Child/YOuth Assess Child/YOuth Assessment and Referral Tool

Child/Youth Assessment and Referral Tool

Project #

OMB NO. 0930-0270
Expiration Date XX/XX/XXXX

The Crisis Counseling Assistance and Training Program (CCP) should have protocols or procedures in place for how a crisis counselor should respond if serious
reactions are indicated while using this tool. Many CCPs have team leaders or other staff with a mental health background to administer this tool to ensure proper
assessment and referral. All crisis counseling staff using this tool should have detailed training and guidance on use of the tool and when to make a referral for more
intensive services. Prior to use of this tool, the CCP should have identified at least one organization or agency that is willing to accept referrals from the CCP for
more intensive mental health or substance use intervention services.

Please use this tool as an interview guide.
1) with children receiving individual crisis counseling on the third and fifth occasions OR
2) with any child at any time if you suspect the child may be experiencing serious reactions to the disaster.

ENCOUNTER INFORMATION
Provider Name

Provider #

Date of Service
(mm/dd/yyyy)

County of Service

1st Employee #

2nd Employee #

ZIP Code of Service

VISIT NUMBER

First visit

Second visit

Third visit

Fourth visit

DURATION

15 - 29 minutes

30 – 44 minutes

45 – 59 minutes

60 minutes or more

Was parent or caregiver present during the visit?

Yes

Fifth visit or later

No

Was the team lead or supervisory staff present during administration of this tool?

Yes

No

READ: Occasionally, we find it helpful to ask children/adolescents or their parents/caregivers a few specific questions about how they were affected by the
disaster and how they are feeling now. May I ask you these questions? My first questions are about various experiences you have had in the disaster.

LOCATION OF SERVICE (select one)
school and child care (all ages through college)

temporary home (including friend or family homes, group homes, shelters,
apartments, trailers, and other dwellings)
IF A TEMPORARY HOME: PLEASE CHECK THIS BOX IF ANY
CHILDREN UNDER AGE 18 LIVE IN THIS HOME.

community center (e.g., recreation club)
provider site/mental health agency (agency involved with the CCP)

permanent home
IF A TEMPORARY HOME: PLEASE CHECK THIS BOX IF ANY
CHILDREN UNDER AGE 18 LIVE IN THIS HOME.

workplace (workplace of the disaster survivor and/or first responder)
disaster recovery center (e.g., Federal Emergency Management
Agency [FEMA], American Red Cross)

phone counseling (15 minutes or longer)

place of worship (e.g., church, synagogue, mosque)

IF HOTLINE, HELPLINE, or CRISIS LINE, please check here.

retail (e.g., restaurant, mall, shopping center, store)

medical center (e.g., doctor, dentist, hospital, mental health specialty center)

public place/event (e.g., street, sidewalk, town square, fair, festival,
sports)

other (specify in box)

RISK CATEGORIES (select all that apply)
family missing/dead

injured or physically harmed (self or household member)

evacuated quickly with no time to prepare

friend missing/dead

life was threatened (self or household member)

displace from home 1 week or more

pet missing/dead

witnessed death/injury (self or household member)

sheltered in place or sought shelter due to
immediate threat of danger

home damaged or destroyed

assisted with rescue/recovery (self or household member)

past substance use/mental health problem

vehicle or major property loss

had to change schools (for children or youth)

preexisting physical disability

other financial loss

prolonged separation from family

past trauma

disaster unemployed (self or household member)

DEMOGRAPHIC INFORMATION
Age (select one)

preschool (0-5 years)

child (6-11 years)

adolescent (12-17 years)

Grade level in school

If you have a disability or other access or functional need, indicate the type (select all that apply).
Physical (mobility, visual, hearing, medical, etc.)
Gender

Male

Intellectual/Cognitive (learning
disability, developmental delay, etc.)

Transgender

Female

Primary language spoken during this encounter (select one)

Mental Health/Substance Use (pyschiatric,
substance dependence, etc.)

None of these
English

Spanish

Other

Race/Ethnicity (select one or more)
American Indian/Alaska Native

Asian

Black/African American

Native Hawaiian/Other Pacific Islander

White

Hispanic/Latino

RESPONSE CARD (COUNSELOR COPY—GIVE THE LARGER VERSION TO CHILD/PARENT BEFORE ASSESSMENT)
Prior to beginning the assessment, please give the larger version of the response card to the child or parent who will be answering your questions. This card will
assist the child or parent in better understanding how often the child is experiencing certain reactions.
Think about your thoughts, feelings, and behavior DURING THE FIRST MONTH. Use these frequency rating options to help answer how often the problem has
happened in the past month. For each question choose ONE of the following responses.
0
S

M

T

W

1
T

F

S

S

M

T

W

2
T

F

S

S

M

X

T

W

3
T

X

F

S

S

X
X
X

X
“Not at all” means never in
the past month.

A “little bit” means about 2
times per month.

T

X

X
X

M

“Somewhat” means about 12 times each week during the
past month.

