ࡱ>  )bjbj ;E) JJJJJ^^^8d^F~ ~(4((()VP+,hDDDDDDD$HoKVDJ,)),,DJJ((HF202020,pJ(J(D20,D2020^;<(1e,^"<rDF0F2<KR-K <<XKJN>$,,20,,,,,DD20,,,F,,,,K,,,,,,,,, : Clinical Summary Template The Childrens System of Care will utilize the Clinical Summary Template to assist in the determination of an appropriate intensity of service for any of the following reasons: Linkage with CSOC Care Management Services Potential linkage to other CSOC services A supplemental document for Care Management-linked youth, who are currently receiving community-based therapeutic services, and are being referred for Out-of-Home (OOH) treatment. Please see the highlighted instructions below. Please note: If a youth is participating in the Community Care Waiver through the Division of Developmental Disabilities, the youth is not eligible for CSOC services. Please do not use this document. If a youth is in need of Substance Use Treatment services, please refer to the PerformCare website, at www.performcarenj.org, for instructions on how to access services. Please do not use this document. Access to SU services can be immediate at a time that the family identifies the services are needed and wanted. Instructions: The Clinical Summary Template is to be completed or undersigned by an independently licensed clinician (i.e. LCSW, LPC, MD, Ph.D., Psy.D) who is currently providing or supervising treatment services to the youth and is informed about the youths current strengths and needs. All fields are mandatory and must be typed. Download the form to complete, then fax to 1-877-736-9166. If you are completing this document to support an Out-of-Home (OOH) referral, this completed document should be provided to the youths Care Management Organization (CMO). The CMO Care Manager should then upload the Clinical Summary Template in conjunction with all other documentation of the OOH referral to the youths record in CYBER. In this situation, please do not fax the Clinical Summary Template to PerformCare.If you need additional information regarding the Clinical Summary Template, or referring a child for CSOC services, please contact PerformCare at 1-877-652-7624 for assistance. Date:  FORMTEXT      Assessor Name:  FORMTEXT      Credentials:  FORMTEXT      Assessor s Agency:  FORMTEXT      Phone Number:  FORMTEXT      Email Address:  FORMTEXT      Mailing Address:  FORMTEXT      Youth s Name:  FORMTEXT      DOB:  FORMTEXT      Youth s Current Address:  FORMTEXT      Gender:  FORMTEXT      Race/Ethnicity:  FORMTEXT      CYBER ID#  FORMTEXT      If the youth has not had services through the Children s System Of Care, please instruct the legal guardian to call 877-652-7624 to register the youth.Parent/Legal Guardian s Name:  FORMTEXT      Relationship:  FORMTEXT      Guardianship Status (i.e. DCP&P Custody or Guardianship):  FORMTEXT      Address:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Primary Phone:  FORMTEXT      Secondary Phone:  FORMTEXT      Primary language spoken in the home:  FORMTEXT      Contact information for DCP&P case worker and supervisors, if involved: DCP&P Case Worker:  FORMTEXT      Phone:  FORMTEXT      DCP&P Supervisor:  FORMTEXT      Phone:  FORMTEXT      Current court orders?  FORMCHECKBOX  Yes FORMCHECKBOX  NoSpecify:  FORMTEXT       Reason for Submission of the Clinical Summary Template: (i.e. youth s presenting needs, youth s level of risk (including risk of Out-of-Home treatment), multisystem involvement, youth s current functioning)  FORMTEXT       Describe the youth and family s understanding of their strengths, needs, and roles in addressing their needs: (Include what makes the youth and family feel better and with whom they feel a sense of connectedness.)  