrate age appropriate play skills. Child does not often respond to or engage in play activities with adults or peers, s/he does not explore or uses toys in a way that is appropriate for their age.
99	Unknown/unable to rate

6. Preschool/Childcare – Child’s behavior in preschool and/or childcare.

NA	Not applicable, child not in preschool or daycare
0	No evidence of problems with functioning in current preschool or childcare environment.
1	Mild problems with functioning in current preschool or daycare environment.
2	Moderate problems with functioning in current preschool or daycare environment. Child has difficulties with behavior in this setting creating significant concerns or problems for others.
3	Profound problems with functioning in current preschool or daycare environment. Child has been removed or is at immediate risk of being removed from program due to behaviors or unmet needs.
99	Unknown/unable to rate

7. Social functioning – Child difficulties with social skills and relationships.

0	No evidence of problems and/or child has developmentally appropriate social functioning.
1	Minor problems in social relationships. (i.e. Infants may be slow to respond to or engage adults, toddlers may need support to interact positively with peers and toddlers and preschoolers may be withdrawn or aggressive.
2	Moderate problems with social relationships. (i.e. Infants and toddlers may be disengaged from adults or peers, hard to soothe, and show difficulty in focusing on toys in social situations. Preschoolers may hit, bite or having difficulty sharing and taking turns even when adults offer support.)
3	Severe disruptions in social relationships. (i.e. Infants and toddlers show limited ability to signal needs or express pleasure. Infants, toddlers, preschoolers are consistently withdrawn and unresponsive to familiar adults. Preschoolers show no joy or sustained interaction with peers or adults, and/or aggression, and or may be place themselves or others at risk.)
99	Unknown/unable to rate

8. Aggression – Aggressive behaviors include biting, hitting, kicking, throwing toys and other objects

0	No evidence of aggressive behaviors.
1	Mild concerns but does not interfere with functioning; adults are able to manage challenging behaviors.
2	Clear evidence of aggressive behavior. Behavior is persistent, and caregiver’s attempts to change behavior have not been successful.
3	Significant challenges with aggressive behaviors, characterized as dangerous and involves threat of harm to others or problems in more than one life domain that significantly threatens child’s growth and development.
99	Unknown/unable to rate

9. Sexualized behaviors –Sexualized behavior includes both age-inappropriate talking or acting out in sexualize

ways.

0	No evidence of problems with sexualized talk or behaviors.
1	Some evidence of sexualize talk or behavior. Child may exhibit occasional inappropriate sexual language or behavior or engages in behaviors that mimic sexualized behaviors.
2	Moderate problems with sexualized behavior, Child may exhibit more frequent masturbation than is age appropriate, may frequently use sexualized language or say or do things related sex that children his/her age do not usually know
3	Significant problems with sexualize behaviors. Child exhibits sexual behaviors that indicates exposure to sexual activity or possible victimization and may try to touch other children.
99	Unknown/unable to rate

10. Child attachment difficulties - Item should be rated within the context of the child's significant parental or

caregiver relationships.

0	No evidence of attachment problems. Child appears able to respond to caregiver cues in a consistent, appropriate manner, and child seeks age-appropriate contact with caregiver for both nurturing and safety needs. Child experiences a sense of security and trust within his/her attachment relationships.
1	Mild problems with attachment. Child may have difficulty accurately reading caregiver efforts to provide attention and nurturance; may be inconsistent in response; or may be occasionally needy. Child may have mild problems with separation (e.g., anxious/clingy behaviors in the absence of obvious cues of danger) or may avoid contact with caregiver in age-inappropriate way.
2	Moderate problems with attachment. Child may consistently misinterpret cues, act in an overly needy way, or ignore/avoid contact even when distressed. Child may have ongoing difficulties with separation, may consistently avoid contact with caregivers.
3	Severe problems with attachment. Child is unable to form attachment relationships with others (e.g., chronic dismissive/avoidant/detached behavior in care giving relationships) OR child presents with diffuse emotional/physical boundaries leading to indiscriminate friendliness with others. Child is considered at ongoing risk due to the nature of his/her attachment behaviors. A child who meets the criteria for an Attachment Disorder in DSM-IV would be rated here.
99	Unknown/unable to rate

11. Developmental concerns –Problems may occur in cognitive, receptive language, expressive language, motor, or social domains

