Download School-Based Mental Health Network Student Assessment and s

School-Based Mental Health Network
Student Assessment and
Referral Application
(SARA)
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I.
Login Information
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I.
LOGIN INFORMATION
Field: LEA Number
Local Education Agency, the unique four-digit number assigned by the ADE
to identify the individual county, district, and cooperatives. The first two digits
represent the county, and the second two digits represent the district, for
example:
6001
60 = Pulaski County
01 = Little Rock School District
Field: Password
The unique password assigned by the ADE to identify the individual
completing the SARA application.
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II. Student Information Screen
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II. Student Information Screen
Button: Support
This button allows the user to choose the SARA User’s Guide, Data Dictionary
and the FAQs.
Button: New Record
This button allows the user to choose start a new student record.
Button: Exit
This button allows the user to exit SARA and return back to the School-Based
Mental Health web page.
Field: Student ID
The nine-digit Social Security number of the student. If a student’s SSN cannot be
obtained, then the ADE assigned number as required by Arkansas Code Ann. 618-208 should be used. This number should remain the same throughout the
student’s school career.
Hyperlink: New Service Entry
This link allows the user to begin a new service entry for the selected student ID
number.
*If any previous student record exists it will appear under this section with the
option to edit or delete.
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III. Student Demographics
and Referral Information
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III.
STUDENT DEMOGRAPHICS AND REFERRAL
INFORMATION
Field: Service Type
The type of SARA intake that the therapist will be completing for the
child/family being treated. The full intake option is for LEAs that choose to
use SARA as the primary intake for the mental health record. The abbreviated
option is for LEAs that choose to another intake format as it’s primary
measurement for the mental health record.
Field: Student ID
The nine-digit Social Security number of the student. If a student’s SSN cannot
be obtained, then the ADE assigned number as required by Arkansas Code
Ann. 6-18-208 should be used. This number should remain the same
throughout the student’s school career.
Field: Service Begin Date
The day, month, and year student begins receiving SBMH services.
Field: First Name
The student’s legal first name as printed on the student’s birth certificate,
social security card, or other legally binding documentation.
Field: Last Name
The student’s legal last name as printed on the student’s birth certificate,
social security card, or other legally binding documentation.
Field: Middle Name
The student’s legal middle name as printed on the student’s birth certificate,
social security card, or other legally binding documentation.
Field: Date of Birth
The student’s date of birth.
Field: Age
The student’s age at the time of referral for services.
Field: Gender
The sexual classification of the student from the following choices:
Male
Female
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Field: Race
The general racial or ethnic heritage with which the individual most identifies
from the following choices:
Asian or Pacific Islander
A person having origins in any of the original peoples of the Far East,
Southeast Asia, the Indian subcontinent, or the Pacific Islands, including, for
example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam. The Pacific Islands include
Hawaii, Guam, and Samoa.
Black
A person having origins in any of the Black racial groups of Africa.
Hispanic
A person of Cuban, Mexican, Puerto Rican, South or Central American, or
other Spanish culture or origin, regardless of race.
American Indian or Alaskan Native
A person having origins in any of the original peoples of North and South
America (including Central America) and who maintains tribal affiliation or
community attachment.
White
A person having origins in any of the original peoples of Europe, the Middle
East, or North Africa.
Field: Grade Level
The grade level in which the student is currently enrolled from the following
choices.
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Non-Graded Elementary
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This category should only be used in extreme situations in which the student’s
grade cannot be appropriately determined. Where possible, use the grade that
will be used for purposes of assessment.
Non-Graded Middle/Jr.
This category should only be used in extreme situations in which the student’s
grade cannot be appropriately determined. Where possible, use the grade that
will be used for purposes of assessment.
Non-Graded Secondary
This category should only be used in extreme situations in which the student’s
grade cannot be appropriately determined. Where possible, use the grade that
will be used for purposes of assessment.
Field: Guardian First Name
The legal guardian’s first name.
Field: Guardian Last Name
The legal guardian’s last name.
Field: Guardian Relationship
The guardian’s relationship to the student who is referred for SBMH services
from the following choices:
Aunt /Uncle
Brother/Sister
Cousin
Father
Friend
Grand Parent
Guardian
Mother
Agency representative
Family member
Foster Parent
Other
Field: Other Guardian Relationship
Specify guardian’s specific relationship to student if the relation is not
included on the list above.
Field: Address
The street number and name, apartment/ room/ suite number, or post office
box of the guardian’s permanent address.
Field: City
The name of the city in which the guardian’s permanent address is located.
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Field: Zip
The five or nine digit zip code portion of the guardian’s permanent address.
Field: Phone (H)
The legal guardian’s home telephone number including the area code.
Field: Phone (W)
The legal guardian’s work telephone number including the area code.
Field: Email Address
The guardian’s electronic mail (email) address.
Field: Additional Comments
This field can contain any additional information related to the student’s
demographic information.
Field: Referral Date
The month, day, and year on which the individual is referred for SBMH
services.
Field: Name of Referral Source
This field includes the name of the person, organization, or agency that made
the original referral for the student.
Field: Referral Relationship
The relationship of the referral source to the student from the following
choices:
Individual (Self-Referral)
This includes only those persons that are requesting services on their own
behalf and have not been referred by any of the other referral sources that are
listed below.
