Child’s First Name: Last Name: DOB: Current Age: Primary Care Physician: Other Treating Clinicians: Primary Health Insurance: Reason for referral: Child/Family Risk Factors: Current Comments need 2+ Hospital admissions past 12 months □ 2+ ED visits related to chronic condition □ 2+ ED visits for behavioral health past 12 months □ 1+ Behavioral health hospitalization past 12 months □ 2+ missed MD appointments □ School issues (low performance, absenteeism, □ behavior) Foster Care □ Parent/Caregiver MH concern or cognitive delay □ Domestic Violence □ Substance Use: Parent Caregiver Child □ □ □ □ Food uncertainty □ Housing Issues □ Other (please specify) □ Chronic Conditions: (Please check all that apply) ADD/ADHD Depression Intellectual Disability Seizure Disorder □ □ □ □ Anxiety Developmental Delay Learning Disability Sickle Cell Anemia □ □ □ □ Asthma Development screening fail Maternal/Caregiver Speech Problems □ □ □ □ (birth-5) Depression Autism, Asperger’s, ASD Diabetes MCHAT Fail Suicide Ideation/Attempt □ □ □ □ Behavioral Problems Down Syndrome ODD Technology Dependence □ □ □ □ Bone, joint, or muscle Eating Disorder Postpartum Depression Tourette Syndrome □ □ □ □ problems Brain Injury Epilepsy Prematurity Transition to Adulthood □ □ □ □ Cerebral Palsy Hearing Problems School Absences (Chronic) Vision Problems □ □ □ □ Cutting and self-injury Other (please specify): □ □ What outcome would you like to see?: Other community resources involved in the child’s care: Does the family require intensive Care Coordination? Was the patient identified on the health plan’s high risk list? Yes Yes □ □ No No □ □ High Risk Qualifiers: at risk for high cost utilization of hospital services; □ at risk of negative health outcome due to health condition (e.g. clinical risk groups) (Short term (1 year)) □ at risk of negative health outcomes due to social and behavioral and family issues (Longer term (2-5 years)) □ ________________________________________________________ Staff Member Name and Date
Child’s First Name: Last Name: DOB: Current Age: Primary Care Physician: Other Treating Clinicians: Primary Health Insurance: Reason for referral: Child/Family Risk Factors: Current need Comments 2+ Hospital admissions past 12 months □ 2+ ED visits related to chronic condition □ 2+ ED visits for behavioral health past 12 months □ 1+ Behavioral health hospitalization past 12 months □ 2+ missed MD appointments □ School issues (low performance, absenteeism, behavior) □ Foster Care □ Parent/Caregiver MH concern or cognitive delay □ Domestic Violence □ Substance Use: □ Parent □ Caregiver □ Child □ Food uncertainty □ Housing Issues □ Other (please specify) □ Chronic Conditions: (Please check all that apply) □ ADD/ADHD □ Depression □ Intellectual Disability □ Seizure Disorder □ Anxiety □ Developmental Delay □ Learning Disability □ Sickle Cell Anemia □ Asthma □ Development screening fail (birth-5) □ Maternal/Caregiver Depression □ Speech Problems □ Autism, Asperger’s, ASD □ Diabetes □ MCHAT Fail □ Suicide Ideation/Attempt □ Behavioral Problems □ Down Syndrome □ ODD □ Technology Dependence □ Bone, joint, or muscle problems □ Eating Disorder □ Postpartum Depression □ Tourette Syndrome □ Brain Injury □ Epilepsy □ Prematurity □ Transition to Adulthood □ Cerebral Palsy □ Hearing Problems □ School Absences (Chronic) □ Vision Problems □ Cutting and self-injury □ Other (please specify): What outcome would you like to see?: Other community resources involved in the child’s care: Does the family require intensive Care Coordination? Was the patient identified on the health plan’s high risk list? □ Yes □ Yes □ No □ No High Risk Qualifiers: □ at risk for high cost utilization of hospital services; □ at risk of negative health outcome due to health condition (e.g. clinical risk groups) (Short term (1 year)) □ at risk of negative health outcomes due to social and behavioral and family issues (Longer term (2-5 years)) ________________________________________________________ Staff Member Name and Date
PCMH-Kids%20High%20Risk%20Screening%20Tool%206.8.17_0.docx