X

T

X
X

X
X

W

4
F

S

X
X

X

S

M

T

W

T

F

S

X

X

X

X

X

X

X

X
X

X
X

X

X

“Quite a bit” means 2-3 times
a week during the past
month.

X

X

X

X

X

X

X

X

X

X

X

“Very much” means almost
every day.

ASSESSMENT QUESTIONS
INTRODUCTION: I want to talk to you about your (your child’s) feelings and thoughts about the disaster and how much they are causing problems now. Think
about your thoughts, feelings, and behavior DURING THE PAST MONTH (please remind child/parent of this for each question). Use the frequency rating options
on the previous page and on the response card to help the chlid answer how often the problem has happened in the past month. For each question choose
ONE of the following responses and check the appropriate box for that question.

0 = not at all

1 = a little bit

2 = somewhat

3 = quite a bit

4 = very much

QUESTIONS TO BE READ

RESPONDENT ANSWERS

1.

Do you get upset, afraid, or sad when something makes you think about the disaster?

0

2.

Do you have bad dreams or nightmares about what happened?

0

1
1
0

2

3

4

2

3

4

1

3.

Do you have upsetting thoughts or pictures that come into your mind about what happened?

0

1

2

3

4

4.

Do you try not to think about or talk about what happened?

0

1

2

3

4

5.

Do you stay away from places, people, or things that make you remember the disaster?

0

1

2

3

4

6.

Do you have difficulty falling asleep or wake up often because of what happened?

0

1

2

3

4

7.

Do you feel jumpy or nervous?

0

1

2

3

4

8.

Do you find it harder to concentrate or pay attention to things than you usually do?

0

1

2

3

4

2

9.

Do you feel irritable or grouchy?

0

1

2

3

4

10.

Do you feel sad, down, or depressed?

0

1

2

3

4

11.

Have you had more aches and pains, such as stomachaches or headaches?

0

1

2

3

4

12.

If in school: Do you find it harder to get your schoolwork done?

0

1

2

3

4

13.

Do you worry about something else bad happening to you/your family/your friends?

0

1

2

3

4

14.

Are you having a harder time getting along with family or your friends?

0

1

2

3

4

15.

Are you finding it harder to do or enjoy activities that you used to enjoy?

0

1

2

3

4

ASSESSMENT QUESTIONS (continued)
ADDITIONAL QUESTIONS FOR PARENTS (required for parents of children ages 0-7; recommended for parents of all children and adolescents)

QUESTIONS TO BE READ

RESPONDENT ANSWERS

16.

Has your child been more clingy or worried about separation?

0

1

2

3

4

17.

Has your child been more quiet and withdrawn?

0

1

2

3

4

18.

Has your child talked repeatedly or asked questions about the disaster?

0

1

2

3

4

19.

Has your child’s play been about the disaster?

0

1

2

3

4

20.

Have you noticed changes in your child’s behavior or development (e.g., bed-wedding, baby talk, fighting
or risk-taking behavior, or decline in school performance)?

0

1

2

3

4

COUNT THE NUMBER OF ENTRIES IN THE LAST 2 COLUMNS ABOVE THAT HAVE A SCORE OF 3 OR 4.
IF TOTAL NUMBER IS 4 OR MORE, DISCUSS THE POSSIBILITY OF A REFERRAL FOR SERVICES.

TOTAL NUMBER

FOR CHILDREN OVER THE AGE OF 10 OR IF YOU ARE CONCERNED ABOUT A YOUNGER CHILD, YOU MAY ASK:
21. In the past few weeks, have you wished you were dead?
YES
NO
22. In the past few weeks, have you felt that you or your family would be better off if you were dead?
YES
NO
23. In the past week, have you been having thoughts about killing yourself?
YES
NO
24. Have you ever tried to kill yourself?
YES
NO
If the patient answers "Yes" to any of the above, ask the following acuity question:
Are you having thoughts of killing yourself right now?
YES
NO
IF THE ANSWER TO ANY OF THE ITEMS ABOVE IS "YES," REFER FOR IMMEDIATE PSYCHIATRIC INTERVENTION. The CCP should has protocols or
procedures in place for how a crisis counselor should respond or react if the response if "YES".

REFERRAL (select all that were communicated)
crisis counseling program services (e.g., group counseling, referral to a
team leader, follow-up visit)

community services (e.g., FEMA, loans, housing, employment, social
services)

mental health services (e.g., professional, longer-term counseling,
treatment, behavioral, or psychiatric services)

resources for those with disabilities, or other access or functional needs

substance use services (e.g., professional, behavioral, or medical treatment
or self-help groups, such as Alcoholics Anonymous or Narcotics Anonymous)

other (specify in box)

Was the referral accepted by the child?

YES

NO

Was the referral accepted by the parent/caregiver?

