Forms and Handouts
 |
All of our printable downloads require the free plug, Adobe Reader. You can get it by clicking on the button to the left. |
| Category | Description |
| Personal Strengths Assessments | Useful before talking about problems and includes measures of what’s working and going right with the child and family. |
| Health and Problem Assessments | Child mental and physical problems and concerns in relation to family, school and community. |
| Data Collection | Observe and record information on positive and negative activities of living, such as sleep, stress, eating, toileting, energy, etc. |
| Team Building | Expand the focus from the child to the cultural community. |
| Resiliency: Your Changing Stories | View what’s important and valued by everyday coping or balancing life and to build purpose, direction or change using restoring of experience. |
| I. Personal Strengths Assessments | [Back to Top] |
FORMS
- Child Reinforcement Survey(likes and dislikes)
- Child Assets Scale (a Practioner’s guide of risks and protections)
- Parent Summary of Child Health Asset (a parent’s guide to the child’s
interaction in the environment)- Child’s Strengths Checklist (for parent or provider to complete)
- Daily Strength Scale (child’s self-report)
- Family Support and Natural Ecology Chart (parent environmental
support)- Family Global Health and Well-being (how families function)
- Past Weeks’ Quality of Family Life (1 – 10 scale of parent/family
significance of everyday functioning)- Play Observation Checklist A guide to observing childs play
- Family Strengths Assessment – prepared by the LINCS Program for use by Able Families
HANDOUTS
- Promise to Families (letter of welcoming to the program)
- Letter to Child
- Solution Focus Handout (use of positive talk as a way to change)
- Enhancing Family Functioning (create special time for children)
OUTSIDE WEBSITES SCREENING TOOLS
- The Holmes-Rahe Life Stress Inventory (Initial assessment of parent’s stress)
- Casey Life Skills (Life skills assesment tools for youth and young adults)
- A useful multi sensory rating of under and over sensitivities reported by the care giver.
- Parent Care Needs(parent form for assessing interests and needs using family centered care coordination)If you can not access this website, it will require signing in to publish this pdf document instead of a link.
- Pediatric Care Plan (sample summary care plan with listed conditions, medications and other health requirements for child)
II. Health and Problem Assessments
FORMS
- Child Development and Family Life Experiences (history form)
- Four Generation Family Genogram (family history, relationships
and significant events)- Combined Health/Risk Checklist (disability illness rating and maybe helpful in determining child and family functional behaviors)
- Sleep Apnea Questionnaire Screening for sleep problems in childhood
HANDOUTS
- Guidelines for Physician Evaluation (Developmental Pediatrics)
- Extended Health Care Provider Assessment of Special Needs Children
(proposed use of nurse for collaborating with teams)
OUTSIDE WEBSITES SCREENING TOOLS
Anxiety Moods
- Early Childhood Trauma Screening Assessment
- TEQ The Trauma Experience Questionnaire is a helpful screen for early childhood trauma provided by the Children’s Center. It lacks scoring but will offer information using the ACES content as to total trauma load.
- Child Dissociative Checklist: Children with a history of trauma and excess stress with lots of anxiety who get labeled ADHD should be considered to have this screen
- Bipolar Mood Screening (standardized screening questionaire)
- Young Mania Scale (mania or for bipolar like moods)
- Young Mania Scale (interpretation of the scale)
- Depression Module – Self Help Report – Reading age children for screen
- Depression Scale for Children (CES-DC)
- Depression Tool Kit a complete tool package for health practitioners for treating child depression
- Obsessive Compulsive Screening Checklist
- Spence Children’s Anxiety Scale – Home Web Site Page Includes: materials on the scales reliability, validity, and availability for use. Linked are the child and parent scored versions, plus the pre-school version. Links are also found for directions and instruction for scoring.
- Scared Anxiety Screen for Children: (includes scoring)
- Scared Anxiety Screen for Parents: (includes scoring)
Autism
- Asperger Screening Scale for Autism
- Informal Screening for Autism Spectrum Disorders
- Rating scale and scoring for adolescent screening for autism
- Rating scale for childhood Asperger Syndrome including scoring
- Friendship and relationship quotient for children
- 2-5 y/o M Chat screening for autism
- scoring for M Chat for autism
- CSBS DP infant toddler questionnaire can be used by toddler caregiver as a part of autism assessment for6-24 mos with scoring
- CSBS Spanish Version
Attention
- Vanderbilt Checklist for ADHD (for parents to complete)
- Vanderbilt Checklist for ADHD (for teachers to complete)
- Side effects to stimulant medication questionnaire (PDF)
- 12 question rating scale for frequent probes in the classroom helpful for fine tuning ADHD with medication titration.
General
- Pediatric Symptom Checklist (child and youth self-report for emotional and behavioral screening, ages 6 – 16)
- The Holmes-Rahe Life Stress Inventory (Initial assessment of parent’s stress)
- Developmental Disorders Symptom Rating Scale (1 – 10 functional scale)
- Attachment questionnaire completed by care giver which promotes a sense of child’s relationship security.
