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Adult Needs and Strengths Assessment

ANSA Manual

An Information Integration Tool for Adults with Behavioral Health Challenges

Version 2.0

Copyright, 1999
The Copyright for the ANSA Information Integration Tool is held by the Praed Foundation to ensure that it remains an open tool, free for anyone to use. Information on guidelines for use and development can be obtained by contacting the foundation at [email protected]

A large number of individuals have collaborated in the development of the ANSA. The ANSA is an open domain tool for use in service delivery systems that address the mental health of adults and their families. The copyright is held by the Buddin Praed Foundation to ensure that it remains free to use. For specific permission to use, please contact Melanie Lewis of the Foundation. For more information on the ANSA assessment tool contact: John S. Lyons, Ph.D. Endowed Chair of Child & Youth Mental Health Research University of Ottawa Children's Hospital of Eastern Ontario 401 Smyth Road, R1118 Ottawa, ON Canada [email protected] 613-562-5800 X8701 Betty Walton, Ph.D. Family Social Services Administration Division of Mental Health and Addiction Indianapolis, IN [email protected]

Along with the ANSA, versions for children and adolescents have been developed. These tools include the Child and Adolescent Needs and Strengths-Mental Health (CANS-MH), the Individual and Adolescents Needs and Strengths-Developmental Disability (CANS-DD), the Child and Adolescent Needs and Strengths-Juvenile Justice (CANS-JJ), and the Child and Adolescent Needs and Strengths-Sexual Development (CANS-SD). A comprehensive multisystem version of the CANS has also been developed. These information integration tools have been designed to support individual case planning and the planning and evaluation of service systems. For more information on any of the tools for children and adolescents contact:

Praed Foundation http://praedfoundation.org [email protected]

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Introduction
When the ANSA is administered, each of the dimensions is rated on its own 4-point scale after the initial intake interview, routine service contact, or following the review of a case file. Even though each dimension has a numerical ranking, the ANSA assessment tool is designed to provide a profile of the needs and strengths of the individual and family. It is a reliable aid to the service planning process and allows for the monitoring of outcomes. The basic structure of the ANSA is: Life Domain Functioning Physical/Medical Family Employment Social Functioning Recreational Intellectual Sexuality Living Skills Residential Stability Legal Sleep Self Care Decision Making Involvement in Recovery Transportation Medication Involvement Acculturation Language Identity Ritual Cultural Stress Behavioral Health Needs Psychosis Impulse Control Depression Anxiety Interpersonal Problems Antisocial Behavior Adjustment to Trauma Anger Control Substance Use Eating Disturbance Risk Behaviors Danger to Self/Others Self Injurious Behavior Other Self Harm Exploitation Gambling Sexual Aggression Criminal Behavior Caregiver Strengths and Needs (optional) Physical/Behavioral Health Involvement Knowledge Social Resources Family Stress Safety

Strengths Family Social Connections Optimism Talents/Interests Educational Volunteering Job History Spiritual/Religious Community Connectedness Natural Supports Resiliency Resourcefulness

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Unless otherwise specified, each rating is based on the last 30 days. Each of the dimensions is rated on a 4-point scale after routine service contact or following review of case files. The basic design for rating NEEDS A 0 indicates no evidence, no need for action, A 1 indicates a need for watchful waiting to see whether action is needed (i.e., flag it for later review to see if any circumstances change or refer for assessment), A 2 indicates a need for action, and A 3 indicates a dangerous or disabling need or the need for either immediate or intensive action.

The basic design for rating STRENGTHS A rating of 0 reflects a significant strength that is present, A rating of 1 reflects that a moderate level of the strength is present, A rating of 2 reflects that a mild level of the strength is present, and A rating of 3 reflects that the strength is not present. For Strengths, a rating of 0 or 1 reflects a strength that can be used to build around, while a rating of 2 or 3 reflects a strength that needs to be developed or identified. The rating of NA for not applicable should be use with cases in the rare instances where an item does not apply to that particular client. The rating of U for unknown can be considered a flag for a need to find this information for a complete profile or picture of the needs and strengths of the individual and their family. The ANSA is an effective assessment tool for used in either the development of individual plans of care or for use in designing and planning systems of care for adults with behavioral health (mental health or substance use) challenges. To administer the ANSA assessment tool found at the end of this manual, the care coordinator or other service provider should read the anchor descriptions for each dimension and then record the appropriate rating on the ANSA assessment form. One ANSA assessment tool is completed for each case reviewed.

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Coding Criteria LIFE DOMAIN FUNCTIONING

PHYSICAL/MEDICAL
This rating includes both health problems and chronic/acute physical conditions.

0 1

There is no evidence of physical or medical problems. Mild or well-managed physical or medical problems are indicated. This might include wellmanaged chronic conditions like diabetes or asthma. A person in need of a physical/medical examination would be rated here. Chronic physical or moderate medical problems are present. Severe, life threatening physical or medical condition exists.

2 3

FAMILY FUNCTIONING
The definition of family should be from the perspective of the individual (i.e., who does the individual consider to be family). Family functioning should be rated independently of the problems experienced or stimulated by the individual currently assessed.

0 1

No evidence of family problems is identified. A mild to moderate level of family problems including marital difficulties and problems between siblings is indicated. A significant level of family problems exists, such as frequent arguments, difficult separation and/or divorce, and siblings with significant mental health, developmental or criminal justice problems. A profound level of family disruption including significant criminality or domestic violence is indicated.

EMPLOYMENT
This rates the performance of the individual in work settings. This performance can include issues of behavior, attendance or productivity.

0 1

No evidence of problems at work is indicated. Individual is gainfully employed. Individual experiences a mild degree of problems with work functioning. Individual may have some problems in work environment involving attendance, productivity or relations with others. A moderate degree of work problems including disruptive behavior and/or difficulties with performing required work is indicated. Supervisors likely have warned individual about problems with his/her work performance. A severe degree of work problems including aggressive behavior toward peers or superiors or severe attendance problems is evidenced. Individual may be recently fired or at very high risk of firing (e.g. on notice). Individual has not worked for an extended period of time. Individual is retired.

NA

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SOCIAL FUNCTIONING
This item refers to the individuals current status in getting along with others in his/her life. 0 1 2 Individual has good relations with others. Individual is having some minor problems with his/her social functioning. Individual is having some moderate problems with his/her social functioning. Problems with relationships currently interfere with functioning in other life domains. Individual is experiencing severe disruptions in his/her social functioning. Individual is socially disabled. Either he/she has no relations with others or all relationships are currently conflictual.

RECREATIONAL
This item is intended to reflect the individuals access to and use of leisure time activities.

0 1

Individual has and enjoys positive recreational activities on an ongoing basis. Individual is adequately engaged in and enjoys recreational activities, although some problems may exist. Individual is having moderate problems with recreational activities. Individual may experience some problems with effective use of leisure time. Individual has no access to or interest in recreational activities. Individual has significant difficulties making positive use of leisure time.

INTELLECTUAL/DEVELOPMENTAL
This rating is intended to capture a functioning problem such as low IQ, mental retardation, or other developmental disability.