FORMTEXT        Current and Past History of Treatment & Youth System Involvement: (Provide detailed information for all applicable sections including start/end dates and name of provider/agency/facility limit to the past 3 years): Behavioral Health (include: Outpatient, Intensive In-Home, Partial Hospitalization/ Partial Care Programs, Out-of-Home Treatment, Inpatient Hospitalizations)  FORMTEXT        Substance Use (include type of substance, pattern of use, age of onset, types of treatment - Outpatient, Intensive Outpatient, Partial Care Programs, Short-Term/Long-Term Residential, Withdrawal Management, Inpatient hospitalizations):  FORMTEXT        Physical Health/ Medical (include active issues and relevant history): FORMTEXT        Child Welfare/DCP&P (include history of abuse or neglect and descriptions. List relevant details including duration, identified perpetrator, as well as services accessed and time spent in resource care):  FORMTEXT        NJ Children s System of Care (CSOC) (include history of Care Management Organization (CMO) services, Mobile Response and Stabilization Services (MRSS), Family Support Organization (FSO), etc.):  FORMTEXT        DD Eligibility Status (include description of any functional challenges or limitations): FORMTEXT        Juvenile Justice (include court involvement, charges pending, FCIU, probation, detention, day program, DAP, incarceration, parole):  FORMTEXT        Specialty Needs (include information about any fire setting behavior and/or problematic sexual behavior, cruelty to animals, and assaultive behaviors that have occurred at any point in their lifetime. Also, include details to the severity and frequency of these behaviors and timeline with most recent occurrence. Also note if any specialty evaluations have been completed, including recommendations and relevant treatment completed): FORMTEXT        School (include information relevant to attendance, achievement, functioning, and type of school placement, i.e. regular education, special education, in district/out of district, home instruction):  FORMTEXT        Current DSM-5 Behavioral Health Diagnoses  All Required: Diagnosing Practitioner:  FORMTEXT      Credentials:  FORMTEXT      Date of diagnosis:  FORMTEXT      List all Behavioral Health Diagnoses and ICD-10 F-codes (Diagnoses must be provided by an independently licensed clinician and must be current within 1 year):  FORMTEXT       Current Intellectual/Developmental Disability Diagnosis, if any:  FORMTEXT       Current Substance Use Diagnosis, if any:  FORMTEXT       Most Recent IQ, if known:  FORMTEXT      Current Prescription Medications (Specify all - Name, dosage, frequency, reason prescribed/diagnosis, start/end dates, prescribing practitioner):  FORMTEXT        Current Presenting Behavioral Symptoms: Youth Behavioral/Emotional Needs (please check any behaviors that are relevant to the treatment needs of the youth and/or exhibited in the last 30 days):  FORMCHECKBOX Psychosis (Hallucinations, delusional thoughts, bizarre, odd behaviors, speech, and thoughts) FORMCHECKBOX Anxiety (Social anxiety, generalized anxiety, panic symptoms)  FORMCHECKBOX Anger Control (The youths ability to manage their anger) FORMCHECKBOX Impulsivity/Attention (Challenges with impulse control)  FORMCHECKBOX Oppositional Behavior (disrespectful, argumentative behaviors, difficulty with accepting rules from authority figures) FORMCHECKBOX Conduct (Antisocial behaviors including stealing, vandalism, cruelty to animals, assaultive behaviors) FORMCHECKBOX Depression (Irritable or depressed mood, isolative, withdrawn behaviors, thoughts of hopelessness, sleep and appetite changes, loss of motivation)  FORMCHECKBOX Exposure to Implicit Trauma (Implicit trauma refers to experiences and historical events which may not result in specific memories or overt reactive behaviors, but may contribute to current behavioral/ emotional symptoms) ex. Adoption, loss of a family member  FORMCHECKBOX Exposure to Explicit Trauma (Explicit trauma refers to traumatic experiences which directly correlate with post-traumatic emotional and behavioral symptoms) ex. Sexual molestation FORMCHECKBOX Technology (The impact of the technology use on the youths daily functioning including their ability to maintain relationships, complete school work etc.) FORMCHECKBOX Gambling (Youth s involvement with all forms of gambling, legal and illegal)  FORMCHECKBOX Other:  FORMTEXT       Detailed description of all checked behaviors/symptoms; please include any current presenting symptoms and any history of these symptoms:  FORMTEXT        Youth Risk Behaviors (please check any issues that are relevant to the treatment needs of