- Guide For Parents(Self Assessment for attachment )
- Child attachment Checklist (Well organized questions about reactive children’s attachment using scaling)
- Questionnaire for Child and Adult Chronic fatigue with scoring
- Family psychosocial Screening by Kathi Kemper (important questions for highly stressed families for interviewing with scoring criteria.)
- We Care Survey(Family Poverty Social and Environmental Concerns, )
- Aces Score The Adverse Childhood Survey linking early developmental traumatic events of children to later mental health and other poor health outcomes in later years.
- Finding aces score using questionnaire
- Social emotional Behaviors Rating Ratings of Social emotional behaviors for individuals with severe Developmental disabilities.
- Family Impariment Scale
- Strengths and Difficulties Questionnaire Brief Questionnaire accessing state of teens (11-17) mental health. Younger children (4 and up) have parent and teacher complete forms. Score on line and compare print outs for alignment.
- Access public domain rating scales for numerous conditions in adults and children
- Collaborative Problem solving (cited with Dr. Ross Greene’s permission)
ADULT MENTAL HEALTH SCREENING:
Screening adults for behavioral primary care
Depression and anxiety adult screening questionnaires. Determination of type of rating to use should come with a consultation with your professional from your child’s school, doctor or mental health consultant. Please Consult the following link for more adult topics and scoring PHQ Screeners
- Patient Health Questionaire-9
- Anxiety Questionnaire (GAD-7)
- Questionnaire includes somatic, depression and anxiety
- Edinburgh Post Natal Depression Scale
Adult ADD
| III. Data Collection | [Back to Top] |
FORMS
- Weekly Log Summary
- Daily Mood Chart (feelings experienced through out the day)
- Self-Monitoring How I Feel Chart (happy, sad, mad faces for the child to discriminate)
- Self-Monitoring Event Calendar (30 day recordings of negative or positive
events)- Self-Monitoring by a Student for single class period
- Self-Monitoring by a Student for a single school day
- Self-Monitoring by a Student for a single school week.
- Functional Behavior Assessments (Scatter plot and ABC Behavior)
OUTSIDE WEBSITES SCREENING TOOLS
- Mood Chart for Manic Depression (self-recording of 30 day mood
cycles)- The Ottawa-Georgia Mood Scales (1 – 10 scales for mood, anger, and anxiety)
- Stress Thermometer (stress related to behavior and coping strategies in a crisis)
- Sleep Diary (child’s self-monitoring, with help, sleep hygiene)
| IV. Team Building | [Back to Top] |
FORMS
- Core Team Satisfaction Survey (for rating on-going group functions)
- Community Meeting Feedback Form
- School District Health Care Plan
- Family Health Promotion Plan (goals for child, school, family and community needs)
- Team Management Rating Scale (useful for parent at any group meeting to identify the team process)
- Medical Home Form for Evaluation and Service Recommendations (a way to input health provider concerns)
HANDOUTS
- Collaborative Coordination for Team Building (steps toward working together over time)
- A Model for Home Meetings (family talking and spending time together)
- School and Community Conference Arrangements (worksheet for community conference notes)
- Health Providers Promotion Prevention Matrix (prevention basis for the Family Health Promotion Plan)
- Guide to Conferencing (action steps to successful consultation)
OUTSIDE WEBSITES
Family input may be obtained using these three sources of information from the families assessment of needs:
- www.pediatricmedhome.org/pdfs/3_Assessment_of_Care_Needs.pdf
Parents summary of the pediatric care plan- www.pediatricmedhome.org/pdfs/3_Pediatric_Care_Plan.pdf
the child’s expressed needs
| V. Resiliency: Your Changing Stories | [Back to Top] |
FORMS
- Family Health Promotion Plan (weaves meaningful story threads that promote child-family strengths)
- Quality-of-Life Outcome Measures (QOM) (cumulative parent’s opinion of child’s progress over time that includes the following four QoLM)
- Comfort/Hassle Scales (1 – 10 scales of both soothing and stressful
moments)- Confidence/Progress Scales (1 – 10 scales of both feeling strong and positive change examples)
- Past Weeks’ Quality of Family Life (1 – 10 scale of parent/family significance of everyday functioning)
- A Family Focus (initial story stem from reflective family meanings)
- Life Quality Change Survey (story lines created from family qualities)
- Team Management Rating Scale (empowers a family’s goals communicating together)
HANDOUTS
- Negotiating Resources for Resilience Handout (building resilient stories from the following forms: Comfort/Hassles Scales, Confidence/Progress Scales, Child Assets Scale, Child’s Strengths Checklist and Daily Strength Scale)
- Perceiving Change Handout (ready, able and willing scale)
- Family Health Promotion Concept Plan (ideas supporting changes for child/family well-being)
- What is Narrative Practice? (basis for changing stories)
Note: All outside websites are public domain access.
| [Back to Top] |
Social Networks
Follow Us