0	Child meets or exceeds all developmental milestones.
1	Child is close to meeting all developmental milestones. Circle domain(s) that needs further consideration: Cognitive Receptive Language Expressive Language Motor Social
2	Child has some problems with immaturity or delay in meeting developmental milestones. Problems occasionally interfere with child’s ability to function. Circle domain(s) that needs further consideration: Cognitive Receptive Language Expressive Language Motor Social
3	Significant difficulties or unevenness with development. Developmental delays significantly impair child’s functioning. Circle domain(s) that needs further consideration: Cognitive Receptive Language Expressive Language Motor Social
99	Unknown/unable to rate

12. Atypical behaviors - Includes mouthing after 1 year, head banging, smelling objects, spinning, twirling, hand flapping, finger-flicking, rocking, toe walking, staring at lights, or repetitive and bizarre verbalizations

0	No evidence of atypical behaviors in the infant/child
1	Child engages in atypical behaviors at times
2	Clear evidence of atypical behaviors reported by caregivers that are observed on an ongoing basis
3	Clear evidence of atypical behaviors that are consistently present and interfere with the infants/child’s functioning on a regular basis
99	Unknown/unable to rate

Services Received
FOLLOW-UP INSTRUCTIONS: Has the child received any of these services or been placed in any of the following (excluding today’s visit) since the last NCTSN Core Dataset collection. These may include services provided by your Center as well as services provided by any other clinician, setting or sector.
Inpatient psychiatric unit or a hospital for mental health problems		0 = No 1 = Yes 99 = Unknown
Residential treatment center (A self-contained treatment facility where the child lives and goes to school)		0 = No 1 = Yes 99 = Unknown
Detention center, training school, jail, or prison		0 = No 1 = Yes 99 = Unknown
Group home (A group residence in a community setting)		0 = No 1 = Yes 99 = Unknown
Treatment foster care (Placement with foster parents who receive special training and supervision to help children with problems)		0 = No 1 = Yes 99 = Unknown
Probation officer or court counselor		0 = No 1 = Yes 99 = Unknown
Day treatment program (A day program that includes a focus on therapy and may also provide education while the child is there)		0 = No 1 = Yes 99 = Unknown
Case management or care coordination (Someone who helps the child get the kinds of services he/she needs)		0 = No 1 = Yes 99 = Unknown
In-home counseling (Services, therapy, or treatment provided in the child’s home)		0 = No 1 = Yes 99 = Unknown
Outpatient therapy (From psychologist, social worker, therapist, or other counselor)		0 = No 1 = Yes 99 = Unknown
Outpatient treatment from a psychiatrist		0 = No 1 = Yes 99 = Unknown
Primary care physician/pediatrician for symptoms related to trauma or emotional/behavioral problems. (Excluding emergency room)		0 = No 1 = Yes 99 = Unknown
School counselor, school psychologist, or school social worker (For behavioral or emotional problems)		0 = No 1 = Yes 99 = Unknown
Special class or special school or Early Intervention Services (Part C or B) (For all or part of the day)		0 = No 1 = Yes 99 = Unknown
Child welfare (excluding foster care)		0 = No 1 = Yes 99 = Unknown
Social services other than child welfare (e.g., TANF, food stamps, child care)
Foster care (Placement in kinship or non-relative foster care)		0 = No 1 = Yes 99 = Unknown
Therapeutic recreation services or mentor		0 = No 1 = Yes 99 = Unknown
Services Received (continued)
Hospital emergency room (For problems related to trauma or emotional or behavioral problems)	0 = No 1 = Yes 99 = Unknown
Self-help groups (e.g., AA, NA)	0 = No 1 = Yes 99 = Unknown
Medication management	0 = No 1 = Yes 99 = Unknown
Home Visiting	0 = No 1 = Yes 99 = Unknown
Head Start Program and service coordination	0 = No 1 = Yes 99 = Unknown
Parent education and skill-building programs	0 = No 1 = Yes 99 = Unknown
Peer support / therapy	0 = No 1 = Yes 99 = Unknown
‘Wraparound’ services	0 = No 1 = Yes 99 = Unknown
Other, Specify__________________________________________	0 = No 1 = Yes 99 = Unknown

28. If the child received outpatient therapy / treatment, please indicate which of the following treatment modalities were received (check all that apply):

Attachment-based therapy
Behavioral therapy
Cognitive therapy
Cognitive behavioral therapy
Expressive therapies (drawing, movement, theater)
Family therapy
Narrative therapy
Phase-oriented trauma treatment
Play therapy
Psychoanalysis
Psychodynamic psychotherapy
Social skills training
Solution-focused therapy
Stress management / relaxation training
Supportive therapy

Treatment by NCTSN Center

Thinking about the period since the last assessment, please complete the following about services and treatment that your agency has provided for this child.