0 1 2 3

There is no evidence of intellectual or developmental impairment. Individual has borderline (IQ 71 to 85) or mild developmental delay. Individual has mild mental retardation (IQ 50 to 70). Individual has moderate to severe mental retardation (IQ less than 50) or severe or Pervasive Developmental Disorder.

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SEXUALITY
This rating describes issues around sexual development including developmentally inappropriate sexual behavior and problematic sexual behavior. Sexual orientation or gender identity issues could be rated here if they are leading to difficulties. 0 1 There is no evidence of any problems with sexuality. Mild to moderate problems with sexuality are indicated. This may include concerns about sexual identity or anxiety about the reactions of others. Significant problems with sexuality are indicated. These may include multiple partners with limited relationships or high-risk sexual behavior. Profound problems with sexuality are indicated. This level would include prostitution, very frequent, risky sexual behavior or sexual aggression.

LIVING SKILLS
This rating focuses on the presence or absence of short or long-term risks associated with impairments in independent living abilities.

This level indicates a person who is fully capable of independent living. There is no evidence of any deficits that could impede maintaining individuals own home. This level indicates a person with mild impairment of independent living skills. Some problems exist with maintaining reasonable cleanliness, diet and so forth. Problems with money management may occur at this level. These problems are generally addressable with training or supervision. This level indicates a person with moderate impairment of independent living skills. Notable problems with completing tasks necessary for independent living are apparent. Difficulty with cooking, cleaning and self-management, when unsupervised, would be common at this level. Problems are generally addressable with in-home services. This level indicates a person with profound impairment of independent living skills. This individual would be expected to be unable to live independently given their current status. Problems require a structured living environment.

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RESIDENTIAL STABILITY
This item is used to rate the individuals or caregivers current and likely future housing circumstances. If the individual lives independently, rate his or her history of residential stability.

There is no evidence of residential instability. The individual has stable housing for the foreseeable future. The individual has relatively stable housing, but has either moved in the past three months or there are indications that housing problems could arise at some point within the next three months. This level also reflects a mild degree of residential instability if living independently, characterized by the potential loss of housing due to the persons difficulty with self-care, disruptive behavior, financial situation, or other psychosocial stressor. A recent move for any reason that the individual found stressful would be rated here. The individual has moved multiple times in the past year. This level also includes a moderate degree of residential instability if the person is living independently, characterized by recent and temporary lack of permanent housing. The individual has experienced periods of homelessness in the past six months. This level also includes a significant degree of residential instability if living independently, characterized by homelessness for at least 30 days as defined by living on the streets, in shelters, or other transitional housing.

LEGAL
This item involves only the individuals involvement with the legal system. 0 1 2 3 Individual has no known legal difficulties. Individual has a history of legal problems but currently is not involved with the legal system. Individual has some legal problems and is currently involved in the legal system. Individual has serious current or pending legal difficulties that place him/her at risk for incarceration.

SLEEP
0 1 Individual gets a full nights sleep each night. Individual has some problems sleeping. Generally, individual gets a full nights sleep, but at least once a week problems arise. This may include occasionally have difficulties falling asleep or awakening early or in the middle of the night. Individual is having problems with sleep. Sleep is often disrupted and individual seldom obtains a full night of sleep Individual is generally sleep deprived. Sleeping is difficult for the individual and they are not able to get a full nights sleep.

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SELF-CARE
This rating focuses on current status of self-care functioning. Suicidal or homicidal behavior would not be rated here, but severe eating disorders could be included.

There is no evidence of self-care impairments. This is characterized by the ability to independently complete all activities of daily living such as bathing, grooming, dressing, cooking, and managing personal finances. A mild degree of impairment with self-care is indicated. This is characterized by self-care difficulties that impair the individuals level of functioning, but do not represent a significant short or long-term threat to the persons well-being. A moderate degree of self-care impairment is evidenced. This is characterized by an extreme disruption in one self-care skill or moderate disruption in more than one self-care skill. Self-care does not represent an immediate threat to the persons safety, but has the potential for creating significant long-term problems if not addressed. A significant degree of self-care impairment is evidenced by extreme disruptions in multiple selfcare skills. Self-care abilities are sufficiently impaired that he/she represents an immediate threat to himself/herself and requires 24-hour supervision.

DECISION-MAKING
This item describes the individuals judgment. This item should reflect the degree to which an individual can concentrate on issues, think through decisions, anticipate consequences and follow-through on decisions.

0 1

There is no evidence of any problems with decision-making. Mild to moderate problems with decision-making are indicated. Individual may have some challenges with thinking through problems or concentrating. Significant problems with decision-making. Individual may be struggling with thinking through problems, anticipating consequences or concentrating. Profound problems with decision-making are evident. Individual is currently unable to make decisions.

INVOLVEMENT IN RECOVERY
This rating focuses on the level of the individuals active participation in treatment and self management of behavioral health needs.

This level indicates a person who is fully involved in his/her recovery. He or she has identified treatment choices and fully participates. This level indicates a person who is generally involved in his/her recovery. He or she participates in treatment but does not actively exercise choice. This level indicates a person who is marginally involved in his/her recovery. He or she is minimally involved in treatment. This level indicates a person who is uninvolved in his/her recovery. He or she is currently not making effort to address needs.

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TRANSPORTATION
This item is used to rate the level of transportation required to ensure that the individual could effectively participate in his/her own treatment.

0 1

The individual has no transportation needs. The individual has occasional transportation needs (e.g., appointments). These needs would be no more than weekly and not require a special vehicle. The individual has occasional transportation needs that require a special vehicle or frequent transportation needs (e.g., daily to work or therapy) that do not require a special vehicle. The individual requires frequent (e.g., daily to work or therapy) transportation in a special vehicle.

MEDICATION INVOLVEMENT
This item focuses on the individuals involvement in using prescription medication.

0 1

The person takes medications as prescribed without assistance or has not been prescribed any medication. The person usually takes medications as prescribed but may intermittently stop, skip or forget to take medications, without causing instability of the underlying medical condition(s); he/she may benefit from reminders and checks to consistently take medications. The person takes medications inconsistently or misuses medications, causing some instability of the underlying medical condition; he/she may benefit from direct supervision of medication. The person does not take medication(s) prescribed for management of underlying medical conditions and his/her underlying medical conditions are not well controlled.

2 3

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STRENGTHS
FAMILY
All family with whom the individual remains in contact, along with other individuals in relationships with these family members.

Significant family strengths are evident. This level indicates a family with much love and mutual respect for each other. Family members are central in each others lives. A moderate level of family strengths is present. This level indicates a loving family with generally good communication and ability to enjoy each others company. There may be some problems between family members. A slight level of family strengths is indicated. Family is able to communicate and participate in each others lives; however, family members may not be able to provide significant emotional or concrete support for each other. This level indicates an individual with no known family strengths.

SOCIAL CONNECTEDNESS
This item is used to refer to the interpersonal skills of the individual as they relate to others.

