San Diego Center for Children: Mental Health Access Program Page 1 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 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. Parent/Authorized Representative Printed Name: Date: If signed by authorized representative, please indicate authorized representative’s relationship to the individual/youth: Page 3 Assessment ID#: Youth ID#: Parent ID#: Child Section First Name of Child: Last Name of Child: Date of Birth: Gender:Please select... Male Female Transgender Male/Transman/FTM Transgender Female/Transwoman/MTF Gender Expansive/Gender Queer Additional category (please specify) Decline to answer Gender Additional Category (please describe): Known Mental Health Diagnosis (if applicable): Child's Race/Ethnicity (select all that apply):White/CaucasianHispanic/LatinoAsianBi/MultiracialDecline to stateSelf-describe (specify)Black/African AmericanNative American/Alaskan NativeNative Hawaiian/Pacific Islander Race/Ethnicity Self-describe (specify): Is your child attending school/childcare?YesNo Grade: Is your child in Special Education?YesNo Does your child have a 504 Plan?YesNo Is your child enrolled in Regional Center?YesNo Is your family involved with child welfare or probation?YesNo Has your child received treatment in the past (mark all that apply)?YesNo If "Yes", mark all that apply?Outpatient therapy/psychiatryIntensive OutpatientWraparoundResidentialPartial hospitalizationInpatient Hospitalization Health InsuranceYesNo Insurance Company: Referred By: Referral Source:Please select... Family Pediatrician Mental Health Professional School Community Program Website Other Other Referral Source: Parent/Caregiver Section Parent/Caregiver's First Name: Parent/Caregiver's Last Name: Birthdate: Gender:Please select... Male Female Transgender Male/Transman/FTM Transgender Female/Transwoman/MTF Gender Expansive/Gender Queer Additional category (please specify) Decline to answer Gender Self-describe: Email Address: Cell Phone: Relationship to Child of person filling out the screening:Please select... Biological Parent Adoptive/Foster Parent Stepparent Relative (specify) Professional (specify) Other (specify) Relative/Professional/Other (Specify): Parents Relationship:Please select... Married Not-married Separated Divorced Single Widowed Other Parents Relationship (Other): Page 4 Child Functioning Please rate your degree of concern about your child in the following areas: Extremely Concerned Concerned Not a Concern 1. Behavior (impulsive, oppositional, aggressive, disruptive) 2. Social skills (cooperation with peers, arguing, temper outbursts, getting along) 3. Emotions (anxious, sad, depressed, angry) 4. Development (cognitive, relational, communication skills) 5. Somatic complains (aches, pain, nutrition) 6. Academic performance 7. Screen time (computer, phone, videogames) 8. Alcohol and Other Drug Use 9. Exposure to trauma (divorce, domestic violence, abuse, homelessness) 10. Self-harm (suicidal thoughts, statements, behaviors) 11. Danger to others (physical aggression, homicidal ideation) 12. Psychiatric medication management/consultation What pleases you most about your child? What worries you most about your child? 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. Of the statements written below, HOW MANY apply to your child? Write the total number in the box: At any point since your child was born....Your child's parents or guardians were separated or divorcedYour child lived with a household member who served time in jail or prisonYour child lived with a household member who was depressed, mentally ill or attempted suicideYour child saw or heard household members hurt or threaten to hurt each otherA 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 hurtSomeone touched your child's private parts or asked your child to touch their private parts in a sexual wayMore than once, your child went without food, clothing, a place to live, or had no one to protect her/himSomeone pushed, grabbed, slapped or threw something at your child OR your child was hit so hard that your child was injured or had marksYour child lived with someone who had a problem with drinking or using drugsYour 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 1. Responding/Managing my child’s behavior 2. Responding/Managing my child’s emotions 3. Relationship with partner/spouse/co-parent 4. Coping with everyday challenges and stressors (financial, work, childcare, schedules) 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.