"Mental Health and Substance Abuse Screen Form - Early and Periodic Screening, Diagnosis, Treatment (Epsdt)" - Delaware

Mental Health and Substance Abuse Screen Form - Early and Periodic Screening, Diagnosis, Treatment (Epsdt) is a legal document that was released by the Delaware Department of Services for Children, Youth and their Families - a government authority operating within Delaware.

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  • Released on July 1, 2013;
  • The latest edition currently provided by the Delaware Department of Services for Children, Youth and their Families;
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State of Delaware
Early and Periodic Screening, Diagnosis, Treatment (EPSDT)
Mental Health and Substance Abuse Screen
Child Name:____________________________________ DOB:______________
Completed By: ____________________________________ Date:_____________
Agency/Position:___________________________ Telephone:________________
Source of Information:______________________________________________
DIRECTIONS:
Please consider the problems that your child is having when filling out the form below. Please think about your
child’s age and developmental level when answering the questions. If the problem applies to your child please
check the most appropriate box. In some cases it will be appropriate to check both boxes. That is okay. If the
problem has never happened please leave the box blank.
In last
CHILD’S HISTORY
30 Days
Ever
1. Suicidal thoughts/threats
2. Suicidal gestures
3. Suicide attempts requiring hospitalization
4. Injures self, e.g., cutting, head-banging , burning, picking skin
5. Homicidal – Statements of killing others
6. Physically violent – Physically hurting others
7. Verbally threatening - Threatening to hurt others
8. Frequent, intense, uncontrollable temper tantrums
9. Hallucinations (sees or hears things that aren’t there)
10. Delusions (has strong beliefs which have no basis in reality)
11. Cruel to animals
12. Willful destruction of property
13. Fire setting
14. Victim of physical Abuse confirmed/suspected
15. Victim of Sexual Abuse confirmed/suspected
16. Victim of Emotional Abuse confirmed/suspected
17. Suspected or confirmed victim of caregiver neglect, e.g. failure to provide
food, shelter or clothing.
18. Inadequate or inappropriate parental supervision and/or discipline
19. Exposure to Domestic Violence
20. Wetting or Soiling (after potty training)
21. Overly sensitive to environment (noise, touch) which causes distress
22. Difficulty separating from parents, school refusal
23. Recurrent intrusive thoughts or repetitive behaviors, such as hand washing,
lock checking, organizing objects
24. Persistent unrealistic worry over physical health
25. Avoids people, places or things
26. Always seems jumpy or afraid
27. Gets upset when remembering bad thing that have happened to him/her.
28. Many nightmares
29. Child has experienced traumatic event, e.g. flood, hurricane; frightening
medical procedure; being or seeing someone severely injured (accident or
assault); seeing a dead body or someone killed.
Revised: 7/2013
State of Delaware
Early and Periodic Screening, Diagnosis, Treatment (EPSDT)
Mental Health and Substance Abuse Screen
Child Name:____________________________________ DOB:______________
Completed By: ____________________________________ Date:_____________
Agency/Position:___________________________ Telephone:________________
Source of Information:______________________________________________
DIRECTIONS:
Please consider the problems that your child is having when filling out the form below. Please think about your
child’s age and developmental level when answering the questions. If the problem applies to your child please
check the most appropriate box. In some cases it will be appropriate to check both boxes. That is okay. If the
problem has never happened please leave the box blank.
In last
CHILD’S HISTORY
30 Days
Ever
1. Suicidal thoughts/threats
2. Suicidal gestures
3. Suicide attempts requiring hospitalization
4. Injures self, e.g., cutting, head-banging , burning, picking skin
5. Homicidal – Statements of killing others
6. Physically violent – Physically hurting others
7. Verbally threatening - Threatening to hurt others
8. Frequent, intense, uncontrollable temper tantrums
9. Hallucinations (sees or hears things that aren’t there)
10. Delusions (has strong beliefs which have no basis in reality)
11. Cruel to animals
12. Willful destruction of property
13. Fire setting
14. Victim of physical Abuse confirmed/suspected
15. Victim of Sexual Abuse confirmed/suspected
16. Victim of Emotional Abuse confirmed/suspected
17. Suspected or confirmed victim of caregiver neglect, e.g. failure to provide
food, shelter or clothing.
18. Inadequate or inappropriate parental supervision and/or discipline
19. Exposure to Domestic Violence
20. Wetting or Soiling (after potty training)
21. Overly sensitive to environment (noise, touch) which causes distress
22. Difficulty separating from parents, school refusal
23. Recurrent intrusive thoughts or repetitive behaviors, such as hand washing,
lock checking, organizing objects
24. Persistent unrealistic worry over physical health
25. Avoids people, places or things
26. Always seems jumpy or afraid
27. Gets upset when remembering bad thing that have happened to him/her.
28. Many nightmares
29. Child has experienced traumatic event, e.g. flood, hurricane; frightening
medical procedure; being or seeing someone severely injured (accident or
assault); seeing a dead body or someone killed.
Revised: 7/2013
30. Psychosocial stressors, e.g., death, absence or loss of significant person in
child’s life and/or multiple life changes, serious illness in family, economic
problems
31. Instability of residential arrangement, e.g., homelessness, multiple placements,
frequent relocations
32. Problems with same age peers
33. Problems with family relationships or relationships with authority figures
34. Inability to give or receive appropriate affection to primary caregivers
35. Arrested, detained, or on probation
36. Gambling
37. Inappropriate sexual activity
38. Running away
39. Suspected or confirmed abuse of alcohol or other drugs/substances
40. Confirmed or suspected developmental/Intellectual delay
41. Problems in school/vocational activity (attendance, behavior, performance)
42. Difficulty in concentration
43. Excessive sadness, crying, withdrawal
44. Easily angered or excessive anger.
45. Excessive irritability
46. Excessive fears or worries
47. Irregular or problematic eating/appetite patterns
48. Medical condition complicated by emotional disturbance or medical
noncompliance
FAMILY HISTORY
PROBLEM
Mother
Father
Guardian
Sibling
Grandparent
Other
1. History of Self Harm - i.e. Cutting,
Burning
2. Attempted Suicide
3. Completed Suicide
4. History of Mental Health Issues
5. Current Mental Health Issues
6. History of Substance Abuse
7. Current Substance Abuse
8. History of Incarceration
9. Current Incarceration
10. Domestic Violence
Submission of this form does not constitute a formal abuse report. Mandated reporters are legally obligated to
report suspected child abuse or neglect to DFS at 1-800-292-9582.
Revised: 7/2013
Any other problems not mentioned above:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Check one of the following:
A. ______
Child Now has one of the problems listed above, but is currently receiving
services to deal with them.
B. ______
Child NOW has at least one of the problems listed above and is not receiving
services to deal with them.
C. ______
Child does not NOW have any of the problems listed above according to the
screener.
Check one of the following:
A. ______
Child IN THE PAST had one of the problems listed above and has received
services to deal with them.
B. ______
Child IN THE PAST had at least one of the problems listed above but has
never received services to deal with them.
C. ______
IN THE PAST, child has not had any of the problems listed above according to
the screener.
Screener Signature: ________________________________________
Date: ______________
Revised: 7/2013
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