Individual has significant interpersonal strengths. The individual is seen as well liked by others and has significant ability to form and maintain positive relationships. The individual has multiple close friends and is friendly with others. Individual has a moderate level of interpersonal strengths. The individual has formed positive interpersonal relationships with peers and other non-caregivers. The individual may currently have no friends, but has a history of making and maintaining friendships with others. Individual has a minimal level of interpersonal strengths. The individual has some social skills that facilitate positive relationships with peers and has a history of making and maintaining healthy friendships with others, but may not have any current healthy relationships. Individual has no known interpersonal strengths. The individual currently does not have any friends nor has he/she had any friends in the past.

OPTIMISM
This rating should be based on the individuals sense of his/her own future. This is intended to rate the individuals positive future orientation.

0 1

Individual has a strong and stable optimistic outlook on his/her life. Individual is future oriented. Individual is generally optimistic. Individual is likely able to articulate some positive future vision. Individual has difficulties maintaining a positive view of him/herself and his/her life. Individual may vary from overly optimistic to overly pessimistic. Individual has difficulties seeing any positives about him/herself or his/her life.

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10

TALENTS/INTERESTS
This rating should be based broadly on any talent, creative or artistic skills an individual may have including art, theater, music, athletics, and so forth.

This level indicates an individual with significant creative/artistic strengths. An individual who receives a significant amount of personal benefit from activities surrounding a talent would be rated here. This level indicates an individual with a notable talent. For example, an individual who is involved in athletics or plays a musical instrument would be rated here. This level indicates an individual who has expressed interest in developing a specific talent or talents even if they have not yet developed that talent. This level indicates an individual with no known talents, interests or hobbies.

EDUCATIONAL
This item is used to refer to the strengths of the school/vocational training environment and may or may not reflect any specific educational/work skills possessed by the individual.

This level indicates an individual who is in school or a training program and is involved with an educational plan or work environment that appears to exceed expectations. The school works exceptionally well with the individual and family to create an effective learning environment. This level indicates an individual who is in school or a training program; however, there have been problems such as tardiness, absenteeism, reductions in productivity, or conflict with supervisors or teachers. This level indicates an individual who is in school but has a plan that does not appear to be effective. This level indicates an individual who has dropped out of school. Completing school or a vocational program is required to meet individuals career aspirations. Participation in an educational or vocational training program is not necessary for the individual to achieve his/her career aspirations.

NA

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VOLUNTEERING
This item describes the degree to which an individual is involved in volunteer activities that give back to the community.

Individual understands the importance of giving back to others and actively seeks out and engages in volunteer activities on a regular basis (e.g., at least once a month). Individual understands the importance of giving back to others, but does not actively seek out volunteer activities. The individual only engages in volunteer activities sporadically (e.g., once or twice per year). Individual is starting to understand the importance of giving back to others. The individual has never engaged in any volunteer activities. Individual does not value giving back to others and refuses to engage in volunteer activities.

JOB HISTORY
This item describes the individuals experience with paid employment.

Individual has significant job history with positive outcomes. Individual is currently employed as a valued employee. Individual has held jobs for a reasonable period of time and has former employers willing to recommend him/her for future employment. Individual has some work history; however, it is marked by periodic job loss. Individual has no positive work history.

2 3

SPIRITUAL/RELIGIOUS
This rating should be based on the individuals involvement in spiritual or religious beliefs and activities.

This level indicates an individual with strong religious and spiritual strengths. The individual may be very involved in a religious community or may have strongly held spiritual or religious beliefs that can sustain or comfort him/her in difficult times. This level indicates an individual with some religious and spiritual strength. The individual may be involved in a religious community. This level indicates an individual with few spiritual or religious strengths. The individual may have little contact with religious institutions. This level indicates an individual with no known spiritual or religious strengths or involvement.

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COMMUNITY CONNECTION
This rating should be based on the individuals level of involvement in the cultural aspects of life in his/her community.

This level indicates an individual with extensive and substantial long-term ties with the community. For example, involvement in a community group for more than one year, may be widely accepted by neighbors, or involved in other community activities or informal networks. This level indicates an individual with significant community ties although they may be relatively short-term (i.e., past year). This level indicates an individual with limited ties and/or supports from the community. This level indicates an individual with no known ties or supports from the community.

2 3

NATURAL SUPPORTS
This rating refers to unpaid individuals other than family members.

Individual has significant natural supports who contribute to helping support his/her health and well-being Individual has identified natural supports who provide some assistance in supporting his/her health and well-being. Individual has some identified natural supports; however they are not actively contributing to his/her health or well-being. Individual has no known natural supports (outside of family and paid caregivers).

RESILIENCY
This rating should be based on the individuals ability to identify and use strengths in managing their lives.

This level indicates an individual who is able to both identify and use strengths to better themselves and successfully manage difficult challenges. This level indicates an individual who is able to identify most of his/her strengths and to partially utilize them. This level indicates an individual who is able to identify strengths, but is not able to utilize them effectively. This level indicates an individual who is not yet able to identify personal strengths.

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RESOURCEFULNESS
0 Individual is quite skilled at finding the necessary resources required to aid in managing challenges. Individual has some skills at finding necessary resources required to aid in a healthy lifestyle, but sometimes requires assistance at identifying or accessing these resources. Individual has limited skills at finding necessary resources required to aid in achieving a healthy lifestyle and requires temporary assistance both with identifying and accessing these resources. Individual has no skills at finding the necessary resources to aid in achieving a healthy lifestyle and requires ongoing assistance with both identifying and accessing these resources.

ACCULTURATION
For Acculturation, the following categories and action levels are used: 0 indicates a dimension where there is no evidence of any needs. 1 indicates a dimension that requires monitoring, watchful waiting, or preventive activities. 2 indicates a dimension that requires action to ensure that this identified need or risk behavior is addressed. 3 indicates a dimension that requires immediate or intensive action.

LANGUAGE
This item includes both spoken language and sign language.

0 1

Individual and significant others speak English well. Individual and significant others speak some English but potential communication problems exist due to limits on vocabulary or understanding of the nuances of the language. Individual and/or significant others do not speak English. Translator or native language speaker is needed for successful intervention, but qualified individual can be identified within natural supports. Individual and/or significant others do not speak English. Translator or native language speaker is needed for successful intervention, and no such individual is available from among natural supports.

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IDENTITY
Cultural identify refers to the individuals view of his/herself as belonging to a specific cultural group. This cultural group may be defined by a number of factors including race, religion, ethnicity, geography or lifestyle.

Individual has clear and consistent cultural identity and is connected to others who share his/her cultural identity. Individual is experiencing some confusion or concern regarding cultural identity. Individual has significant struggles with his/her own cultural identity. Individual may have cultural identity but is not connected with others who share this culture. Individual has no cultural identity or is experiencing significant problems due to conflict regarding his/her cultural identity.

1 2

RITUAL
Cultural rituals are activities and traditions that are culturally including the celebration of culturally specific holidays such as Kwanza, Cinco de Mayo, etc. Rituals also may include daily activities that are culturally specific (e.g. praying toward Mecca at specific times, eating a specific diet, access to media).

Individual and significant others are consistently able to practice rituals consistent with their cultural identity. Individual and significant others are generally able to practice rituals consistent with their cultural identity; however, they sometimes experience some obstacles to the performance of these rituals. Individual and significant others experience significant barriers and are sometimes prevented from practicing rituals consistent with their cultural identity. Individual and significant others are unable to practice rituals consistent with their cultural identity.