the youth and/or exhibited in the last 30 days):  FORMCHECKBOX Suicide Risk (This includes suicidal thoughts, plans, behaviors, and relevant history) FORMCHECKBOX Danger to Others (This includes actual and threatened violence, along with relevant history) FORMCHECKBOX Flight Risk (This includes any planned or unplanned wandering, impulsive running; consider age of the youth, frequency, duration of escape episodes, timing, and context) FORMCHECKBOX Problematic Sexual Behaviors (This includes any sexually aggressive behavior where an older youth takes advantage of a younger youth) (Specialty Evaluation may be indicated if this form is being completed as part of an Out-of-Home (OOH) treatment referral process.) FORMCHECKBOX Other Self Harm (Other high risk behaviors which impacts personal safety and increases the risk of personal injury that is not considered suicidal behavior or intentional self-injurious behavior) FORMCHECKBOX Substance Use (This refers to any use of tobacco, alcohol, or illegal drugs) (Specialty Evaluation may be indicated if this form is being completed as part of an Out-of-Home (OOH) treatment referral process.) FORMCHECKBOX Self-Injurious Behaviors (Any intentional self-harming behaviors that do not have suicidal intent) FORMCHECKBOX Judgment (This refers to the youths decision-making ability) FORMCHECKBOX Legal/ Juvenile Justice (This includes any behavior which a youth exhibits that results in involvement with the legal system) FORMCHECKBOX Fire Setting (This refers to when youth intentionally start fires) (Specialty Evaluation may be indicated if this form is being completed as part of an Out-of-Home (OOH) treatment referral process.) FORMCHECKBOX Other:  FORMTEXT       Detailed description of all checked risk behaviors; please include any current presenting risk behaviors and any history of these risk behaviors:  FORMTEXT        Youth Strengths (please check any issues that are relevant to the treatment needs of the youth and/or exhibited in the last 30 days):  FORMCHECKBOX Family Strengths - Ability to support the youths overall progress and development FORMCHECKBOX Relationship Stability - Stability of relationships with friends and family  FORMCHECKBOX Talents / Interests which the youth exhibits FORMCHECKBOX Community Involvement - The quality of the youths connection to their community FORMCHECKBOX Youths involvement with care  FORMCHECKBOX Optimism - Youths personal sense of optimism FORMCHECKBOX Self-Expression - Youths ability to express his/her thoughts and feelings FORMCHECKBOX Spiritual- Youths involvement with spiritual or religious beliefs and practices and activities FORMCHECKBOX Wellness Behaviors - Indicators that the youth exhibits health-promoting behaviors and makes good lifestyle choices FORMCHECKBOX Resiliency - The youths innate ability to enjoy positive life experiences and manage negative life experiences FORMCHECKBOX Other:  FORMTEXT       Detailed description of all checked strengths:  FORMTEXT        Life Domain Functioning (please check any issues that are relevant to the treatment needs of the youth and/or exhibited in the last 30 days):  FORMCHECKBOX Living Environment (This refers to the youths functioning in the current living arrangement) FORMCHECKBOX Cultural Stress (This refers to experiences and feelings of discomfort related to real or perceived conflict between an individuals own cultural identity and the predominant culture in which he/she lives in. 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to distorted body image cognitions) FORMCHECKBOX Sexual Health (This refers to the youths physical, emotional, mental, and social wellbeing in relation to sexuality) FORMCHECKBOX School Behavior (This refers to any disruptive behavior which the youth exhibits in a school or day care setting) FORMCHECKBOX School Attendance (This refers to how consistently the youth attends school) FORMCHECKBOX Academic Achievement (This refers to the youths grades and test scores) FORMCHECKBOX Bullied by Others (This refers to the degree to which a youth has been bullied or is being bullied by others) FORMCHECKBOX Learning Disability (This refers to any innate difficulty in a specific academic