Parent/Legal Guardian
A referral for services made by the student’s parent/guardian.
School Counselor
A referral for services made by a school counselor.
Teacher
A referral for services made by a teacher within the school district.
Principal
A referral for services made by a principal within the school district.
School Resource/Security Officer
A referral for services made by a school resource/security officer.
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Mental Health Care Provider
This includes psychiatric hospitals or institutions, community mental health
centers and licensed health care professionals who provide counseling,
psychological, or psychiatric treatment.
Juvenile Justice
This includes referrals made by the state’s juvenile justice system. This may
be a direct or indirect referral.
Physician/Doctor
This includes persons who are referred by their doctor or another physician
for services.
Other
Any person not included in the above choices.
Field: Other Referral Source
If a student was referred by more than one source, list name and specify the
specific relation to the student.
Field: Reason for Referral—Academic
If box is selected, this is indication that the nature of the student’s presenting
problem is related to problems with academic functioning (e.g., grades).
Field: Reason for Referral—Behavior
If box is selected, this is indication that the nature of the student’s presenting
problem is related to problems that are behavioral in nature (e.g., discipline
violations).
Field: Reason for Referral—Emotional
If box is selected, this is indication that the nature of the student’s presenting
problem is related to problems with emotional functioning (e.g., depressive or
angry).
Field: Reason for Referral—Social
If box is selected, this is indication that the nature of the student’s presenting
problem is related to problems with social functioning (e.g., relationships with
peers or teachers).
Field: Reason for Referral—Family
If box is selected, this is indication that the nature of the student’s presenting
problem is related to problems with the student’s family functioning (e.g.,
divorce or death in the family).
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Field: Reason for Referral—Other
If box is selected, this is indication that the nature of the student’s presenting
problem is not described by the indicators listed above. Specify the other
reason(s) for referral.
Field: Additional Comments
This field can include any additional comments related to the student’s
referral for SBMH services.
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IV. Evaluations, Interventions and Outcomes
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IV.
EVALUATIONS, INTERVENTIONS AND
OUTCOMES
Field: Psychological Evaluation
A systematic evaluation performed by an appropriately licensed individual
that provides detailed information about an individual’s psychological
functioning. Indicate
Yes—student has participated in a psychological evaluation.
No —student has not participated in a psychological evaluation.
If YES is selected, indicate if the student received any of the following
services as a result of the psychological evaluation:
Psychotherapy
Medication(s)
School Counseling
Day Treatment
Acute/Residential Care
Case Management
Other Services
Field: Additional Comments (Psychological Evaluation)
This field can include any additional comments related to the student’s history
of psychological evaluations, interventions, and outcomes. For example, this
field may contain information such as treatment provider and duration of
treatment.
Field: Psychiatric Evaluation
Activities performed by an appropriately licensed individual to determine the
client’s need for services and to recommend a course of treatment. Indicate
Yes—student has participated in a psychiatric evaluation.
No—student has not participated in a psychiatric evaluation.
If YES is selected, indicate if the student received any of the following
services as a result of the psychiatric evaluation:
Psychotherapy
Medication(s)
School Counseling
Day Treatment
Acute/Residential Care
Case Management
Other Services
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Field: Additional Comments (Psychiatric Evaluation)
This field can include any additional comments related to the student’s history
of psychiatric evaluations, interventions, and outcomes. For example, this
field may contain information such as treatment provider and duration of
treatment.
Field: Medical Evaluation
Activities provided by an appropriately licensed individual that provides a
complete medical evaluation identifying developmental problems and/or
coexisting medical problem. Indicate
Yes—student has participated in a medical evaluation.
No —student has not participated in a medical evaluation.
If YES is selected, indicate if the student received any of the following
services as a result of the medical evaluation:
Psychotherapy
Medication(s)
School Counseling
Day Treatment
Residential Care
Case Management
Other Services
Field: Additional Comments (Medical Evaluation)
This field can include any additional comments related to the student’s history
of medical evaluations, interventions, and outcomes. For example, this field
may contain information such as treatment provider and duration of
treatment.
Field: Other Evaluation
Indicate if the student has participated in any other evaluations not identified
on the list above. Indicate
Yes—student has participated in other evaluations.
No —student has not participated in other evaluations.
If YES is selected, indicate if the student received any of the following
services as a result of the evaluation:
Case Management
Speech/Language Services
Occupational Therapy
Physical Therapy
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Personal Care
Private Duty Nursing
Other Services
Field: Additional Comments (Other Evaluation)
This field can include any additional comments related to the student’s history
of other evaluations, interventions, and outcomes. For example, this field may
contain information such as treatment provider and duration of treatment.
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V.
Educational Functioning
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V. EDUCATIONAL FUNCTIONING
Field: Meal Status
A student who has limited eligibility for federal assistance or by being
disadvantaged may qualify for free or reduced breakfast and/or lunch as
designated:
Free
Reduced
Full-price Paid
Field: Gifted/Talented
Students identified as having high potential or ability whose learning
characteristics and educational needs require qualitatively differentiated
educational experiences and/or services.
Yes – student is identified as gifted/talented.
No – student is not identified as gifted/talented.