YES

NO

INSTRUCTIONS: CHILD/YOUTH ASSESSMENT AND REFERRAL TOOL
It is recommended that this form be used with all children or youth who are intensive users of services. Intensive users are people who are participating in their third individual crisis
counseling vist with any crisis counselor from the program or who continue to suffer severe distress that may be impacting their ability to perform routine daily activities. This form should be
used as an interview guide (1) with children receiving individual crisis counseling on the third and fifth occasions OR (2) with any child at any time if you suspect the child may be
experiencing serious reaction sto the disaster.
PROJECT #—FEMA disaster declaration number, e.g., DR-XXX-State

PROVIDER NAME—The name of the program/agency.

PROVIDER #—The unique number under which your program/agency is providing services.
1st EMPLOYEE #—YOUR employee number.

2nd EMPLOYEE #—Employee number of your teammate during this encounter.

DATE OF SERVICE—The date of the encounter in the format mm/dd/yyy, e.g., 01/01/2012.
COUNTY OF SERVICE—The county where the encounter occurred.

ZIP CODE OF SERVICE—The ZIP code of the location where the encounter occurred.

VISIT NUMBER—Is this the first, second, third, fourth, fifth, or later visit for this person to your program? All visits did not have to be with you. SELECT ONLY ONE.
DURATION—How lond did your encounter last? SELECT ONLY ONE. If the encounter was under 15 minutes, record it on the Weekly Tally Sheet.
LOCATION OF SERVICE—Where did the encounter occur? SELECT ONLY ONE.
RISK CATEGORIES—These are factors than an individual may have experienced or may have present in his or her life that could increase his or her need for services. MORE THAN ONE
CATEGORY MAY APPLY. SELECT ALL CATEGORIES THAT APPLY.

DEMOGRAPHIC INFORMATION:
AGE—What age does the person or his or her parent indicate he or she is? SELECT ONLY ONE.
GRADE LEVEL IN SCHOOL—Please enter the number, e.g., 4 = fourth grade.
PERSONS WITH DISABILITIES OR OTHER ACCESS OR FUNCTIONAL NEEDS—If the participant or his or her parent considers the participant to have a disability or an access or
functional need, what type is indicated (physical, intellectual/cognitive, or mental health/substance use)? SELECT ALL THAT APPLY.
•
•
•

Physical: Includes disorders that impair mobility, seeing, or hearing, as well as medical conditions, such as diabetes, lupus, Parkinson’s, AIDS, or multiple sclerosis (MS).
Intellectual: Includes a learning disability, birth defect, neurological disorder, developmental disability, or traumatic brain injury (e.g., Down syndrome).
Mental Health/Substance Use: Includes psychiatric disorders, such as bipolar disorder, depression, post-traumatic stress disorder (PTSD), schizophrenia, and substance
dependence.
GENDER—The gender the person reports him- or herself to be. SELECT ONLY ONE.

PRIMARY LANGUAGE SPOKEN DURING ENCOUNTER(S)—What language did you actually and primarily use to speak with this individual during the encounter? This may be
different from the preferred language. If “OTHER” (not English or Spanish), fill in the other language that the person used (may include sign language). SELECT ONLY ONE.
RACE/ETHNICITY—What race does the person identify as being? SELECT ALL THAT APPLY.
REFERRALS—Based on your conversation with this individual, you may have referred him or her for other services. In the REFERRAL box, select all of the types of services to which
you referred the person.
ASSESSMENT QUESTIONS--GIVE THE RESPONSE CARD TO THE INDIVIDUAL.
For each question, put a check mark in the appropriate box based on the individual's responses. COUNT THE NUMBER OF ENTRIES IN THE LAST 2 COLUMNS THAT
HAVE A SCORE OF 3 OR 4. IF TOTAL NUMBER IS 4 OR MORE, DISCUSS THE POSSIBILITY OF A REFERRAL FOR SERVICES.
For questions 21-24, indicate "yes" or "no" based on the individual's responses. SELECT ONLY ONE.
If the child responds "yes" to any question 21-24, ask question 25 and indicate "yes" or "no" based on the individual's response. SELECT ONLY ONE.
REFERRALS ACCEPTED—This refers to whether or not the child or parent took the information you offered, not if they followed up on the referral. SELECT ONLY ONE.

Please submit the completed form to the designated person in your agency who will review the form.
Thank you for taking the time to complete this form accurately and fully!
Paperwork Reduction Act Statement This information is being collected to assist the Substance Abuse and Mental Health Services Administration
(SAMHSA) with program monitoring of FEMA’s Crisis Counseling Assistance and Training Program. Crisis counselors are required to complete this form
following the delivery of crisis counseling services to disaster survivors (44 CFR 206.171 [F][3]). Information collected through this form will be used at
an aggregate level to determine the reach, consistency, and quality of the Crisis Counseling Assistance and Training Program. Under the Privacy Act of
1974, any personally identifying information obtained will be kept private to the extent of the law. 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 0930-0270. Public reporting burden for this collection of information is estimated to average 15 minutes per assessment, 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, 5600 Fishers Ln, Room 15E57B, Rockville, MD 20857.