San Diego Center for Children: Mental Health Access Program

Page 1

SDCC Logo

Welcome

As a parent/guardian of a child who may be experiencing behavioral and/or emotional challenges, you most likely have questions and concerns related to your child's well-being as well as your family. To clearly identify what these needs may be, and how to best assist you with useful information and services, we have developed a brief screening tool that has been specifically designed for this purpose at the San Diego Center for Children. 

After you review and approve the Consent Form for screening services and provide some information about your child, you will be directed to complete this brief tool. This process is designed to help our staff develop, together with you, a plan to access appropriate services to benefit your child and your family's well-being.

Page 2

SDCC Logo

San Diego Center for Children - Screening Informed Consent 


I understand that my answers to the questions in the Mental Health Access Plan - Screening (MHAPS) may contain sensitive and/or confidential information that can be shared only with proper written authorization and consent.  


I understand that the completion of the MHAPS is voluntary and will take 10 minutes or less. After this brief screening is completed, a San Diego Center for Children professional will contact me to make an appointment to review the information and explore options to address my child/family’s needs.  At the time of my/our initial appointment, an informed consent form will be reviewed that explains limits of confidentiality.

This screening process is not designed to respond to emergencies or crisis situations.  If you have an urgent concern that requires immediate attention, please contact the Access and Crisis line at 888-724-7240.


By signing below, you are indicating that you have read, understand, and agree with the above sections in the Center’s Screening Informed Consent. This consent will end when you state it should end or when your services end.




Page 3

SDCC Logo



Child Section


















Referred By:





Parent/Caregiver Section













Page 4

SDCC Logo

Child Functioning


Please rate your degree of concern about your child in the following areas:
Extremely Concerned Concerned Not a Concern


Many children experience stressful life events that can affect their health and wellbeing. Please read the statements below. Count the number of statements that apply to your child and write the total number in the box provided.


At any point since your child was born....
  • Your child's parents or guardians were separated or divorced
  • Your child lived with a household member who served time in jail or prison
  • Your child lived with a household member who was depressed, mentally ill or attempted suicide
  • Your child saw or heard household members hurt or threaten to hurt each other
  • A household member swore at, insulted, humiliated, or put down your child in a way that scared your child OR a household member acted in a way that made your child afraid that s/he might be physically hurt
  • Someone touched your child's private parts or asked your child to touch their private parts in a sexual way
  • More than once, your child went without food, clothing, a place to live, or had no one to protect her/him
  • Someone pushed, grabbed, slapped or threw something at your child OR your child was hit so hard that your child was injured or had marks
  • Your child lived with someone who had a problem with drinking or using drugs
  • Your child often felt unsupported, unloved and/or unprotected

As it relates to your child's development, cognitive, emotional and/or behavioral health, please mark the space that best describes your need for assistance:

High Need Moderate Need No Need or Not Applicable

Thank you for sharing this information.  A member of our team will be reaching out soon to review your concerns and explore options to develop an individualized Mental Health Access Plan.



Scroll to Top