Field: Special Education
A student has been determined to be eligible for special education under the
Individuals with Disabilities Education Act and has an individualized
education program (IEP). Does not include students determined handicapped
under Section 504 of the Rehabilitation Act of 1973. Indicate
Yes – student is receiving special education services.
No – student does not receive special education services.
Field: Primary Disability
This field only applies to students receiving Special Education services.
Indicate the student’s primary disability, if student is eligible for special
education services.
Autism
“. . . a developmental disability significantly affecting verbal and nonverbal
communication and social interaction, generally evident before age 3, that
adversely affects a child’s educational performance. Other characteristics often
associated with autism are engagement in repetitive activities and stereotyped
movements, resistance to environmental change or change in daily routines, and
unusual responses to sensory experiences. The term does not apply if a child’s
educational performance is adversely affected primarily because the child has an
emotional disturbance, as defined in paragraph (b)(4) of this section.” [taken
from 34 Code of Federal Regulations §300.7(c)(1)(i)]
Deaf-Blindness
“. . . concomitant hearing and visual impairments, the combination of which
causes such severe communication and other developmental and educational
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needs that they cannot be accommodated in special education programs solely
for children with deafness or children with blindness.” [taken from 34 Code of
Federal Regulations §300.7(c)(2)]
Emotional Disturbance
“(i) The term means a condition exhibiting one or more of the following
characteristics over a long period of time and to a marked degree that adversely
affects a child’s educational performance:
(A) An inability to learn that cannot be explained by intellectual,
sensory, or health factors.
(B) An inability to build or maintain satisfactory interpersonal
relationships with peers and teachers.
(C) Inappropriate types of behavior or feelings under normal
circumstances.
(D) A general pervasive mood of unhappiness or depression.
(E) A tendency to develop physical symptoms or fears associated with
personal or school problems.
(ii) The term includes schizophrenia. The term does not apply to children who
are socially maladjusted, unless it is determined that they have an emotional
disturbance.” [taken from 34 Code of Federal Regulations §300.7(c)(4)]
Deaf/Hearing Impairment
Deafness: “. . . a hearing impairment that is so severe that the child is impaired
in processing linguistic information through hearing, with or without
amplification, that adversely affects a child’s educational performance.” [34
Code of Federal Regulations §300.7(c)(3)]
Hearing Impairment: “. . . an impairment in hearing, whether permanent or
fluctuating, that adversely affects a child’s educational performance but that is
not included under the definition of deafness in this section.”[taken from 34
Code of Federal Regulations §300.7(c)(5)]
Multiple Disabilities
“. . . concomitant impairments (such as mental retardation-blindness, mental
retardation, orthopedic impairment, etc.), the combination of which causes such
severe educational needs that they cannot be accommodated in special education
programs solely for one of the impairments. The term does not include deafblindness.” [taken from 34 Code of Federal Regulations §300.7(c)(7)]
Mental Retardation
“. . . significantly subaverage general intellectual functioning, existing
concurrently with deficits in adaptive behavior and manifested during the
developmental period, that adversely affects a child’s educational performance.”
[taken from 34 Code of Federal Regulations §300.7(c)(6)]
Other Health Impairment
“(9) Other health impairment means having limited strength, vitality or
alertness, including a heightened alertness to environmental stimuli, that results
in limited alertness with respect to the educational environment, that-(i) Is due to chronic or acute health problems such as asthma, attention
deficit disorder or attention deficit hyperactivity disorder, diabetes,
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epilepsy, a heart condition, hemophilia, lead poisoning, leukemia,
nephritis, rheumatic fever, and sickle cell anemia; and
(ii) Adversely affects a child’s educational performance.”[taken from 34
Code of Federal Regulations §300.7(c)(9)]
Orthopedic Impairment
“. . . a severe orthopedic impairment that adversely affects a child’s educational
performance. The term includes impairments caused by congenital anomaly (e.g.,
clubfoot, absence of some member, etc.), impairments caused by disease (e.g.,
poliomyelitis, bone tuberculosis, etc.), and impairments from other causes (e.g.,
cerebral palsy, amputations, and fractures or burns that cause contractures).”
[taken from 34 Code of Federal Regulations §300.7(c)(8)]
Speech/Language Impairment
“. . . a communication disorder, such as stuttering, impaired articulation,
language impairment, or a voice impairment, that adversely affects a child’s
educational performance.” [taken from 34 Code of Federal Regulations
§300.7(c)(11)]
Specific Learning Disability
“. . . a disorder in one or more of the basic psychological processes involved in
understanding or in using language, spoken or written, that may manifest itself in
an imperfect ability to listen, think, speak, read, write, spell, or to do
mathematical calculations, including conditions such as perceptual disabilities,
brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia. . .
The term does not include learning problems that are primarily the result of
visual, hearing, or motor disabilities, of mental retardation, of emotional
disturbance, or of environmental, cultural, or economic disadvantage.” [taken
from 34 Code of Federal Regulations §300.7(c)(10)]
Traumatic Brain Injury
“. . . an acquired injury to the brain caused by an external physical force,
resulting in total or partial functional disability or psychosocial impairment, or
both, that adversely affects a child’s educational performance. The term applies
to open or closed head injuries resulting in impairments in one or more areas,
such as cognition; language; memory; attention; reasoning; abstract thinking;
judgment; problem-solving; sensory, perceptual, and motor abilities;
psychosocial behavior; physical functions; information processing; and speech.
