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(Rate mother in caregiver domain)

Alex is a 15-year-old male, recently discharged after a thirty-day stay in an in-patient psychiatric hospital. He was hospitalized because he heard voices telling him “terrible things about himself” and telling him to kill himself. He reported this to the school social worker who notified his parents. He was taken from school to the hospital. Alex presents as depressed and withdrawn, but will engage in one-on-one interaction with an adult. Alex has been telling people that he has been hearing voices since he was 5 years old. The parents have expressed their gratitude to the school personnel for believing Alex and responding quickly because when he has said similar things at home, they didn’t know what to do. Now they are worried that they might not be able to keep him safe at home.

Alex lives with his mother, father, and two older sisters. It is a loving family with close emotional ties. All of the children are kind, obedient, and care about other people. Alex’s mother has severe mental illness and is often overwhelmed by Alex’s needs which causes a lot of stress in their family. She says she feels a special connection to Alex because she can relate to his feelings of being unable to escape the ‘voices in his head’. Alex’s older sisters have also struggled with mental health issues in the past. Alex has no relatives in the area and the family has no child care resources.

Although his family has moved many times over the past few years, Alex has remained enrolled in the same school district. He exhibits no behavioral problems at school but he often responds verbally to his auditory hallucinations. In addition, these hallucinations make it difficult for him to concentrate which has impacted his grades. While he has educational goals appropriate for a tenth-grader, he is currently struggling to complete his requirements. He also often comes to school in the same clothes, which appear unwashed, several days a week. The teacher has expressed concern because he is regularly teased by other children. The teacher and the school social worker have met with Alex’s parents who have a hard time understanding the immediate risk that Alex’s hallucinations pose for him. Alex has no friends at school but is interacts well with all staff. He attends school regularly.

Alex and his family have been seen at the same clinic for the past four years. His mother was recently referred to a treatment program that she attends Monday through Friday during the day and is doing well. In an effort to get good housing in a safe neighborhood, the family has moved six times in the past 18 months. The family receives financial assistance through programs such as Section 8 benefits, SSI, and food stamps and is able to provide for the basic needs of their family.

When Alex was six years old, he witnessed the shooting of his uncle in front of their house. His uncle died on the sidewalk. The police questioned Alex a number of times about the incident. He experienced sleeplessness consistently for months after the incident and still does periodically. He will randomly ask his parents if they remember “when Uncle Sammy got killed.” He sometimes refers to the ‘voices in his head’ as Uncle Sammy’s killers who tell him he is to blame for Sammy being killed.

Place ratings in the section that are marked red


Put rating (number) next to each.

0. No evidence of need


1. History or   Suspicion


2. Action Needed, Need   interferes with Functioning


3. Immediate Action   Needed, Need is dangerous or disabling



1. Psychosis 


2.   Impulsivity/Hyperactivity 


3. Depression 


4. Anxiety 


5. Oppositional 


6. Conduct 


7. Anger Control 


8. Substance Use 


9. Adjustment to Trauma 

Caregiver Needs & Resources


0. No evidence of need


1. History or Suspicion


2. Action Needed, Need   interferes with Functioning


3. Immediate Action   Needed, Need is dangerous or disabling



1. Supervision 


2. Involvement with Care   


3. Knowledge 


4. Safety 


5. Residential Stability   


6. Organization 


7. Social Resources 


8. Mental   Health/Substance Use 


9.   Medical/Physical/Developmental 

Cultural Factors Domain


0. No evidence of need


1. History or   Suspicion


2. Action Needed, Need   interferes with Functioning


3. Immediate Action   Needed, Need is dangerous or disabling



1. Language 


2. Traditions and   Rituals 


3. Cultural Stress 

Life Functioning Domain


0. No evidence of need


1. History or Suspicion


2. Action Needed, Need   interferes with Functioning


3. Immediate Action   Needed, Need is dangerous or disabling



1. Family Functioning 


2. Living Situation 


3. School Achievement 


4. School Attendance 


5. School Behavior 


6. Social Functioning 


7.   Developmental/Intellectual 


8. Decision-Making 


9. Medical/Physical 


10. Sexual Development 


11. Sleep 

Risk Behaviors Domain


0. No evidence of need


1. History or   Suspicion


2. Action Needed, Need   interferes with Functioning


3. Immediate Action   Needed, Need is dangerous or disabling



1. Suicide Risk 0


2. Non-Suicidal   Self-Injurious Behavior 


3. Other Self-Harm 


4. Danger to Others 


5. Sexually Problematic   Behavior 


6. Delinquent Behavior 


7. Runaway 

Strengths Domain


0. Centerpiece   Strength


1. Useful Strength


2. Identified Strength


3. No Evidence



1. Family Strengths 


2. Interpersonal 


3. Educational Settings 


4. Talents and Interests   


5. Spiritual/Religious 


6. Cultural Identity 


7. Community Life 


8. Natural Supports 


9. Optimism 


10. Resilience 


11. Resourcefulness 

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