CULTURAL STRESS
Culture stress refers to experiences and feelings of discomfort and/or distress arising from friction (real or perceived) between an individuals own cultural identity and the predominant culture in which he/she lives.

There is no evidence of stress between individuals cultural identity and current living situation. Some mild or occasional stress exists as a result of friction between the individuals cultural identity and his/her current living situation. Individual is experiencing cultural stress that is causing problems of functioning in at least one life domain. Individual is experiencing a high level of cultural stress that is making functioning in any life domain difficult under the present circumstances.

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BEHAVIORAL HEALTH NEEDS

PSYCHOSIS/THOUGHT DISTURBANCE
This item is used to rate symptoms of psychosis such as hallucinations, delusions, very bizarre behavior and very strange ways of thinking.

This level indicates an individual with no evidence of thought disturbances. Both thought processes and content are within normal range. This rating indicates an individual with evidence of mild disruption in thought processes or content. The individual may be somewhat tangential in speech or evidence somewhat illogical thinking. This also includes persons with a history of psychotic symptoms but none currently. This rating indicates an individual with evidence of moderate disturbance in thought process or content. The individual may be somewhat delusional or have brief or intermittent hallucinations. The persons speech may be at times quite tangential or illogical. This rating indicates an individual with severe psychotic disorder. The individual frequently experiences symptoms of psychosis and frequently has no reality assessment. There is evidence of ongoing delusions or hallucinations or both. Command hallucinations would be coded here.

IMPULSE CONTROL
Symptoms of Impulse Control problems that might occur in a number of disorders including Intermittent Explosive Disorder or Borderline Personality Disorder would be rated here.

This rating is used to indicate an individual with no evidence of impulse problems. Individual is able to regulate and self-manage behavior and affect. This rating is used to indicate an individual with evidence of mild problems with impulse control problems. An individual may have some difficulties with sitting still or paying attention or may occasionally engage in impulsive behavior. This rating is used to indicate an individual with moderate impulse control problems. An individual who meets DSM-IV diagnostic criteria for impulse control disorder would be rated here. Persons who use poor judgment or put themselves in jeopardy would be rated here (e.g., picking fights). This rating is used to indicate an individual with severe impulse control. Frequent impulsive behavior is observed or noted that carries considerable safety risk (e.g., running into the street and dangerous driving).

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DEPRESSION
Symptoms included in this dimension are depressed mood, social withdrawal, anxious, sleep disturbances, weight/eating disturbances, and loss of motivation.

0 1

This rating is given to an individual with no evidence of depression. This rating is given to an individual with mild depression. Brief duration of depression, irritability, or impairment of peer, family, vocational or academic function that does not lead to extreme avoidance behavior. This rating is given to an individual with a moderate level of depression. This level is used to rate individuals who meet the criteria for an affective disorder as listed above. This rating is given to an individual with a severe level of depression. This would include a person who stays at home or in bed all day due to depression or whose emotional symptoms prevent any participation in school/work, social settings, or family life. More severe forms of depressive diagnoses would be coded here. This level is used to indicate a person who is disabled in multiple life domains by his/her depression.

ANXIETY
This item is used to rate worrying and fearfulness.

0 1

This rating is given to an individual with no evidence of problems with anxiety. This level is used to rate either a mild phobia or anxiety problem or a level of symptoms that is below the threshold for the other listed disorders. This could include major conversion symptoms, frequent anxiety attacks, obsessive rituals, flashbacks, hypervigilance, or school/work avoidance. This rating is given to an individual with a severe level of anxiety. This would include a person who stays at home or in bed all day due to anxiety or whose emotional symptoms prevent any participation in school/work, social settings, or family life. More severe forms of anxiety disorder diagnoses would be coded here. This level is used to indicate a person who is disabled in multiple life domains by his/her anxiety.

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INTERPERSONAL PROBLEMS
This rating identifies problems with relating to other people including significant manipulative behavior, social isolation or significant conflictual relationships.

0 1

No evidence of notable interpersonal problems is identified. Evidence of a mild degree, probably sub-threshold for the diagnosis of a personality disorder, exists. For example, mild but consistent dependency in relationships might be rated here or some evidence of mild antisocial or narcissistic behavior. Also, an unconfirmed suspicion of the presence of a diagnosable personality disorder would be rated here. Evidence of significant degree of interpersonal problems exists. Individuals relationship problems may warrant a DSM-IV Axis II diagnosis. Evidence of severe interpersonal problems that has significant implications for the individuals long-term functioning. Interpersonal problems are disabling and block the individuals ability to function independently.

ANTISOCIAL BEHAVIOR (Compliance with Societys Rules)

These symptoms include antisocial behaviors like shoplifting, lying, vandalism, cruelty to animals, and assault.

0 1

This rating indicates an individual with no evidence of antisocial disorder. This rating indicates an individual with a mild level of conduct problems. Some difficulties in school/work and home behavior. Problems are recognizable but not notably deviant. This might include occasional lying or petty theft from family. This rating indicates an individual with a moderate level of conduct disorder. This could include episodes of planned aggression or other antisocial behavior. This rating indicates an individual with a severe Antisocial Personality Disorder. This could include frequent episodes of unprovoked, planned aggression or other antisocial behavior.

ADJUSTMENT TO TRAUMA
This rating covers the reactions of individuals to a variety of traumatic experiences. This dimension covers both adjustment disorders and post traumatic stress disorder from DSM-IV.

The individual has not experienced any trauma or has adjusted well to significant traumatic experiences. The individual has some mild adjustment problems and exhibits some signs of distress. The individual has marked adjustment problems and is symptomatic in response to a traumatic event (e.g., anger, depression, and anxiety). The individual has post traumatic stress difficulties. Symptoms may include intrusive thoughts, hyper-vigilance, constant anxiety, and other common symptoms of Post Traumatic Stress Disorder (PTSD).

1 2

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ANGER CONTROL
This item captures the individuals ability to identify and manage their anger when frustrated.

This rating indicates an individual with no evidence of any significant anger control problems. This rating indicates an individual with some problems with controlling anger. He/she may sometimes become verbally aggressive when frustrated. Peers and family members are aware of and may attempt to avoid stimulating angry outbursts. This rating indicates an individual with moderate anger control problems. His/her temper has gotten him/her in significant trouble with peers, family and/or work. This level may be associated with some physical violence. Others are likely quite aware of anger potential and may be intimidated by the individual. This rating indicates an individual with severe anger control problems. His/her temper is likely associated with frequent fighting that is often physical. Others likely fear him/her.

SUBSTANCE USE
This item includes use of alcohol and other drugs, the misuse of prescription medications and the inhalation of any substance. This dimension is rated consistent with DSM-IV Substance Related Disorders. This item does not apply to the use of tobacco or caffeine.