The term does not apply to brain injuries that are congenital or degenerative, or
to brain injuries induced by birth trauma.” [34 Code of Federal Regulations
§300.7(c)(12)]
Visual Impairment
“. . . an impairment in vision that, even with correction, adversely affects a
child’s educational performance. The term includes both partial sight and
blindness.” [34 Code of Federal Regulations §300.7(c)(13)]
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Field: Educational Placement
This field only applies to students receiving Special Education services.
Indicate the student’s current educational placement:
Public Day School
If a student receives special education and related services for greater than 50
percent of the school day in a publicly funded facility that does not house
programs for students without disabilities.
Private Day School
If a student receives special education and related services for greater than 50
percent of the school day in a privately funded facility that does not house
programs for students without disabilities.
Hospital/Homebound
If a student receives special education in medical treatment facilities on an inpatient basis or at home.
Public Residential
If a student receives special education and related services for greater than 50
percent of the school day in a public residential facility.
Regular Class with Special Education (up to 21% of the school
day)
If a student receives special education and related services outside the regular
classroom for less than 21 percent of the school day. This may include children
and youth with disabilities placed in: regular class with special education/related
services provided within regular class, regular class with instruction within the
regular class and with special education/related services provided outside
regular class, or regular class with special education services provided in a
resource room.
Students who receive special education and related services in age-appropriate
community-based settings that include individuals with and without disabilities,
such as college campuses or vocational sites, receiving special education and
related services outside regular classrooms or community-based settings for less
than 21 percent of the school day.
Private Residential
If a student receives special education and related services for greater than 50
percent of the school day in a private residential facility.
Resource Room (between 21% to 60% of the school day)
If a student receives special education and related services outside the regular
classroom for 60 percent or less of the school day and at least 21 percent but no
more than 60 percent of the school day. This may include children and youth
placed in: resource rooms with special education/related services provided
within the resource room, or resource room with part-time instruction in a
regular class. Students who receive special education and related services in
age-appropriate community-based settings that include individuals with and
without disabilities, such as college campuses or vocational sites, receiving
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special education and related services outside the regular classrooms or
community-based settings for at least 21 percent but no more than 60 percent of
the school day.
Self-contained (60% or more of the school day in special
education)
If a student receives special education and related service outside the regular
classroom for more than 60 percent of the school day. This includes only
children and youth with disabilities educated on the regular school campus. This
does not include pupils who received education programs in public or private
separate day or residential facilities. This may include children and youth placed
in: self-contained special classrooms with part-time instruction in a regular
class, or self-contained special classrooms full-time on a regular school campus.
Students who receive special education and related services in age-appropriate
community-based settings that include individuals with and without disabilities,
such as college campuses or vocational sites, receiving special education and
related services outside the regular classroom or community-based setting for
more than 60 percent of the school day.
Field: Section 504
A student has been determined to be eligible under Section 504 of the
Rehabilitation Act of 1973. For purposes of this database, this does not
include special education students. Indicate
Yes – student is eligible under Section 504.
No – student is not eligible under Section 504.
Field: Medicaid Eligible
Yes – student is eligible for Medicaid.
No – student does not qualify for Medicaid assistance.
Field: Medicaid Number
Enter the Medicaid case number if student is eligible for Medicaid assistance.
Field: Private Insurance
Yes – student has private insurance.
No – student does not have private insurance.
Field: Insurance
If “Yes” was chosen in the previous field then this field should indicate the
type of insurance that covers the student.
Field: Policy Number
This field indicates the policy number for the private insurance.
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Field: Migrant Status
Indicates a student who changes schools throughout the year, often crossing
school districts and state lines to follow their families who seek work in
agriculture, fishing, dairies, logging, or the food processing industry. Indicate
Yes – student is considered migrant status.
No – student is not considered migrant status.
Field: English Language Learner (ELL)
The student has a language background other than English, and his or her
proficiency in English is such that the probability of the student’s academic
success in an English-only classroom is below that of native English language
students. Indicate
Yes – student is classified as an English Language Learner.
No – student is not classified as an English Language Learner.
Field: GPA (Grade Point Average)
Is to be entered for students who have a GPA on the most recent report
card. The GPA is to be calculated in accordance with Rules and regulations
establishing the Academic Standards for Student Population in Competitive
Interscholastic Activities by the State Board of Education. The GPA is to be
based on a 4.0 scale and is to be calculated using academic courses as
defined in the regulations.
Field: Classes Passed
Is to be entered for students for whom a GPA is not calculated. Indicate the
number of classes passed (C or above) on the most recent report card.
Field: Classes Failed
Is to be entered for students for whom a GPA is not calculated. Indicate the
number of classes failed (D’s and F’s) on the most recent report card.
Field: ACTAAP Literacy Score
The student’s performance on the ACTAAP Literacy according to the
following choices:
Below Proficiency
Proficiency and Above
Field: ACTAAP Mathematics Score
The student’s performance on the ACTAAP Mathematics according to the
following choices:
Below Proficiency
Proficiency and Above
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Field: Retention
Flag indicating a student has been retained from the prior year in the same
grade level. Indicate
Yes – student has been retained during his/her school career.