1. Has the child received any inpatient or residential treatment?

0 = No

1 = Yes

If Yes: Specify type (Check all that apply)

Hospital, please specify number of days: ___

Residential treatment center, please specify number of days: ___

Group home or other community-based treatment placement, please specify number of days: ___

Other, please specify: _______________ Please specify number of days: ___

2. Has the child received any outpatient therapy?

0 = No

1 = Yes

If Yes: Specify type (Check all that apply)

Individual therapy for child, please specify number of visits: ___

Individual therapy for parent, please specify number of visits: ___

Family or Dyadic therapy, please specify number of visits: ___

Group therapy with other youth, please specify number of visits: ___

Multi-family group therapy, please specify number of visits: ___

Other, please specify: _______________ Please specify number of visits: ___

3. In what setting(s) has your agency provided services for this child and/or family? (Check all that apply)

Clinic

Home

School

Day treatment/partial hospitalization

Other, please specify________________________

4. Please indicate all general modalities of treatment provided. (Check all that apply)

Attachment-based therapy

Behavioral therapy

Cognitive therapy

Cognitive behavioral therapy

Day treatment or partial hospitalization

Expressive therapies (Drawing, movement, theater)

Family therapy

Intensive in-home services

Narrative therapy

Parent training

Peer therapy

Pharmacotherapy/medication

Phase-oriented trauma treatment

Play therapy

Psychoanalysis

Psychodynamic psychotherapy

School-based treatment

Social skills training

Solution-focused therapy

Stress management/relaxation training

Supportive therapy

‘Wrap around’ services

Other, please specify___________________________

Treatment by NCTSN Center (continued)

5. Please indicate the primary general modality of treatment provided. (Select only one)

1 = Attachment-based therapy

2 = Behavioral therapy

3 = Cognitive therapy

4 = Cognitive behavioral therapy

5 = Day treatment or partial hospitalization

6 = Expressive therapies (Drawing, movement, theater)

7 = Family therapy

8 = Intensive in-home services

9 = Narrative therapy

10 = Parent training

11 = Peer therapy

12 = Pharmacotherapy/medication

13 = Phase-oriented trauma treatment

14 = Play therapy

15 = Psychoanalysis

16 = Psychodynamic psychotherapy

17 = School-based treatment

18 = Social skills training

19 = Solution-focused therapy

20 = Stress management/relaxation training

21 = Supportive therapy

22 = ‘Wrap around’ services

98 = Other, specified in question 4

Treatment by NCTSN Center (continued)

Thinking about the period since the last assessment, please complete the following about services and treatment that your agency has provided for this child.

6. Please indicate all specific intervention protocols provided, if any. Items should ONLY be checked if treating clinician has been formally trained in the specific intervention protocol. (Check all that apply)

None

Abuse-Focused Cognitive Behavioral Therapy for Child Physical Abuse (AF-CBT)

Adapted Dialectical Behavior Therapy for Special Populations (DBT-SP)

Attachment, Self-Regulation, and Competence (ARC): A Comprehensive Framework for Intervention with Complexly Traumatized Youth

Child-Parent Psychotherapy (CPP)

Cognitive-Behavioral Intervention for Trauma in Schools (CBITS)

Combined Parent Child Cognitive-Behavioral Approach for Children & Families At-Risk for Child Physical Abuse

Combined Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and Selective Serotonin Reuptake Inhibitors (SSRI) Treatment

Culturally Modified Trauma-Focused Treatment (CM-TFT)

Eye Movement Desensitization and Reprocessing (EMDR)

Group Treatment for Children Affected by Domestic Violence

Integrative Treatment of Complex Trauma (ITCT)

Life Skills/Life Stories

Multimodality Trauma Treatment Trauma-Focused Coping (MMTT)

Multisystemic Treatment (MST)

Parent-Child Interaction Therapy (PCIT)

Real Life Heroes (RLH)

Safety, Mentoring, Advocacy, Recovery, and Treatment (SMART)