This rating is for an individual who has no notable substance use difficulties at the present time. If the person is in recovery for greater than 1 year they should be coded here. This rating is for an individual with mild substance use problems that might occasionally present problems of living for the person (i.e., intoxication, loss of money, and reduced work performance). This rating would be used for someone early in recovery (less than 1 year) who is currently not using for at least 30 days. This rating is also used to reflect a history of substance use problems without evidence of current problems related to use. This rating is for an individual with a moderate substance use problem that requires treatment. A substance use problem that consistently interferes with the ability to function optimally, but does not completely preclude functioning in an unstructured setting. This rating is for an individual with a severe substance use problem that presents significant complication to the management (e.g., need for detoxification) of the individual.

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EATING DISTURBANCES
These symptoms include problems with eating including disturbances in body image, refusal to maintain normal body weight and recurrent episodes of binge eating. These ratings are consistent with DSM-IV Eating Disorders.

0 1

This rating is for an individual with no evidence of eating disturbances. This rating is for an individual with a mild level of eating disturbance. This could include some preoccupation with weight, calorie intake, or body size or type when individual is of normal weight or below weight. This could also include some binge eating patterns. This rating is for an individual with a moderate level of eating disturbance. This could include a more intense preoccupation with weight gain or becoming fat when underweight, restrictive eating habits or excessive exercising in order to maintain below normal weight, and/or emaciated body appearance. This level could also include more notable binge eating episodes that are followed by compensatory behaviors in order to prevent weight gain (e.g., vomiting, use of laxatives, excessive exercising). The individual may meet criteria for a DSM-IV Eating Disorder (Anorexia or Bulimia Nervosa). This rating is for an individual with a more severe form of eating disturbance. This could include significantly low weight where hospitalization is required or excessive binge-purge behaviors (at least once per day).

RISK BEHAVIORS
DANGER TO SELF OR OTHERS
A rating of 2 or 3 would indicate the need for a safety plan.

0 1

No evidence or history of dangerous behavior to either self or others. The individual has a history of suicidal or violent behavior, but no such behavior during the past 30 days. The individual has recent suicidal or violent behavior. Current/acute suicidal or violent behavior in the past 24 hours.

2 3

SELF-INJURIOUS BEHAVIOR
This rating includes repetitive physically harmful behavior that generally serves a self-soothing functioning with the individual.

0
1

There is no evidence of any forms of intentional self-injury (e.g. cutting, burning, face slapping, head banging) The individual has a history of intentional self-injury but none evident in the past 30 days. The individual has engaged in intentional self injury that does not require medical attention. The individual has engaged in intentional self injury that requires medical attention.

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OTHER SELF HARM

This rating includes reckless and dangerous behaviors that while not intended to harm self or others, place the individual or others at some jeopardy. Suicidal or self-mutilative behavior is NOT rated here.

0
1

There is no evidence of behaviors that place the individual at risk of physical harm.
The individual has a history of behavior, other than suicide or self-mutilation, which places the individual at risk of physical harm. This includes reckless and risk-taking behavior that may endanger the individual. The individual is engaged in behavior, other than suicide or self-mutilation, which places him/her in danger of physical harm. This includes reckless behavior or intentional risk-taking behavior. The individual is engaged in behavior, other than suicide or self-mutilation, which places him/her at immediate risk of death. This includes reckless behavior or intentional risk-taking behavior.

EXPLOITATION
This item is used to examine a history and level of current risk for exploitation.

This level indicates a person with no evidence of recent exploitation and no significant history of exploitation within the past year. The person may have been robbed or burglarized on one or more occasions in the past, but no pattern of exploitation exists. Person is not presently at risk for re-exploitation. This level indicates a person with a history of exploitation but who has not been exploited or victimized to any significant degree in the past year. Person is not presently at risk for reexploitation. This level indicates a person who has been recently exploited (within the past year) but is not in acute risk of re-exploitation. This might include physical or sexual abuse, significant psychological abuse by family or friend, extortion or violent crime. This level indicates a person who has been recently exploited and is in acute risk of reexploitation. Examples include working as a prostitute and living in an abusive relationship.

GAMBLING
This item includes all forms of gamblinglegal and illegal, organized and social.

0 1

Individual has no evidence of any problem gambling. Individual has either a history or suspicion of problems with gambling; however, currently gambling behavior is not known to impact his/her functioning. Individual has problems with gambling that impact his/her functioning and/or wellbeing. Individual has problems with gambling that dramatically impacts his/her life and make functioning difficult or impossible in at least one life domain.

2 3

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SEXUAL AGGRESSION
This includes all sexual offending that could result in charges be made against the individual. Sexual aggression includes the use or threat of physical force or taking advantage of a power differential to engage in non-consenting sexual activity.

0 1

No evidence of problems with sexual aggression is identified. Individual has a history of sexual aggression, but no known sexually aggressive behavior in the past year. Individual has recently been sexually aggressive, but is not at immediate risk of re-offending. Individual has recently been sexually aggressive with acute risk of re-offending due to attitude, behavior, or circumstances.

2 3

CRIMINAL BEHAVIOR
This rating includes both criminal behavior and status offenses that may result from the individual failing to follow required behavioral standards. This category does not include drug usage but it does include drug sales and other drug related activities. Sexual offenses should be included as criminal behavior.

0 1 2

No evidence or history of criminal behavior exists. Individual has a history of criminal behavior, but none in the past year. A moderate level of criminal activity is indicated. This level indicates a person who has been engaged in criminal activity during the past year, but the criminal activity does not represent a significant physical risk to others in the community. Examples would include vandalism and shoplifting. A severe level of criminal activity is indicated. This level indicates a person who has been engaged in violent criminal activity during the past year which represents a significant physical risk to others in the community. Examples would include rape, armed robbery, and assault.

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FAMILY/CAREGIVER STRENGTHS AND NEEDS (OPTIONAL)

Caregiver refers to parent(s) or other adult with primary care-taking responsibilities for the individual. This dimension would not be applicable to an individual living in an institutionalized setting; however it would apply to someone living in a group home.

PHYSICAL/BEHAVIORAL HEALTH
Physical and Behavioral Health includes medical, physical, mental health, and substance abuse challenges faced by the caregiver(s).

The caregiver(s) has no physical or behavioral health limitations that impact assistance or attendant care. The caregiver(s) has some physical or behavioral health limitations that interfere with provision of assistance or attendant care. The caregiver(s) has significant physical or behavioral health limitations that prevent them from being able to provide some needed assistance or that make attendant care difficult. The caregiver(s) is unable to provide any needed assistance or attendant care.

INVOLVEMENT WITH CARE

This item is used to rate the level of involvement the caregiver(s) has in the planning and provision of mental health related services.

This level indicates a caregiver(s) who is actively involved in the planning and/or implementation of services and is able to be an effective advocate on behalf of the individual. This level indicates a caregiver(s) who is consistently involved in the planning and/or implementation of services for the individual, but is not an active advocate on their behalf. This level indicates a caregiver(s) who is minimally involved in the care of the individual. Caregiver(s) may visit the individual when living in an out-of-home placement, but does not become involved in service planning and implementation. This level indicates a caregiver(s) who is uninvolved with the care of the individual. The caregiver(s) may want the individual out of home or fails to visit the individual when in residential placement.