No – student has not been retained during his/her school career.
Field: Attendance
The number of days the student was NOT in school during the most recent
reported quarter of the school year.
Field: Tardies
The number of tardies the student received that was reported during the most
recent reported quarter of the school year.
Field: Additional Comments—Educational Functioning
This field can include any additional comments related to the student’s
educational functioning.
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VI. Behavioral and Family Functioning
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VI. BEHAVIORAL, EMOTIONAL, AND SOCIAL
FUNCTIONING
Field: Discipline Violations/Infractions
Enter the number of discipline violations or infractions that were reported
during the most recent quarter.
Field: In-School Suspension
Enter the number of days the student received in-school suspension that was
reported during the most recent quarter.
Field: Out-of-School Suspension
Enter the number of days the student was suspended from school that was
reported during the most recent quarter.
Field: Expulsion
Indicate if student has been expelled from school:
Yes – student has expelled during his/her school career.
No – student has not been expelled during his/her school career.
Field: Alternative Learning Environment Placement
Indicate if student has been referred to an alternative school or program:
Yes – student has been referred to an alternative school or
program during his/her school career.
No – student has not been referred to an alternative school or
program during his/her school career.
Field: Legal Problems
Provide a description of any relevant current/past legal problems and
consequences.
Field: Agency Involvement
The involvement of the student with an outside agency as listed below:
None
Mental Health
Physical Health
Child Welfare
Legal
Other
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Field: Other Agency Involvement—Specify
Specify any other agency involvement that is not identified by the list above.
Field: Student Strengths
Description of student strengths. For example, strengths may include
academic, behavioral, emotional, personal, social, or family attributes.
Field: Additional Comments—Behavioral, Emotional, and Social
Functioning
This field can include any additional comments related to the student’s
behavioral, emotional, and/or social functioning.
FAMILY FUNCTIONING
Field: Current Living Arrangement
Description of persons residing in the student’s home—include names,
relationship to student, and age.
Field: Family Interactions
Description of interactions within student’s family.
Field: Family Motivation for Treatment
Description of family’s motivation for treatment.
Field: Relevant Family History
Description of any relevant family psychoeducational, psychiatric, substance
abuse and/or medical history.
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VII.
Medical and Developmental History
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VII. MEDICAL AND DEVELOPMENTAL HISTORY
Field: Physical Illnesses, Injuries, or Other Health Conditions
A description of any physical illnesses, injuries, or other health conditions
which might or does affect the student’s school performance.
Field: Medications
A description of any medications and dosages the student is currently taking.
Field: Primary Physician
List the name, address, and phone number of the student’s primary physician.
Field: Pregnancy/Birth Complications
Indicate any problems during pregnancy or birth complications, the
description of a child’s medical and mental health condition observed or
diagnosed at birth which may indicate the need for further medical care or
assessment. Such conditions may include anoxia, premature birth, low birth
weight, respiratory distress syndrome, and metabolic or central nervous
system disorders.
Field: Developmental Delays
Indicate the presence of any developmental delays in the development of
specific skills or abilities, such as delays in learning to crawl, walk, or speak.
Field: Substance Abuse
Indicate if the student has a documented history of substance abuse—an
instance during which an individual is known to have used licit or illicit drugs
(e.g., heroin, amphetamines, barbiturates, prescription drugs, or alcohol) in
an amount, frequency, and/or pattern of use that interfered with his or her
psychological, physiological, social, and/or academic functioning. Indicate
Yes—student does have documented history of substance abuse
No—student does not have documented history of substance abuse
Field: Description of Substance Abuse
If student has a history of substance abuse, indicate the licit and/or illicit
drugs that were used and any current or previous substance abuse treatment.
Field: Other Health Concerns
This field can include any additional comments related to any other health
concerns of this student or family member that may have an impact on the
student’s psychological, physiological, social, and/or academic functioning.
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VIII. Requested/Recommended Services or Interventions
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VIII. REQUESTED/RECOMMENDED SERVICES OR
INTERVENTIONS
Field: Psychiatric Evaluation
Indicate YES or NO if a psychiatric evaluation is requested or
recommended. A comprehensive evaluation performed by an appropriately
licensed individual, that investigates a client’s clinical status including the
presenting problem; the history of the present illness; previous psychiatric,
physical, and medication history; relevant personal and family history;
personal strengths and assets; and a mental status examination.
Field: Psychological Evaluation
Indicate YES or NO if a psychological evaluation is requested or
recommended. A systematic evaluation performed by an appropriately
licensed individual. This procedure should reflect the mental abilities,
aptitudes, interests, attitudes, motivation, emotional and personality
characteristics of the client as prescribed by the purpose of the evaluation.
Field: Individual Therapy
Indicate YES or NO if individual therapy is requested or recommended.
Scheduled individual outpatient care provided by an appropriately licensed
Mental Health Professional to a client for the purposes of treatment and
remediation of a condition described in DSM-IV and subsequent revisions.
Field: Group Therapy
Indicate YES or NO if group therapy is requested or recommended. A direct
service contact between a group of clients and one or more appropriately
licensed Mental Health Professionals for the purposes of treatment and
remediation of a psychiatric condition. This procedure does not include
psychosocial group activities.
