ADT Concurrent CPS/DV Assessment CPS Assessment Section 1: Child/Youth Assessment (Complete for each child) Intake ID: Case: (Case Name) Individual: Interview Interview Native American Refused to be interviewed No Unable to be interviewed Unknown Yes Declined to disclose Child Physical/Mental Health (check all that apply) Risk Factors Protective Factors Hearing or vision impaired No physical/mental health issues History of seizures Received care for identified mental health issues Medical diagnosis requiring life sustaining measure Receives care for identified medical issues Medical diagnosis requiring ongoing care Up to date on immunizations Medical issues (asthma, broken arm, severe allergy) Mental health diagnosis ongoing medications Physical disability Requires psychotropic meds to function No Risk Factors
ADT Concurrent CPS/DV Assessment CPS Assessment Section 1: Child/Youth Assessment (Complete for each child) Intake ID: Case: (Case Name) Individual: Interview Interview Refused to be interviewed Unable to be interviewed Native American No Unknown Yes Declined to disclose Child Physical/Mental Health (check all that apply) Risk Factors Hearing or vision impaired History of seizures Medical diagnosis requiring life sustaining measure Medical diagnosis requiring ongoing care Medical issues (asthma, broken arm, severe allergy) Mental health diagnosis ongoing medications Physical disability Requires psychotropic meds to function No Risk Factors Protective Factors No physical/mental health issues Received care for identified mental health issues Receives care for identified medical issues Up to date on immunizations
ADT%20Concurrent%20CPS%20DV%20Assessment.docx