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KNOWLEDGE
This item is used to rate the caregivers knowledge of the specific strengths of the individual and any problems experienced by the individual and their ability to understand the rationale for the treatment or management of these problems.

This level indicates that the present caregiver(s) is fully knowledgeable about the individuals psychological strengths and weaknesses, talents and limitations. This level indicates that the present caregiver(s), while being generally knowledgeable about the individual, has some mild deficits in knowledge or understanding of either the persons psychological condition or his/her talents, skills and assets. This level indicates that the caregiver(s) does not know or understand the individual well and that significant deficits exist in the caregivers ability to relate to the persons problems and strengths. This level indicates that the present caregiver(s) has little or no understanding of the individuals current condition. The caregiver(s) is unable to cope with the individual given his/her status at the time, not because of the needs of the person but because the caregiver(s) does not understand or accept the situation.

SOCIAL RESOURCES
This item is used to refer to the financial and social assets (extended family) and resources that the caregiver(s) can bring to bear in addressing the multiple needs of the individual and family.

The caregiver(s) has sufficient resources so that there are few limitations on what can be provided for the individual. The caregiver(s) has the necessary resources to help address the individuals major and basic needs, but those resources might be stretched. The caregiver(s) has limited resources (e.g., a relative living in the same town who is sometimes available to assist with the individual). The caregiver(s) has severely limited resources that are available to assist in the care and treatment of the individual.

FAMILY STRESS
This item reflects the degree of stress or burden experienced by the family as a result of the individuals needs as described elsewhere in the assessment.

0 1 2

Caregiver is able to manage the stress of the individuals needs. Caregiver has some problems managing the stress of the individuals needs. Caregiver has notable problems managing the stress of the individuals needs. This stress interferes with their capacity to give care. Caregiver is unable to manage the stress associated with the individuals needs. This stress prevents caregiver from providing care.

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SAFETY
This item is used to refer to the safety of the assessed individual. It does not refer to the safety of other family or household members. The presence of an individual (family or stranger) that presents a safety risk to the individual should be rated. This item does not refer to the safety of the physical environment in which the individual lives (e.g., a broken or loose staircase).

This rating indicates that the current placement presents no risk to the safety of the individual in his/her present condition. This rating indicates that the current placement presents some mild risk of neglect or exposure to drug use, but that no immediate risk is present. This rating indicates that there is risk to the individual including such things as the risk of abuse or exposure to individuals who could harm the individual. This rating indicates that the current placement presents a significant risk to the well-being of the individual. Risk of harm is imminent and immediate.

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INDIVIDUALIZED ASSESSMENT MODULES Complete any specific module only if indicated on the initial rating page.

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EMPLOYMENT/CAREER MODULE Coding Definitions

Check
0 1 2 3

CAREER ASPIRATIONS Please rate the highest level from the past 30 days.
Individual has clear and feasible career plans. Individual has career plans but significant barriers may exist to achieving these plans. Individual wants to work but does not have a clear idea regarding jobs or careers. Individual has no career plans or aspirations

Check
0 1 2 3

JOB TIME Please rate the highest level from the past 30 days.
Individual works at least full-time. Individual works more than 20 hours per week but not full-time. Individual works less than 20 hours per week. Individual is not working.

Check
0 1 2 3 NA

JOB ATTENDANCE Please rate the highest level from the past 30 days.
Individual goes to work consistently as scheduled. Individual has occasional problems going to work. He/she may sometimes call in sick when not ill. Individual has difficulty consistently going to work. Individual has severe job attendance problems that threaten termination or have resulted in recent firing. Not applicable

Check
0 1 2 3 NA

JOB PERFORMANCE Please rate the highest level from the past 30 days.
Individual is a productive employee. Individual is generally a productive employee but some performance issues exist. Individual is having problems performing adequately on the job. Individual has severe performance problems that threaten termination or have resulted in recent firing. Not applicable

Check
0 1 2 3 NA

JOB RELATIONS Please rate the highest level from the past 30 days.
Individual gets along well with superiors and co-workers. Individual is experiencing some problems with relationships at work. Individuals is having problems with his/her relationships with superiors and/or co-workers. Difficulties are causing functioning problems at work. Individual is having severe relationship problems with superiors and/or co-workers. Relationship issues threaten employment or have resulted in recent firing. Not applicable

Check
0 1 2 3

JOB SKILLS Please rate the highest level from the past 30 days.
Individual has significant job skills consistent with career aspirations. Individual has basic job skills but they may not match career aspirations. Individual has limited job skills. Individual has no job skills.

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DEVELOPMENTAL NEED MODULE

Coding Criteria

Check
0 1 2 3

COGNTIVE Please rate the highest level from the past 30 days.
Individual's intellectual functioning appears to be in normal range. There is no reason to believe that the individual has any problems with intellectual functioning. Individual has low IQ (70 to 85) or has identified learning challenges. Individual has mild mental retardation. IQ is between 55 and 70. Individual has moderate to profound mental retardation. IQ is less than 55.

Check
0 1 2 3

COMMUNICATION Please rate the highest level from the past 30 days.
Individual's receptive and expressive communication appears developmentally appropriate. There is no reason to believe that the individual has any problems communicating. Individual has receptive communication skills, but limited expressive communication skills. Individual has both limited receptive and expressive communication skills. Individual is unable to communicate. DEVELOPMENTAL Please rate the highest level from the past 30 days. Individual's development appears within normal range. There is no reason to believe that the individual has any developmental problems. Evidence of a mild developmental delay is apparent. Evidence of a pervasive developmental disorder including Autism, Tourette's, Down's Syndrome or other significant developmental delay is apparent. Severe developmental disorder is evident.

Check
0 1 2 3

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TRAUMA MODULE
Coding Definitions Characteristics of the Traumatic Experiences:

Check
0 1 2 3

SEXUAL ABUSE Please rate within the lifetime.

There is no evidence that individual has experienced sexual abuse. Individual has experienced one episode of sexual abuse or there is a suspicion that individual has experienced sexual abuse, but there is no confirming evidence. Individual has experienced repeated sexual abuse. Individual has experienced severe and repeated sexual abuse. Sexual abuse may have caused physical harm.

Check
0 1 2 3

PHYSICAL ABUSE Please rate within the lifetime.

There is no evidence that individual has experienced physical abuse. Individual has experienced one episode of physical abuse or there is a suspicion that individual has experienced physical abuse, but there is no confirming evidence. Individual has experienced repeated physical abuse. Individual has experienced severe and repeated physical abuse that causes sufficient physical harm to necessitate hospital treatment.

Check
0 1 2 3

EMOTIONAL ABUSE Please rate within the lifetime.

There is no evidence that individual has experienced emotional abuse. Individual has experienced mild emotional abuse. Individual has experienced emotional abuse over an extended period of time (at least one year). Individual has experienced severe and repeated emotional abuse over an extended period of time (at least one year).

Check
0 1 2 3

MEDICAL TRAUMA Please rate within the lifetime.

There is no evidence that individual has experienced any medical trauma. Individual has experienced mild medical trauma including minor surgery (e.g. stitches, bone setting). Individual has experienced moderate medical trauma including major surgery or injuries requiring hospitalization. Individual has experienced life threatening medical trauma.