Field: Family Therapy
Indicate YES or NO if family therapy is requested or recommended. Therapy
of a client and family member(s), or other person significant to the client for
the purpose of improving the client/family function conducted by an
appropriately licensed Mental Health Professional.
Field: Case Management - Targeted
Indicate YES or NO if targeted case management is requested or
recommended. Services conducted by an appropriately licensed case
management provider that are designed to improve planning for the
individual’s service needs. Services include Assessment/Service Plan
Updating, Service Management, and Service Monitoring.
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Field: Parent Education
Indicate YES or NO if parent education is requested or recommended. The
purpose of this service is to provide education to parents regarding the nature
of the student’s condition.
Field: Crisis Intervention
Indicate YES or NO if crisis intervention is requested or recommended. The
purpose of this service is to prevent an inappropriate or premature more
restrictive placement and/or to maintain the eligible patient in an appropriate
outpatient modality. This procedure is an unscheduled direct service contact
occurring either on- or off-site between an eligible patient with a diagnosable
psychiatric disorder and a mental health professional.
Field: Respite Care
Indicate YES or NO if respite care is requested or recommended. Provision
of periodic relief to the caregiver(s) of the client/patient.
Field: Day Treatment
Indicate YES or NO if day treatment is requested or recommended. Day
treatment includes special education, counseling, parent training, vocational
training, skill building, crisis intervention, and recreational therapy, lasting at
least 4 hours a day.
Field: Acute/Residential Treatment
Indicate YES or NO if residential treatment is requested or recommended.
Services provided over a 24-hour period or any portion of the day in which a
patient resides on an on-going basis in a State facility or other facility and
receives treatment.
Field: Medication Management
Indicate YES or NO if medication management is requested or
recommended. Pharmacologic management, including prescription, use and
review of medication with no more than minimal medical psychotherapy by a
physician.
Field: Other Service/Intervention
Describe the requested/recommended service or intervention that is not
identified on the list above.
Field: Additional Comments—Requested/Recommended Services
or Interventions
This field can include any additional comments related to the
requested/recommended services or interventions.
32
IX. Post Treatment Outcomes
33
IX. Post Treatment Outcomes
Educational Functioning
Field: Educational Placement at Discharge
NOTE: This field will only activate if a student was indicated as receiving
Special Education services. Indicate the student’s educational placement at
time of discharge from SBMH services:
Public Day School
If a student receives special education and related services for greater than 50
percent of the school day in a publicly funded facility that does not house
programs for students without disabilities.
Private Day School
If a student receives special education and related services for greater than 50
percent of the school day in a privately funded facility that does not house
programs for students without disabilities.
Hospital/Homebound
If a student receives special education in medical treatment facilities on an inpatient basis or at home.
Public Residential
If a student receives special education and related services for greater than 50
percent of the school day in a public residential facility.
Regular Class with NO Special Education
If a student has exited special education and is no longer receiving special
education services.
Regular Class with Special Education (up to 21% of the school
day)
If a student receives special education and related services outside the regular
classroom for less than 21 percent of the school day. This may include children
and youth with disabilities placed in: regular class with special education/related
services provided within regular class, regular class with instruction within the
regular class and with special education/related services provided outside
regular class, or regular class with special education services provided in a
resource room.
Students who receive special education and related services in age-appropriate
community-based settings that include individuals with and without disabilities,
such as college campuses or vocational sites, receiving special education and
related services outside regular classrooms or community-based settings for less
than 21 percent of the school day.
34
Private Residential
If a student receives special education and related services for greater than 50
percent of the school day in a private residential facility.
Resource Room (between 21% to 60% of the school day)
If a student receives special education and related services outside the regular
classroom for 60 percent or less of the school day and at least 21 percent but no
more than 60 percent of the school day. This may include children and youth
placed in: resource rooms with special education/related services provided
within the resource room, or resource room with part-time instruction in a
regular class. Students who receive special education and related services in
age-appropriate community-based settings that include individuals with and
without disabilities, such as college campuses or vocational sites, receiving
special education and related services outside the regular classrooms or
community-based settings for at least 21 percent but no more than 60 percent of
the school day.
Self-contained (60% or more of the school day in special
education)
If a student receives special education and related service outside the regular
classroom for more than 60 percent of the school day. This includes only
children and youth with disabilities educated on the regular school campus. This
does not include pupils who received education programs in public or private
separate day or residential facilities. This may include children and youth placed
in: self-contained special classrooms with part-time instruction in a regular
class, or self-contained special classrooms full-time on a regular school campus.
Students who receive special education and related services in age-appropriate
community-based settings that include individuals with and without disabilities,
such as college campuses or vocational sites, receiving special education and
related services outside the regular classroom or community-based setting for
more than 60 percent of the school day.
Field: GPA (at discharge)
Is to be entered at the time of discharge from SBMH services for students
who have a GPA on the most recent report card. The GPA is to be calculated
in accordance with Rules and regulations establishing the Academic
Standards for Student Population in Competitive Interscholastic Activities by
the State Board of Education. The GPA is to be based on a 4.0 scale and is to
be calculated using academic courses as defined in the regulations.
