Form DHS-5704A-ENG "Child/Adolescent Diagnostic Assessment - Part I: Parent/Caregiver" - Minnesota

What Is Form DHS-5704A-ENG?

This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2014;
  • The latest edition provided by the Minnesota Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHS-5704A-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.

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Download Form DHS-5704A-ENG "Child/Adolescent Diagnostic Assessment - Part I: Parent/Caregiver" - Minnesota

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Clear Form
*DHS-5704A-ENG*
DHS-5704A-ENG
1-14
Children’s Mental Health
Child/Adolescent Diagnostic Assessment
(TO BE COMPLETED BY PARENT/CAREGIVER)
PART 1
– Please provide the following information in preparation for the interview with your
DATE
mental health clinician.
CHILD NAME (FIRST, MI, LAST)
CLIENT NUMBER
REFERRAL SOURCE
REASON FOR REFERRAL
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
NAME OF INDIVIDUAL COMPLETING FORM
RELATIONSHIP TO CHILD
{PROVIDER: Enter the phone number your agency uses to provide help interpreting.}
Attention. If you need free help interpreting this document, call the above number.
.‫مالحظة: إذا أردت مساعدة مجانية لترجمة هذه الوثيقة، اتصل على الرقم أعاله‬
kM N t’ s M K al’ . ebI G ~ k ¨tU v karCM n Y y k~ ¬ g karbkE¨bäksarenHeday²tKi t «f sU m ehATU r s& B Í t amelxxagelI .
Pažnja. Ako vam treba besplatna pomoć za tumačenje ovog dokumenta, nazovite gore naveden broj.
Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb,
ces hu rau tus najnpawb xov tooj saum toj no.
ໂປຣດຊາບ. ຖ ້ າ ຫາກ ທ ່ າ ນຕ ້ ອ ງການການຊ ່ ວ ຍເຫຼ ື ອ ໃນການແປເອກະສານນ ີ ້ ຟ ຣ ີ , ຈ ົ ່ ງ ໂທຣໄປທ ີ ່ ໝາຍເລກຂ ້ າ ງເທ ີ ງ ນ ີ ້ .
Hubachiisa. Dokumentiin kun bilisa akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bibili.
Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по
указанному выше телефону.
Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda qoraalkan, lambarka kore wac.
Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado
arriba.
Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.
ADA1 (12-12)
This information is available in accessible formats for individuals with
disabilities by calling 651-431-2321, toll-free 800-627-3529, or by
using your preferred relay service. For other information on disability
rights and protections, contact the agency’s ADA coordinator.
Page 1 of 9
Clear Form
*DHS-5704A-ENG*
DHS-5704A-ENG
1-14
Children’s Mental Health
Child/Adolescent Diagnostic Assessment
(TO BE COMPLETED BY PARENT/CAREGIVER)
PART 1
– Please provide the following information in preparation for the interview with your
DATE
mental health clinician.
CHILD NAME (FIRST, MI, LAST)
CLIENT NUMBER
REFERRAL SOURCE
REASON FOR REFERRAL
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
NAME OF INDIVIDUAL COMPLETING FORM
RELATIONSHIP TO CHILD
{PROVIDER: Enter the phone number your agency uses to provide help interpreting.}
Attention. If you need free help interpreting this document, call the above number.
.‫مالحظة: إذا أردت مساعدة مجانية لترجمة هذه الوثيقة، اتصل على الرقم أعاله‬
kM N t’ s M K al’ . ebI G ~ k ¨tU v karCM n Y y k~ ¬ g karbkE¨bäksarenHeday²tKi t «f sU m ehATU r s& B Í t amelxxagelI .
Pažnja. Ako vam treba besplatna pomoć za tumačenje ovog dokumenta, nazovite gore naveden broj.
Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb,
ces hu rau tus najnpawb xov tooj saum toj no.
ໂປຣດຊາບ. ຖ ້ າ ຫາກ ທ ່ າ ນຕ ້ ອ ງການການຊ ່ ວ ຍເຫຼ ື ອ ໃນການແປເອກະສານນ ີ ້ ຟ ຣ ີ , ຈ ົ ່ ງ ໂທຣໄປທ ີ ່ ໝາຍເລກຂ ້ າ ງເທ ີ ງ ນ ີ ້ .
Hubachiisa. Dokumentiin kun bilisa akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bibili.
Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по
указанному выше телефону.
Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda qoraalkan, lambarka kore wac.
Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado
arriba.
Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.
ADA1 (12-12)
This information is available in accessible formats for individuals with
disabilities by calling 651-431-2321, toll-free 800-627-3529, or by
using your preferred relay service. For other information on disability
rights and protections, contact the agency’s ADA coordinator.
Page 1 of 9
Living situation
Parent’s Home
Residential Care/Treatment Facility**
Other**
l
l
l
l
l
RENT
HOSPITAL
TEMPORARY HOUSING
FRIEND’S HOME
RELATIVE/GUARDIAN’S HOME
l
l
l
l
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OWN
RESIDENTIAL CARE
NURSING HOME
HOMELESS
FOSTER HOME
**IDENTIFY PERSON’S NAME OR FACILITY
Primary Household
Household member name
Relationship to child
Age
Occupation/School
Highest level of education Quality of relationship
STREET ADDRESS (If different from child’s address listed on Demographic Information form.)
Does the client live in more than one household?
l
l
NO If no, skip to “Additional Family Members”
YES If yes, complete the secondary household information below.
Secondary Household
Household member name
Relationship to child
Age
Occupation/School
Highest level of education Quality of relationship
STREET ADDRESS (If different from child’s address listed on Demographic Information form.)
Family members who live in both households
l
ONLY CHILD
l
CHILD and (list):
________________________________________________________________________________________________________________________________________
Additional family members
l
NO, parents or sibling other than those listed in primary or secondary households
l
YES, list family members:
_________________________________________________________________________________________________________________________________
Custody and parenting plan
l
LIVES WITH BOTH PARENTS (biological or adoptive) in same household
l
SINGLE PARENT
l
SHARED CUSTODY – parents in different households
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OTHER (describe):
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Page 2 of 9
DHS-5704A-ENG 1-14
Developmental issues
Have you ever had concerns about the following issues with this child?
Pregnancy
Yes
No
Unknown
l
l
l
Had bleeding during first three (3) months
l
l
l
Had bleeding during second three (3) months
l
l
l
Had bleeding during last three (3) months
l
l
l
Had toxemia