Sanctuary Model

Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)

Trauma Affect Regulation: Guidelines for Education and Therapy for Adolescents and Pre-Adolescents (TARGET-A)

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Grief (TG-CBT)

Trauma-Informed Brief Intervention Services

Trauma System Therapy (TST)

UCLA Trauma/Grief Program for Adolescents: Component Therapy for Trauma and Grief (CTTG)

Youth Dialectical Behavioral Therapy

Other, please specify:_____________________________

Treatment by NCTSN Center (continued)

7. Please indicate the primary specific intervention protocol provided, if any. Items should ONLY be checked if treating clinician has been formally trained in the specific intervention protocol. (Select only one).

1 = None

2 = Abuse-Focused Cognitive Behavioral Therapy for Child Physical Abuse (AF-CBT)

3 = Adapted Dialectical Behavior Therapy for Special Populations (DBT-SP)

4 = Attachment, Self-Regulation, and Competence (ARC): A Comprehensive Framework for Intervention with Complexly Traumatized Youth

5 = Child-Parent Psychotherapy (CPP)

6 = Cognitive-Behavioral Intervention for Trauma in Schools (CBITS)

7 = Combined Parent Child Cognitive-Behavioral Approach for Children & Families At-Risk for Child Physical Abuse

8 = Combined Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and Selective Serotonin Reuptake Inhibitors (SSRI) Treatment

9 = Culturally Modified Trauma-Focused Treatment (CM-TFT)

10 = Eye Movement Desensitization and Reprocessing (EMDR)

11 = Group Treatment for Children Affected by Domestic Violence

12 = Integrative Treatment of Complex Trauma (ITCT)

13 = Life Skills/Life Stories

14 = Multimodality Trauma Treatment Trauma-Focused Coping (MMTT)

15 = Multisystemic Treatment (MST)

16 = Parent-Child Interaction Therapy (PCIT)

17 = Real Life Heroes (RLH)

18 = Safety, Mentoring, Advocacy, Recovery, and Treatment (SMART)

19 = Sanctuary Model

20 = Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)

21 = Trauma Affect Regulation: Guidelines for Education and Therapy for Adolescents and Pre-Adolescents (TARGET-A)

22 = Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

23 = Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Grief (TG-CBT)

24 = Trauma-Informed Brief Intervention Services

25 = Trauma System Therapy (TST)

26 = UCLA Trauma/Grief Program for Adolescents: Component Therapy for Trauma and Grief (CTTG)

27 = Youth Dialectical Behavioral Therapy

98 = Other, specified in question 1

Treatment by NCTSN Center (continued)

8. Please indicate all other psychosocial intervention, brief treatment, crisis stabilization, educational services, auxiliary services or prevention modalities provided. (Check all that apply)

Acupuncture

Advocacy activities

Assessment-Based Treatment for Traumatized Children: Trauma Assessment Pathway (TAP)

Case management/case coordination

Child Adult Relationship Enhancement (CARE)

Child Development-Community Policing Program (CDCP)

Community Outreach Program-Esperanza (COPE)

Competence based auxiliary services

Debriefing

Honoring Children, Making Relatives (HC-MR)

Honoring Children, Mending the Circle (HC-MC)

Honoring Children, Respectful Ways (HC-RW)

International Family Adult and Child Enhancement Services (IFACES)

Meditation/Yoga

Mentoring

Posttraumatic Stress Management (PTSM)

Psycho-education

Psychological First Aid (PFA)

Safe Harbor Program

Self-Management/Coaching

Support groups

Streetwork Project

Therapeutic recreational activities including summer camp

Other, please specify:_________________________________

9. Please indicate ALL the types of clinicians/providers from your agency who have worked with this child. (Check all that apply)

Psychologist (Master’s or Ph.D.)

School psychologist (Not recorded above)

Psychology trainee/intern

Social worker (MSW, LCSW)

School social worker

Social worker trainee/intern

Psychiatrist

Other physician not psychiatrist

Physician extender: (NP, PA), Advanced practice nurse (MSN, CNS)

Nurse (RN, LPN)

Therapist/counselor (Not recorded above)

Occupational therapist/physical therapist

Paraprofessional

Translator/interpreter

Other, please specify:_____________________________

Treatment by NCTSN Center (continued)

10. Please indicate the primary lead clinician/provider from your agency who worked with this child.
    (Select only one)

1 = Psychologist (Master’s or Ph.D.)

