Child and Family Interview Form - School - Island Community Services

Child & Youth Mental Health General Screening Questionnaire

Completed by School / Community Referral

This information will assist us in providing the best possible care for this youth and their family. Your answers will be kept as part of the child’s or teen’s clinical record which they have the right to request in future.

Please know that answering these questions is completely voluntary and will not affect the services the young person may receive from Salt Spring Island Community Services. We invite you, however, to be as forthright as you can be to help us to determine how best to support this youth. There may be questions you cannot answer due to limited information – this is not a concern.

The form is in six parts and must be completed in one session before submission so please allow yourself ample time – approximately 10 or 15 minutes.

- Step 1 of 6

Date *

Submitted by (Name and Position) *

Email of submitter *

Youth Name *

First

Last

Youth DOB *

Age

Youth Phone

Youth Email *

Youth Address

Address Line 1

City

State / Province / Region

Postal Code

Parent / Caregiver Name

Parent / Caregiver Phone

Parent / Caregiver Email

Gender ID

Pronouns

Indigenous Background

Ethnicity

North American
South Asian (East Indian, Pakistani, Sri Lankan)
Southeast Asian (Vietnamese, Cambodian, Malaysian, Laotian)
West Asian (Iranian, Afghani)
Chinese
Black
Filipino
Latin American
Arab
Korean
Japanese
European

Language at Home

Is the youth currently attending school? *

School Name

Grade

Youth's Doctor Name

Is there a School Designation IEP in place? If yes, which one (R, H, etc.)?

Medications

Is the parent / caregiver aware of this referral

Is the youth aware of this referral?

Are you aware of this youth accessing counselling services previously?

If yes, comment

Please tell me about your concerns and any help you would like for this youth. *

How long have you been aware of this problem? Please check one. *

Less than 3 months
3 to 6 months
6 to 12 months
More than 1 year

What steps have you taken to deal with the problem, if any?

Is the person working with, or scheduled to work with a psychologist or psychiatrist?

Is there a formal diagnosis that would be important for us to know? If yes, please specify.

Have there been recent visits to the hospital? If so, how many in the last year?

None
1-3
More than 3

Are there any cultural customs, beliefs, or traditions that it would be helpful to know about?

Are you aware of any of the following that may apply to this youth's situation (Check any that apply).

Separation / Divorce
Custody / Access dispute
Major Physical Illness (Parent)
Major Physical Illness {Child}
Financial Stressors
Death of a Loved One
Family Violence
History of abuse {child}
Substance use {Parent}
Substance use {Child / Teen}
Moved Homes or School
Traumatic Event {e.g. fire, accident etc}
Mental Health {Parent}
Mental Health {diagnosed child}

Comments

Please indicate whether each is NEVER (0) true, SOMETIMES (1) true, or OFTEN (2) true for this child.

Do you notice that this student....

Is distractible or has trouble sticking to any activity? *

Fails to finish things they start? *

Has difficulty following directions or instructions? *

Is impulsive or acts without stopping to think? *

Jumps from one activity to another? *

Fidgets? *

Comments:

Do you notice that this student...

Worries that bad things will happen to loved ones? *

Worries about being separated from loved ones? *

Is scared to sleep without parents nearby? *

Is overly upset when leaving loved ones? *

Is overly upset when away from loved ones? *

Is overly upset when leaving loved ones? (copy) *

Complains of feeling sick before separating? *

Comments:

Do you notice that this student....

Is cranky? *

Is defiant or talks back to adults? *

Blames others for their own mistakes? *

Is easily annoyed by others? *

Argues a lot with adults? *

Is angry and resentful? *

Comments:

Does this student....

Cut classes, skip school? *

Destroy things belonging to others? *

Engage in vandalism? *

Steal? *

Physically attack people? *

Use weapons when fighting? *

Comments:

Do you notice that this student...

Worries about doing better at things? *

Worries about past behaviour? *

Worries about doing the wrong thing? *

Worries about things in the future? *

Is afraid of making mistakes? *

Is overly anxious to please people? *

Comments

Do you notice that this student....

Has no interest in their usual activities? *

Gets no pleasure from usual activities? *

Has trouble enjoying themselves? *

Is not as happy as other children? *

Feels hopeless? *

Seems unhappy, sad or depressed? *

Comments:

Total Score

The next section asks a few questions about how these problems have affected this student's teachers, friends, and school. Please indicate if it is NONE, A LITTLE, or A LOT. If unsure, please skip.

How much has the youth withdrawn or isolated themselves as a result of these problems?

None
A Little
A Lot

How much less has the youth been doing things with other kids as a result of the problems?

None
A Little
A Lot

How much has the youth's life become less enjoyable as a result of these problems?:

None
A Little
A Lot

How much trouble has the youth had getting along with teachers as a result of these problems?

None
A Little
A Lot

How much has the youth been irritable or fighting with friends as a result of these problems?

None
A Little
A Lot

Comments:

How much school has the student missed as a result of these problems?

None
A Little
A Lot

How much have the student's grades gone down as a result of these problems?