Field: Classes Passed (at discharge)
Is to be entered at the time of discharge from SBMH services for students
for whom a GPA is not calculated. Indicate the number of classes passed (C
or above) on the most recent report card.
Field: Classes Failed (at discharge)
Is to be entered at the time of discharge from SBMH services for students
for whom a GPA is not calculated. Indicate the number of classes failed (D’s
and F’s) on the most recent report card.
35
Field: Attendance
At the time of discharge from SBMH services, enter the number of days the
student was not in school during the most recent reported quarter of the
school year.
Field: Tardies
At the time of discharge from SBMH services, enter the number of tardies
the student received that was reported during the most recent reported
quarter of the school year.
Behavioral, Emotional, and Social Functioning
Field: In-School Suspension (at discharge)
At the time of discharge from SBMH services, enter the number of days the
student received in-school suspension that was reported during the most
recent quarter.
Field: Out-of-School Suspension (at discharge)
At the time of discharge from SBMH services, enter the number of days the
student was suspended from school that was reported during the most recent
quarter.
Field: Expulsion (at discharge)
At the time of discharge from SBMH services, indicate if student has been
expelled from school:
Yes – student has been expelled after he/she was referred for SBMH
services.
No – student has not been expelled he/she was referred for SBMH
services.
Field: Alternative Learning Environment Placement (at
discharge)
At the time of discharge from SBMH services, indicate if student has been
referred to an alternative school or program:
Yes – student has been referred to an alternative school or
program after he/she was referred for SBMH services.
No – student has not been referred to an alternative school or
program after he/she was referred for SBMH services.
Field: Legal Problems (at discharge)
Provide a description of any relevant current/past legal problems and
consequences at the time of discharge from SBMH services.
36
Requested/Recommended Services or Interventions
Field: Day Treatment (at discharge)
Indicate YES or NO if day treatment is requested or recommended at the time
of discharge from SBMH services. Day treatment includes special education,
counseling, parent training, vocational training, skill building, crisis
intervention, and recreational therapy, lasting at least 4 hours a day.
Field: Residential Treatment
Indicate YES or NO if residential treatment is requested or recommended at
the time of discharge from SBMH services. Services provided over a 24-hour
period or any portion of the day which a patient resided on an on-going basis
in a State facility or other facility and received treatment.
Field: Out-of-State Placement (at discharge)
Indicate YES or NO if out-of-state placement is requested or recommended at
the time of discharge from SBMH services.
Field: Acute Treatment (at discharge)
Indicate YES or NO if acute treatment is requested or recommended at the
time of discharge from SBMH services.
Field: Additional Comments—Post Treatment Outcomes
This field can include any additional comments related to the student’s post
treatment outcomes at the time of discharge from SBMH services.
Field: Date Services Ended
The day, month, and year that the student is discharged from receiving SBMH
services.
Treatment Utilization
Field: GAF
The Global Assessment of Functioning Scale level score for the child at the
time of discharge from treatment.
Field: Individual Sessions Provided (#)
The number of individual therapy sessions provided to the child between the
time of admission and the date of discharge (if discharged prior to update
period). The number of individual therapy sessions provided to the child
between the last update period and the date of discharge.
Field: Family Sessions Provided (#)
37
The number of family therapy sessions provided to the child/family between
the time of admission and the date of discharge (if discharged prior to update
period). The number of individual therapy sessions provided to the child/
family between the last update period and the date of discharge.
Field: Group Sessions Provided (#)
The number of group therapy sessions provided to the child between the time
of admission and the date of discharge (if discharged prior to update period).
The number of group therapy sessions provided to the child between the last
update period and the date of discharge.
Field: Collateral Sessions Provided (#)
The number of collateral sessions provided for the child/ family between the
time of admission and the date of discharge (if discharged prior to update
period). The number of collateral sessions provided for the child/family
between the last update period and the date of discharge.
Field: Crisis Management Sessions Provided (#)
The number of crisis management sessions provided to the child/ family
between the time of admission and the date of discharge (if discharged prior
to update period). The number of crisis management sessions provided to the
child/ family between the last update period and the date of discharge.
Field: Parent Education Classes Provided (#)
The number of parent education classes provided to the parents between the
time of admission and the date of discharge (if discharged prior to update
period). The number of parent education classes provided to the parents
between the last update period and the date of discharge.
Field: Student Process Completion Status
By default, this field is answered as NO. When the Student Process
Completion Status field is answered as YES, this screen will be locked and the
user can only view the entries made.
38
X. Semester Data Update
39
X. Semester Data Update
Educational Functioning
Field: Educational Placement at the time of update
NOTE: This field will only activate if a student was indicated as receiving
Special Education services. Indicate the student’s educational placement at
time of discharge from SBMH services:
Public Day School
If a student receives special education and related services for greater than 50
percent of the school day in a publicly funded facility that does not house
programs for students without disabilities.
Private Day School
If a student receives special education and related services for greater than 50
percent of the school day in a privately funded facility that does not house
programs for students without disabilities.
Hospital/Homebound
If a student receives special education in medical treatment facilities on an inpatient basis or at home.
Public Residential
If a student receives special education and related services for greater than 50
percent of the school day in a public residential facility.