2 = School psychologist (Not recorded above)

3 = Psychology trainee/intern

4 = Social worker (MSW, LCSW)

5 = School social worker

6 = Social worker trainee/intern

7 = Psychiatrist

8 = Other physician not psychiatrist

9 = Physician extender: (NP, PA), Advanced practice nurse (MSN, CNS)

10 = Nurse (RN, LPN)

11 = Therapist/counselor (Not recorded above)

12 = Occupational therapist/physical therapist

13 = Paraprofessional

14 = Translator/interpreter

15 = Other, specified in question 4

Clinical Evaluation
THIS FORM COMPLETED ONLY FOR CLIENTS REMAINING IN TREATMENT. Based on your clinical evaluation, for questions 1-21 please check each problem/symptom/disorder currently displayed by the child. For question 22 please indicate the primary problems/symptom/disorder currently displayed by the child.
Clinical Problems, Symptoms, and Disorders	Child has/exhibits this problem? (Answer all that apply)
Acute stress disorder	0 = No 1 = Probable 2 = Definite
Post traumatic stress disorder	0 = No 1 = Probable 2 = Definite
Traumatic/complicated grief	0 = No 1 = Probable 2 = Definite
Dissociation	0 = No 1 = Probable 2 = Definite
Somatization	0 = No 1 = Probable 2 = Definite
Generalized anxiety	0 = No 1 = Probable 2 = Definite
Separation disorder	0 = No 1 = Probable 2 = Definite
Panic disorder	0 = No 1 = Probable 2 = Definite
Phobic disorder	0 = No 1 = Probable 2 = Definite
Obsessive compulsive disorder	0 = No 1 = Probable 2 = Definite
Depression	0 = No 1 = Probable 2 = Definite
Attachment problems	0 = No 1 = Probable 2 = Definite
Sexual behavioral problems	0 = No 1 = Probable 2 = Definite
Oppositional defiant disorder	0 = No 1 = Probable 2 = Definite
Conduct disorder	0 = No 1 = Probable 2 = Definite
General behavioral problems	0 = No 1 = Probable 2 = Definite
Attention deficit hyperactivity disorder	0 = No 1 = Probable 2 = Definite
Suicidality	0 = No 1 = Probable 2 = Definite
Substance abuse	0 = No 1 = Probable 2 = Definite
Sleep disorder	0 = No 1 = Probable 2 = Definite
Adjustment disorder		0 = No 1 = Probable 2 = Definite
Disorders of infancy, childhood, or adolescence NOS		0 = No 1 = Probable 2 = Definite
Feeding disorder of infancy or early childhood		0 = No 1 = Probable 2 = Definite
Are there any other additional problems currently displayed by this child? Please specify: _______________________________________________________________________________
Please indicate the primary problem/symptom/disorder currently displayed by this child. (Select only one) 1 = Acute stress disorder 2 = Post traumatic stress disorder 3 = Traumatic/complicated grief 4 = Dissociation 5 = Somatization 6 = Generalized anxiety 7 = Separation disorder 8 = Panic disorder 9 = Phobic disorder 10 = Obsessive compulsive disorder 11 = Depression 12 = Attachment problems 13 = Sexual behavioral problems 14 = Oppositional defiant disorder 15 = Conduct disorder 16 = General behavioral problems 17 = Attention deficit hyperactivity disorder 18 = Suicidality 19 = Substance abuse 20 = Sleep disorder 21 = Adjustment disorder 22 = Disorders of infancy, childhood, or adolescence NOS 23 = Feeding disorder of infancy or early childhood 24 = Other

26. Please rate the child and caregiving system

0 = Resilient

1 = Average adaptive, could benefit from education or information on post-trauma adjustment

2 = Risk of disturbance and intervention recommended

3 = Disturbance and need of intensive intervention

27. Please rate the family’s resources (income and other resources available to address family needs)

0 = Family has financial resources necessary to meet needs

1 = Family has financial resources necessary to meet most needs; however, some limitations exist

2 = Family has financial difficulties that limit their ability to meet significant family needs

3 = Family experiencing financial hardship, poverty

99 = Unknown

This form is part of the Core Data Set designed for the National Child Traumatic Stress Initiative funded by SAMHSA based on NCTSN- Follow-up-CRF Version 5.0 20080206.

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