l
l
l
Had to take medications
Specify any medication:
______________________________________________________________________________________
l
l
l
Got injured or hurt
l
l
l
Gained less than 15 lbs. (7 kgs.)
Specify:
________________________________________________________________________________________________________
l
l
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Took narcotic drugs
l
l
l
Drank alcohol
l
l
l
Had an infection
l
l
l
Smoked during pregnancy
l
l
l
Length of pregnancy:
months
_________
l
l
l
Other pregnancy problems/illnesses
Specify:
________________________________________________________________________________________________________
Birth/Early Infancy
Yes
No
Unknown
l
l
l
Born prematurely
l
l
l
Born with cord around neck
l
l
l
Injured during birth
l
l
l
Had trouble breathing
l
l
l
Turned blue (cyanosis)
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l
l
Was a twin or triplet
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l
l
Had an infection
l
l
l
Had seizures (fits, convulsions)
l
l
l
Needed oxygen
l
l
l
Was very jittery
Childhood Health Issues
Yes
No
Unknown If yes, age first noted If yes, still occurring?
l
l
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l
Seizures (convulsions) or spells
l
l
l
l
High fevers (over 103° F. or 39° C.)
l
l
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Head injury
l
l
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Asthma
l
l
l
l
Trouble with hearing
l
l
l
l
Trouble with vision
l
l
l
l
Lead poisoning
l
l
l
l
Other poisoning or overdose
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l
l
l
Other serious illness
l
l
l
l
Other hospitalizations
Page 3 of 9
DHS-5704A-ENG 1-14
Functioning
Yes
No
Unknown If yes, age first noted If yes, still occurring?
l
l
l
l
Poor appetite
l
l
l
l
Constipation
l
l
l
l
Stomach aches
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l
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l
Trouble falling asleep
l
l
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Trouble staying asleep
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Overactivity
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Head banging
l
l
l
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Rocking in bed
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l
l
l
Temper tantrums
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l
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Self-destructive behavior
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l
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l
Difficulty in being comforted or consoled
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l
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Stiffness or rigidity
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l
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Looseness or floppiness
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l
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Crying often and easily
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l
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Shyness with strangers
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l
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Irritability
l
l
l
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Extreme reaction to noise or sudden movement
Attention problems
Yes
No
Unknown If yes, age first noted If yes, still occurring?
l
l
l
l
Can concentrate for only a short time unless things are very
interesting
l
l
l
l
Understand the main ideas of things but misses important
details
l
l
l
l
Does work or performs many tasks carelessly without
thinking
l
l
l
l
Learns a new skill well one day and then can’t seem to do
it a few days later
l
l
l
l
Receives very unpredictable (inconsistent) grades or test
scores in school
l
l
l
l
Can work well only on things he/she really enjoys doing or
thinking about
l
l
l
l
Often doesn’t notice when he/she makes mistakes
l
l
l
l
Seems not to realize when he/she is disturbing someone
l
l
l
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Doesn’t do much better after punishment or correction
l
l
l
l
Makes comments about or is distracted by background
noises or unimportant things
l
l
l
l
Seems to want things right away and/or is hard to satisfy
l
l
l
l
Annoys or bothers other children
l
l
l
l
Behavior is variable and hard to predict
l
l
l
l
Is a troublemaker; bullies others
Page 4 of 9
DHS-5704A-ENG 1-14
Behaviors
Yes
No
Unknown If yes, age first noted If yes, still occurring?
l
l
l
l
Has bad dreams
l
l
l
l
Is often very quiet or withdrawn
l
l
l
l
Is often “down” on himself/herself
l
l
l
l
Is often tired
l
l
l
l
Speaks unclearly, stutters, or stammers
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l
l
l
Wets bed or pants often
l
l
l
l
Soils underwear or has accidents with bowel movements
l
l
l
l
Is often too neat or orderly
l
l
l
l
Is often too concerned about cleanliness
l
l
l
l
Often plays with matches
l
l
l
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Destroys objects at home
l
l
l
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Destroys objects away from home
l
l
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Is fearless
l
l
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Is cruel to animals
l
l
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Is not liked by other children
l
l
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Feels ill on school mornings
l
l
l
l
Has eating problems (either overeats or undereats)
l
l
l
l
Is preoccupied with food or diet
l
l
l
l
Is part of a clique or gang that causes trouble
l
l
l
l
Other behaviors not noted above
l
l
l
l
Have you ever had concerns about your child’s early
development (i.e. walking, talking, learning)?
l
l
l
l
Have you ever had concerns about your child’s sexual
development or behaviors?
IF THERE ARE INDICATIONS OF ISSUES, PLEASE EXPLAIN
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________
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_________________________________________________________________________________________________________________________________________________________________________
Page 5 of 9
DHS-5704A-ENG 1-14