Check
0 1 2 3

NATURAL DISASTER Please rate within the lifetime.

There is no evidence that individual has experienced any natural disaster. Individual has been indirectly affected by a natural disaster. Individual has experienced a natural disaster which has had a notable impact on his/her well-being. Individual has experienced life threatening natural disaster.

Check
0 1 2 3

WITNESS TO FAMILY VIOLENCE Please rate within the lifetime

There is no evidence that individual has witnessed family violence. Individual has witnessed one episode of family violence. Individual has witnessed repeated episodes of family violence, but no significant injuries (i.e. requiring emergency medical attention) have been witnessed. Individual has witnessed repeated and severe episodes of family violence. Significant injuries have occurred as a direct result of the violence.

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TRAUMA MODULE (continued)

Coding Definitions

Check
0 1 2 3

WITNESS TO COMMUNITY VIOLENCE Please rate within the lifetime.

There is no evidence that individual has witnessed violence in the community. Individual has witnessed fighting or other forms of violence in the community. Individual has witnessed the significant injury of others in his/her community. Individual has witnessed the death of another person in his/her community.

Check
0 1 2 3

WITNESS/VICTIM TO CRIMINAL ACTIVITY Please rate within the lifetime.

There is no evidence that individual has been victimized or witnessed significant criminal activity. Individual is a witness of significant criminal activity. Individual is a direct victim of criminal activity or witnessed the victimization of a family or friend. Individual is a victim of criminal activity that was life threatening or caused significant physical harm or individual witnessed the death of a loved one.

Check
0 1

WAR AFFECTED This rating describes the degree of severity of exposure to war, political violence, or torture. Violence or trauma related to Terrorism is not included here. Please rate within the lifetime. There is no evidence that individual has been exposed to war, political violence or torture. Individual did not live in war-affected region or refugee camp, but family was affected by war. Family members directly related to the individual may have been exposed to war, political violence, or torture; family may have been forcibly displaced due to the war, or both. This does not include individuals who have lost parents or children during a war. Individual is/was affected by war or political violence. He or she may have witnessed others being injured in the war, may have family members who were hurt or killed in the war, and may have lived in an area where bombings or fighting took place. Individual may have lost one family member. Individual may have spent extended amount of time in refugee camp. Individual has experienced the direct affects of war. Individual may have feared for his or her own life during war. Individual may have lost multiple family members due to a war. They may have been directly injured, tortured, kidnapped or prisoner of war. They may have served as soldiers, guerrillas or other combatants in a war. TERRORISM AFFECTED This rating describes the degree to which an individual has been affected
by terrorism. Terrorism is defined as "the calculated use of violence or the threat of violence to inculcate fear, intended to coerce or to intimidate governments or societies in the pursuit of goals that are generally political, religious, or ideological." Terrorism includes attacks by individuals acting in isolation (e.g. sniper attacks). Please rate within the lifetime. There is no evidence that individual has been affected by terrorism or terrorist activities. Individuals community has experienced an act of terrorism, but the individual was not directly impacted by the violence (e.g. individual lives close enough to site of terrorism that they may have visited before or individual recognized the location when seen on TV, but individuals family and neighborhood infrastructure was not directly affected). Exposure has been limited to pictures on television. Individual has been affected by terrorism within his/her community, but did not directly witness the attack. Individual may live near the area where attack occurred and be accustomed to visiting regularly in the past, infrastructure of individuals daily life may be disrupted due to attack (e.g. utilities or school), and individual may see signs of the attack in neighborhood (e.g. destroyed building). Individual may know people who were injured in the attack. Individual has witnessed the death of another person in a terrorist attack, or has had friends or family members seriously injured as a result of terrorism, or has directly been injured by terrorism leading to significant injury or lasting impact.

Check

0 1

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Adjustment:
Check
0 1 2 3

AFFECT REGULATION Please rate the highest level from the past 30 days.
Individual has no problems with affect regulation. Individual has mild to moderate problems with affect regulation. Individual has severe problems with affect regulation but is able to control affect at times. Problems with affect regulation interfere with individuals functioning in some life domains. Individual unable to regulate affect.

Check
0 1 2 3

INTRUSIONS Please rate the highest level from the past 30 days.
There is no evidence that individual experiences intrusive thoughts of trauma. Individual experiences some intrusive thoughts of trauma, but they do not affect his/her functioning. Individual experiences intrusive thoughts that interfere in his/her ability to function in some life domains. Individual experiences repeated and severe intrusive thoughts of trauma.

Check
0 1 2

ATTACHMENT Please rate the highest level from the past 30 days.
No evidence of attachment problems is identified. Parent-individual relationship is characterized by satisfaction of needs, and individual's development of a sense of security and trust. Mild problems with attachment are present. This could involve either mild problems with separation or mild problems of detachment. Moderate problems with attachment are indicated. Individual is having problems with attachment that require intervention. An individual who meets the criteria for an Attachment Disorder in DSM-IV would be rated here. Severe problems with attachment. An individual who is unable to separate or an individual who appears to have severe problems with forming or maintaining relationships with caregivers would be rated here.

Check
0 1 2 3

DISSOCIATION Please rate the highest level from the past 30 days.
There is no evidence of dissociation. Individual may experience some symptoms of dissociation. Individual clearly experiences episodes of dissociation. Profound dissociation occurs.

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SUBSTANCE USE DISORDER (SUD) MODULE Coding Definitions Check

0 1

SEVERITY OF USE Please rate the highest level from the past 30 days.
Individual has been free from alcohol and/or drug use for at least six months. Individual is currently free from alcohol and/or drug use, but only in the past 30 days, or individual has been free from alcohol or drug use for more than 30 days, but is living in an environment that makes staying alcohol or drug free difficult. Individual actively uses alcohol and/or drugs, but not daily. Individual uses alcohol and/or drugs on a daily basis.

2 3

Check
0 1 2 3

DURATION OF USE Please rate the highest level from the past 30 days.
Individual has begun use in the past year. Individual has been using alcohol and/or drugs for at least one year, but has had periods of at least 30 days where he/she did not have any use. Individual has been using alcohol or drugs for at least one year (but less than five years), but not daily. Individual has been using alcohol and/or drugs daily for more than the past year or intermittently for at least five years.

Check
0 1 2 3

STAGE OF RECOVERY Please rate the highest level from the past 30 days.
Individual is in maintenance stage of recovery. Individual is free from alcohol and/or drug use and able to recognize and avoid risk factors for future alcohol and/or drug use. Individual is actively trying to use treatment to remain free from alcohol and/or drug use. Individual is in contemplation phase, recognizing a problem but not willing to take steps for recovery. Individual is in denial regarding the existence of any substance use problem.

Check
0 1 2 3

PEER INFLUENCES Please rate the highest level from the past 30 days.
Individual's primary peer social network does not engage in alcohol and/or drug use. Individual has peers in his/her primary peer social network who do not engage in alcohol and/or drug use, but has some peers who do. Individual predominantly has peers who engage in alcohol and/or drug use. Individual is a member of a peer group that consistently engages in alcohol and/or drug use.