None
A Little
A Lot

Comments:

The following section is about the student's interactions with peers. Please answer how they apply with RARELY, SOMEWHAT, CERTAINLY. If unsure, skip. Does the student.....

Invite bystanders to join in a game?

Rarely
Somewhat
Certainly

Take an opportunity to praise the work of less successful students?

Rarely
Somewhat
Certainly

Show sympathy for someone who has made a mistake?

Rarely
Somewhat
Certainly

Offer to help other students who are having difficulty with a task in the classroom?

Rarely
Somewhat
Certainly

Try to be fair in games?

Rarely
Somewhat
Certainly

Try to stop it when there is an argument or a dispute between peers?

Rarely
Somewhat
Certainly

Comments:

Other Concerns Checklist

Other types of concerns that help us to understand the student's overall situation better. Only select items which seem to be a concern to the school or others.

Bullying: Repeatedly bullies, teases, harasses or excludes other children from social activities.

None
A Little
A Lot

Cruelty to Animals: Cruel to animals, hurts and/or teases animals repeatedly

None
A Little
A Lot

Fire: Inappropriate involvement with fire, matches etc.

None
A Little
A Lot

Substance use: Recurrent use of alcohol or drugs leading to impaired functioning (e.g. substance related absences, suspension, or expulsions from school).

None
A Little
A Lot

Specific Fear: Unusually strong and persistent fear of something specific (e.g. travel, animals, needles, heights).

None
A Little
A Lot

Social Phobia: Persistent fear & avoidance of social situations with peers or social performance demands due to a fear of embarassment or scrutiny.

None
A Little
A Lot

Obsessions: Recurrent thoughts or impulses that cause distress or impair functioning.

None
A Little
A Lot

Compulsions: Repetitive behaviours (e.g. hand-washing, ordering, checking) that causes distress or impair functioning.

None
A Little
A Lot

Movement Problems: Recurrent move ents (tics) or vocalizations that cause stress or impairment.

None
A Little
A Lot

Thought Probems: Delusions, hallucinations, paranoia, disorganized speaking or behaviour resulting in significant impairment.

None
A Little
A Lot

School Refusal: Persistent unwillingness or refusal to regularly attend school due to anxiety or a fear of separation.

None
A Little
A Lot

Selective Mutism: Consistent failure to speak in some situations (e.g. school) but speaks commfortably in other situations (e.g. home).

None
A Little
A Lot

Victimized / Bullied: Is repeatedly bullied, teased, harassed or excluded from social activities.

None
A Little
A Lot

Trauma: Experienced or witnessed event(s) threatening death or serious injury to self or others. Re-experienced it, tries to avoid similar setting; has increased arousal, sleep difficulties.

None
A Little
A Lot

Speech Problems: Significant difficulty speaking or undertanding speech.

None
A Little
A Lot

Developmental Problems: General development significantly below age.

None
A Little
A Lot

Learning Problems: Academic progress significantly below ability (comments section).

None
A Little
A Lot

Sleep Difficulties: Persistent difficulty falling asleep, staying asleep, awakening from anxiety-provoking nightmares or prolonged sleep during the day which causes stress or impairment.

None
A Little
A Lot

Eating Problems: Not maintaining weight, significant loss of weight, fear of being overweight, disturbed thinking about body shape or weight.

None
A Little
A Lot

Urination Problems: Urinates in bed or clothing several times per week.

None
A Little
A Lot

Bowel Movement Problems: Bowel movements in inappropriate places (e.g. clothes, floor) several times over a 3 month period.

None
A Little
A Lot

Sexual Problems: Problems with sexual behaviour or identity which cause distress or impairment.

None
A Little
A Lot

Comments:

There are a few follow-up questions about the student's school success or barriers.

Has this student ever repeated a grade or got held behind?

Yes
No
Unsure

Is the student currently receiving special education, behavioural, speech, language or other supports?

Yes
No
Unsure

Has this student been assessed by psychological or speech and language services?

Yes
No
Unsure

Are you aware of any barriers that may prevent this student or their family from accessing services?

Yes
No
Unsure

Comments:

Talents and Skills

Does the student have special skills or interest in.... (Identify details in comments beneath each category if applicable).

Sports

Yes
No
Unsure

Details if applicable

Academics

Yes
No
Unsure

Details if applicable

Creative Arts

Yes
No
Unsure

Details if applicable

Music or Dance

Yes
No
Unsure

Details if applicable

Animals

Yes
No
Unsure

Details if applicable

Technical Skills

Yes
No
Unsure

Details if applicable

Interpersonal or Leadership Skills

Yes
No
Unsure

Details if applicable

Other

Yes
No
Unsure

Details if applicable

Comments:

Have we missed anything important that we need to know about this student, their home, or family?

Thank you for taking the time to support this young person.

Child and Family Interview Form – School

Child & Youth Mental Health General Screening Questionnaire

Completed by School / Community Referral

Please indicate whether each is NEVER (0) true, SOMETIMES (1) true, or OFTEN (2) true for this child.

Other Concerns Checklist

Talents and Skills

Contact Information

FETCH Salt Spring

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