Download mental health screening tool

MENTAL HEALTH SCREENING TOOL – YOUTH (Ages 6 to 17 Years)
For each section below, check all applicable boxes.
This list is not exhaustive. If you have a question about whether or not to check “Yes,” check “Unknown” and provide
relevant information in the comment section. PLEASE COMPLETE BOTH SIDES OF THE SCREENING TOOL.
Has the youth been a danger to him/herself or to others in the last 90 days?
 Attempted suicide
 Made suicidal gestures
 Yes
 Expressed suicidal ideation
 No
 Assaultive to other children or adults
 Unknown
 Reckless and puts self in dangerous situations
 Attempts to or has sexually assaulted or molested other children
Has this youth experienced severe physical or sexual abuse or has he/she been exposed to extreme violent behavior
in his/her home in the last 90 days?
 Physical abuse
 Domestic violence
 Yes
 Sexual abuse
 No
 Severe bruising in unusual areas
 Unknown
 Forced to watch torture or sexual assault
 Witness to murder
Does this youth have behaviors that are so difficult that maintaining him/her in his/her current living situation is in
jeopardy?
 Persistent chaotic, impulsive or disruptive behaviors
 Daily verbal outbursts
 Yes
 Excessive noncompliance
 No
 Constantly challenges the authority caregiver
 Unknown
 Requires constant direction and supervision in all activities
 Excessive truancy
 Fails to respond to limit setting or other discipline
Has the youth exhibited bizarre or unusual behavior in the last 90 days?
 Fire-setting
 Cruelty to animals
 Yes
 Excessive, compulsive, or public masturbation
 No
 Appears to hear voices or respond to other internal stimuli (including alcohol and drug
 Unknown
induced); repetitive body motions (e.g., head banging)
 Vocalization (e.g., echolalia)
 Smears feces
Comments/ Additional Information:
Please fax this completed form to the Youth Alliance (YA) at 831-636-2850.
Reviewed by:
Referred to:  YA Services
*** FOR YA OFFICE USE ONLY***
Date:
 SBC Behavioral Health (Fax 831-636-4025)
Youth Alliance
MENTAL HEALTH SCREENING TOOL
YOUTH (Ages 6 to 17 Years)
Page 1 of 2
 Other:
Youth Name:
Youth DOB:
Today’s Date:
Completed By:
Location (School or Agency Name):
CONFIDENTIAL PATIENT INFORMATION (SEE CALIFORNIA WELFARE AND INSTITUTIONS CODE SECTION 5328)
Rev10/3/11
MENTAL HEALTH SCREENING TOOL – YOUTH (Ages 6 to 17 Years)
For each section below, check all applicable boxes.
This list is not exhaustive. If you have a question about whether or not to check “Yes,” check “Unknown” and provide
relevant information in the comment section. PLEASE COMPLETE BOTH SIDES OF THE SCREENING TOOL.
Does the youth have problems with social adjustments?
 Regularly involved in physical fights with other children or adults
 Verbally threatens people
 Damages possessions of self or others
 Runs away
 Truant
 Yes
 Steals
 No
 Habitual lying
 Unknown
 Gang Involvement
 Arrested and confined due to serious law violations
 Does not seem to feel guilt after misbehavior
 Chooses sedentary activity over age appropriate activities
(i.e. excessive TV and/or computer use)
Does the youth have problems making and maintaining healthy relationships?
 Yes
 Unable to form positive relationships with peers
 No
 Provokes and victimizes other children
 Unknown
 Does not form bond with caregiver
Does the youth have significant problems managing his/her feelings?
 Severe temper tantrums
 Screams uncontrollably
 Cries inconsolably
 Significant and regular nightmares
 Yes
 Withdrawn and uninvolved with others
 No
 Whines or pouts excessively
 Unknown
 Regularly expresses the feeling that others are out to get him/her
 Worries excessively and preoccupied compulsively with minor annoyances
 Regularly expresses feelings of worthlessness or inferiority
 Frequently appears sad or depressed
 Constantly restless or overactive
Does the youth have a history of psychiatric hospitalization, mental health care, and/or prescribed psychotropic
medication?
 Yes
 History of inpatient psychiatric hospitalization(s)
 No
 History of outpatient mental health care
 Unknown
 History of prescribed psychotropic medication(s)
Is the youth known to abuse alcohol and/or drugs?
 Yes
 Abuses alcohol
 No
 Abuses substances
 Unknown
Comments/ Additional Information:
Please fax this completed form to the Youth Alliance (YA) at 831-636-2850.
Youth Alliance
MENTAL HEALTH SCREENING TOOL
YOUTH (Ages 6 to 17 Years)
Page 2 of 2
Youth Name:
Youth DOB:
Date of Completion:
CONFIDENTIAL PATIENT INFORMATION (SEE CALIFORNIA WELFARE AND INSTITUTIONS CODE SECTION 5328)
Rev10/3/11
AUTHORIZATION FOR RELEASE OF INFORMATION
Youth Alliance and San Benito County Behavioral Health
INSTRUCTIONS: In order to make a referral for mental health services, please discuss the referral with the
child's parent or guardian. If the parent or guardian agrees with the referral, please obtain the following
information, including the parent/guardian's signature. Fax this Authorization and the completed Mental
Health Screening Tool to the Youth Alliance at 831-636-2850.
Youth First Name:
Youth Last Name:
 Male
Gender:
Date of Birth:
Ethnicity:
Is the youth of Hispanic or Latino origin?  Yes
Race:
 African American
 American Indian or Alaska Native
Asian
(Check all that
apply)
Primary
Language
(Check only one)
 English
 Spanish
 Female
 No
 Unknown
 Caucasian / White
 Native Hawaiian or Other Pacific Islander
 Other: ____________________________________________
 Other: ______________
Parent/Guardian Name:
Phone Number:
I hereby authorize _________________________________________________________________________
Name of School or Agency, Address
to release to the Youth Alliance and San Benito County Behavioral Health the information list below.
Records may be copied and/or faxed, and shall be limited to (check all that apply)  requesting  releasing
the following types of information (check all applicable items):
 Mental health information  Behavioral information
 Social information
 School Performance
This information is required in order to make a referral for a mental health evaluation.
This Authorization for Release of Information becomes effective _________________.
Month / Day / Year
I understand that this Authorization may be revoked by me at any time, except to the extent that action has
already been taken. If not revoked, it shall terminate at the end of (check one):  1 year  Other: __________
I understand that I may request a copy of this Authorization.
________________________________________________
__________________________________
Signature of Parent or Guardian
Date
Relationship to Child:  Parent  Guardian  Other authorized representative: __________________________
________________________________________________
__________________________________
Signature of Person Obtaining Authorization
Date
Youth Alliance and San Benito County Behavioral Health
AUTHORIZATION FOR RELEASE OF INFORMATION
CONFIDENTIAL PATIENT INFORMATION (SEE CALIFORNIA WELFARE AND INSTITUTIONS CODE SECTION 5328)
Rev10/3/11