Regular Class with NO Special Education
If a student has exited special education and is no longer receiving special
education services.
Regular Class with Special Education (up to 21% of the school
day)
If a student receives special education and related services outside the regular
classroom for less than 21 percent of the school day. This may include children
and youth with disabilities placed in: regular class with special education/related
services provided within regular class, regular class with instruction within the
regular class and with special education/related services provided outside
regular class, or regular class with special education services provided in a
resource room.
Students who receive special education and related services in age-appropriate
community-based settings that include individuals with and without disabilities,
such as college campuses or vocational sites, receiving special education and
related services outside regular classrooms or community-based settings for less
than 21 percent of the school day.
40
Private Residential
If a student receives special education and related services for greater than 50
percent of the school day in a private residential facility.
Resource Room (between 21% to 60% of the school day)
If a student receives special education and related services outside the regular
classroom for 60 percent or less of the school day and at least 21 percent but no
more than 60 percent of the school day. This may include children and youth
placed in: resource rooms with special education/related services provided
within the resource room, or resource room with part-time instruction in a
regular class. Students who receive special education and related services in
age-appropriate community-based settings that include individuals with and
without disabilities, such as college campuses or vocational sites, receiving
special education and related services outside the regular classrooms or
community-based settings for at least 21 percent but no more than 60 percent of
the school day.
Self-contained (60% or more of the school day in special
education)
If a student receives special education and related service outside the regular
classroom for more than 60 percent of the school day. This includes only
children and youth with disabilities educated on the regular school campus. This
does not include pupils who received education programs in public or private
separate day or residential facilities. This may include children and youth placed
in: self-contained special classrooms with part-time instruction in a regular
class, or self-contained special classrooms full-time on a regular school campus.
Students who receive special education and related services in age-appropriate
community-based settings that include individuals with and without disabilities,
such as college campuses or vocational sites, receiving special education and
related services outside the regular classroom or community-based setting for
more than 60 percent of the school day.
Field: GPA (at time of update)
Is to be entered at the time of discharge from SBMH services for students
who have a GPA on the most recent report card. The GPA is to be calculated
in accordance with Rules and regulations establishing the Academic
Standards for Student Population in Competitive Interscholastic Activities by
the State Board of Education. The GPA is to be based on a 4.0 scale and is to
be calculated using academic courses as defined in the regulations.
Field: Classes Passed (at the time of update)
Is to be entered at the time of update for whom a GPA is not calculated.
Indicate the number of classes passed (C or above) on the most recent report
card.
Field: Classes Failed (at the time of update)
Is to be entered at the time of update for whom a GPA is not calculated.
Indicate the number of classes failed (D’s and F’s) on the most recent report
card.
41
Field: Attendance (at time of update)
At the time of the update, enter the number of days the student was not in
school during the most recent reported quarter of the school year.
Field: Tardies (at time of update)
At the time of the update, enter the number of tardies the student received
that was reported during the most recent reported quarter of the school year.
Behavioral, Emotional, and Social Functioning
Field: In-School Suspension (at time of update)
At the time of update, enter the number of days the student received in-school
suspension that was reported during the most recent quarter.
Field: Out-of-School Suspension (at time of update)
At the time of update, enter the number of days the student was suspended
from school that was reported during the most recent quarter.
Field: Expulsion (at time of update)
At the time of update, indicate if student has been expelled from school:
Yes – student has been expelled after he/she was referred for SBMH
services.
No – student has not been expelled he/she was referred for SBMH
services.
Field: Alternative Learning Environment Placement (at time of
update)
At the time of update, indicate if student has been referred to an alternative
school or program:
Yes – student has been referred to an alternative school or
program after he/she was referred for SBMH services.
No – student has not been referred to an alternative school or
program after he/she was referred for SBMH services.
Field: Legal Problems (at time of update)
Provide a description of any relevant current/past legal problems and
consequences at the time of discharge from SBMH services.
42
Treatment Utilization
Field: GAF
The Global Assessment of Functioning Scale level score for the child at the
time of discharge from treatment.
Field: Individual Sessions Provided (#)
The number of individual therapy sessions provided to the child between the
time of admission and the time of the update. The number of individual
therapy sessions provided to the child between the last update period and the
current update period.
Field: Family Sessions Provided (#)
The number of family therapy sessions provided to the child/family between
the time of admission and the time of the update. The number of individual
therapy sessions provided to the child/ family between the last update period
and the current update period.
Field: Group Sessions Provided (#)
The number of group therapy sessions provided to the child between the time
of admission and the time of the update. The number of group therapy
sessions provided to the child between the last update period and the current
update period.
Field: Collateral Sessions Provided (#)
The number of collateral sessions provided for the child/ family between the
time of admission and the time of the update. The number of collateral
sessions provided for the child/family between the last update period and the
current update period.
Field: Crisis Management Sessions Provided (#)
The number of crisis management sessions provided to the child/ family
between the time of admission and the time of the update. The number of
crisis management sessions provided to the child/ family between the last
update period and the current update period.
Field: Parent Education Classes Provided (#)
The number of parent education classes provided to the parents between the
time of admission and the time of the update. The number of parent education
classes provided to the parents between the last update period and the current
update period.
43