subject which could require additional educational supports) FORMCHECKBOX Developmental Delay (Autism, Cerebral Palsy, Down Syndrome, and other Genetic Disorders are rated here) FORMCHECKBOX Educational Agency Involvement (This refers to the Schools ability to address youths educational and behavioral health needs; and the quality of the schools relationship with the youth and family) FORMCHECKBOX Physical (This refers to any physical limitations the youth may experience due to health or other factors as well as the youths abilities to use sense of vision and hearing.) FORMCHECKBOX Other:  FORMTEXT       Detailed description of all checked life domain functioning needs; please include any current presenting life domain functioning needs and any history of these life domain functioning needs:  FORMTEXT        Caregiver(s) Information/Needs: Caregiver(s) Name(s):  FORMTEXT      Caregiver(s) Relationship to Youth:  FORMTEXT      Caregiver(s) strengths and needs (check all that apply):  FORMCHECKBOX Caregiver Physical/ Medical Needs  FORMCHECKBOX Caregiver Substance Use Needs FORMCHECKBOX Safety of Immediate Living Environment FORMCHECKBOX Caregiver Mental Health Needs FORMCHECKBOX Caregiver Needs related to Intellectual/ Developmental Disability FORMCHECKBOX Knowledge of Youths Strengths/ Needs  FORMCHECKBOX Caregiver Optimism FORMCHECKBOX Family Stress  FORMCHECKBOX Caregiver Resourcefulness FORMCHECKBOX Residential Stability  FORMCHECKBOX Involvement with Care FORMCHECKBOX Supervision FORMCHECKBOX Caregiver Strengths and Needs involving Transitioning from Military Services FORMCHECKBOX Natural Supports FORMCHECKBOX Child/Adolescent Protection Detailed description of all checked caregiver(s) strengths and needs:  FORMTEXT       For youth referral for Residential Out-of-Home (OOH) Treatment Services: Please complete the following if this form is being completed as part of an Out-of-Home (OOH) referral process. If the youth has not been successful with community-based services and supports - please describe, in detail, the reasons why community based services and supports were not successful. FORMTEXT       What are the resources, supports, and alternative interventions that could be considered in order to potentially maintain the youth in the community? 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services referral. In this case, it should b|̼μRηΨqdWBd8dqh3'OJQJaJ)h+Y4hO"B*OJPJQJ^JaJphh+Y4hO"OJQJaJh+Y4hITOJQJaJh+Y4hITCJOJQJaJh+Y4hIT5CJOJQJaJh&h,OJQJh h,OJQJaJh(ih,CJOJQJaJ,jh(ih9x*OJQJUaJmHnHu!jh(ih9x*OJQJUaJ'jpsh(ih9x*OJQJUaJh(ih9x*OJQJaJҽxxx (($Ifgdxgd,qkds$$Ifl$h% t0644 lap yt,.0:<>@TVXbdfhj~ʶןהʀןהlןהXןה'jvh(ih9x*OJQJUaJ'juh(ih9x*OJQJUaJ'jyuh(ih9x*OJQJUaJh(ih @OJQJ,jh(ih9x*OJQJUaJmHnHu'juh(ih9x*OJQJUaJh(ih9x*OJQJaJ!jh(ih9x*OJQJUaJh&h @OJQJh&h @5OJQJ!>f`SSS (($Ifgdkdmt$$IflF $x x x t06    44 lapytfh`SSS (($Ifgdkdev$$IflF $x x x t06    44 lapytξоҾܾ޾   "$.024HJLڸګڸګxڸګdڸګP'jyh(ih9x*OJQJUaJ'jiyh(ih9x*OJQJUaJ'jxh(ih9x*OJQJUaJh&h @OJQJ'jwh(ih9x*OJQJUaJh(ih9x*OJQJaJh(ih @OJQJ,jh(ih9x*OJQJUaJmHnHu!jh(ih9x*OJQJUaJ'jqwh(ih9x*OJQJUaJ 2Z`SSS (($Ifgdkd]x$$IflF $x x x t06    44 lapytLVXZ\^$&(*BD²؋wئ¦k_؋Kئ¦_'j{h(ih9x*OJQJUaJh&h9x*5OJQJh&hU5OJQJ'jzh(ih9x*OJQJUaJh(ih9x*OJQJaJh&h9x*5OJQJaJh&h @5OJQJh&h @5CJOJQJaJh&h @OJQJh(ih @OJQJ!jh(ih9x*OJQJUaJ,jh(ih9x*OJQJUaJmHnHuZ\^`XK (($Ifgddhgd @kdUz$$IflF $x x x t06    44 lapyt( (($Ifgdnkda{$$Ifl$h% t0644 lap yt(*l (($IfgdnkdY|$$Ifl$h% t0644 lap ytDFZ\^hjto_SDh*hpCJOJQJaJhpCJOJQJaJh&h"5CJOJQJaJh&h$Hv5CJOJQJaJh&h @OJQJ'jQ}h(ih9x*OJQJUaJh&hU5OJQJh&h @5OJQJ,jh(ih9x*OJQJUaJmHnHu'j|h(ih9x*OJQJUaJh(ih9x*OJQJaJ!jh(ih9x*OJQJUaJLxppeR$dxx$Ifa$gd* $da$gdpdhgd @kd}$$Ifl0H$ t0644 lapyt0<>l(HM~  1ΣvnjnjnjnjZhhN5CJOJQJaJ(hs jhs Uh&h"5CJOJQJaJ h&h"0J CJOJQJaJhCJOJQJaJh&h"CJOJQJaJh)5CJOJQJaJUhP'5CJOJQJaJh*hpCJOJQJaJ"h*hp5>*CJOJQJaJh*hp5CJOJQJaJ!e given to the youths CMO Care Manager so it can be uploaded into CYBER. If you need additional information regarding the Clinical Summary Template, or referring a child for CSOC services, please contact PerformCare at 1-877-652-7624 for assistance.     Clinical Summary Template All fields are mandatory and must be typed. 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