Check
0 1 2 3

ENVIRONMENTAL INFLUENCES Please rate the environment around the individuals living
situation. No evidence that the individual's environment stimulates or exposes the individual to any alcohol and/or drug use. Mild problems in the individual's environment that might expose the individual to alcohol and/or drug use. Moderate problems in the individual's environment that clearly expose the individual to alcohol and/or drug use. Severe problems in the individual's environment that stimulate the individual to engage in alcohol and/or drug use.

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DANGEROUSNESS MODULE
Coding Criteria

Check
0 1 2 3

DANGER TO OTHERS Please rate the highest level from the past 30 days.
No evidence found of danger to others. Individual has history of homicidal ideation, physically harmful aggression or fire setting that has put self or others in danger of harm. Individual has recent homicidal ideation, physically harmful aggression or dangerous fire setting, but not in the past 24 hours. Individual has acute homicidal ideation with a plan or physically harmful aggression OR command hallucinations that involve the harm of others. Or, individual intentionally set a fire that placed others at significant risk of harm.

Check
0 1 2 3

SUICIDE RISK Please rate the highest level from the past 30 days.
No evidence found of suicide risk. Individual has history of risk, but no recent ideation or gesture. Individual has recent suicidal ideation or gesture, but not in past 24 hours. Current ideation and intent OR command hallucinations that involve self-harm.

If either Suicide Risk or Danger to Others (or both) is rated as a 2 or 3: Check

0 1 2 3

IDEATION Please rate the highest level from the past 30 days.
No evidence History but no recent ideation Recent ideation, but not in past 24 hours Current ideation OR command hallucinations that involve self-harm

Check
0 1 2 3

INTENT Please rate the highest level from the past 30 days.
No evidence History, but no recent intent to commit suicide Recent intention to commit suicide Current intention

Check
0 1 2 3

PLANNING Please rate the highest level from the past 30 days.
No evidence of a concrete plan Vague notions of a plan, but that plan is not realistic Individual has a plan to commit suicide or to harm others that is feasible. Individual has a plan that is immediately accessible and feasible.

Check
0 1 2 3

SUICIDE HISTORY Please rate the highest level from the past 30 days.
No history of suicidal ideation or attempt. History of significant suicidal ideation but no potentially lethal attempts History of a potentially lethal suicide attempt History of multiple potentially lethal suicide attempts

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Emotional/Behavioral Risks (Dangerousness) Check

0 1 2 3

FRUSTRATION MANAGEMENT Please rate the highest level from the past 30 days.
Individual appears to be able to manage frustration well. No evidence of problems of frustration management. Individual has some mild problems with frustration. He/she may anger easily when frustrated; however, he/she is able to calm self down following an angry outburst. Individual has problems managing frustration. His/her anger when frustrated is causing functioning problems in school, at home, or with peers. Individual becomes explosive and dangerous to others when frustrated. He/she demonstrates little self control in these situations and others must intervene to restore control

Check
0 1 2 3

HOSTILITY Please rate the highest level from the past 30 days.
Individual appears to not experience or express hostility except in situations where most people would become hostile. Individual appears hostile but does not express it. Others experience individual as being angry. Individual expresses hostility regularly. Individual is almost always hostile either in expression or appearance. Others may experience individual as full of rage or seething PARANOID THINKING Please rate the individuals highest level in the past 30 days. Individual does not appear to engage in any paranoid thinking. Individual is suspicious of others but is able to test out these suspicions and adjust their thinking appropriately. Individual believes that others are out to get him/her. Individual has trouble accepting that these beliefs may not be accurate. Individual at times is suspicious and guarded but at other times can be open and friendly. Suspicions can be allayed with reassurance. Individual believes that others plan to cause them harm. Individual is nearly always suspicious and guarded. SECONDARY GAINS FROM ANGER Please rate the individuals highest level in the past 30 days. Individual either does not engage in angry behavior or, when they do become angry, does not appear to derive any benefits from this behavior. Individual unintentionally has benefited from angry behavior; however, there is no evidence that individual intentionally uses angry behavior to achieve desired outcomes. Individual sometimes uses angry behavior to achieve desired outcomes others. Individual routinely uses angry behavior to achieve desired outcomes with others. Others in individuals life appear intimidated. VIOLENT THINKING Please rate the individuals highest level in the past 30 days. There is no evidence that individual engages in violent thinking. Individual has some occasional or minor thoughts about violence. Individual has violent ideation. Language is often characterized as having violent themes and problem solving often refers to violent outcomes. Individual has specific homicidal ideation or appears obsessed with thoughts about violence. For example, an individual who spontaneously and frequently draws only violent images may be rated here.

Check
0 1 2

Check
0 1 2 3

Check
0 1 2 3

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Resiliency Factors (Dangerousness) Check

0 AWARENESS OF VIOLENCE POTENTIAL Please rate the individuals highest level in the past 30 days. Individual is completely aware of his/her level of risk of violence. Individual knows and understands risk factors. Individual accepts responsibility for past and future behaviors. Individual is able to anticipate future challenging circumstances. An individual with no violence potential would be rated here. Individual is generally aware of his/her potential for violence. Individual is knowledgeable about his/her risk factors and is generally able to take responsibility. Individual may be unable to anticipate future circumstances that may challenge him/her. Individual has some awareness of his/her potential for violence. Individual may have tendency to blame others but is able to accept some responsibility for his/her actions. Individual has no awareness of his/her potential for violence. Individual may deny past violent acts or explain them in terms of justice or as deserved by the victim. RESPONSE TO CONSEQUENCES Please rate the individuals highest level in the past 30 days. Individual is clearly and predictably responsive to identified consequences. Individual is regularly able to anticipate consequences and adjust behavior. Individual is generally responsive to identified consequences; however, not all appropriate consequences have been identified or he/she may sometimes fail to anticipate consequences. Individual responds to consequences on some occasions, but sometimes does not appear to care about consequences for his/her violent behavior. Individual is unresponsive to consequences for his/her violent behavior. COMMITMENT TO SELF CONTROL Please rate the individuals highest level in the past 30 days. Individual fully committed to controlling his/her violent behavior. Individual is generally committed to controlling his/her violent behavior; however, individual may continue to struggle with control in some challenging circumstances. Individual ambivalent about controlling his/her violent behavior. Individual not interested in controlling his/her violent behavior at this time. TREATMENT INVOLVEMENT Please rate the individuals highest level in the past 30 days. Individual fully involved in his/her own treatment. Family supports treatment as well. Individual or family involved in treatment but not both. Individual may be somewhat involved in treatment, while family members are active or individual may be very involved in treatment while family members are unsupportive. Individual and family are ambivalent about treatment involvement. Individual and/or family may be skeptical about treatment effectiveness or suspicious about clinician intentions. Individual and family are uninterested in treatment involvement. An individual with treatment needs who is not currently in treatment would be rated here.

2 3

Check
0 1 2 3

Check
0 1 2 3

Check
0 1

2 3

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SEXUALLY AGGRESSIVE BEHAVIOR (SAB) MODULE Coding Definitions Check

0 1 2 3

RELATIONSHIP Please rate the most recent episode of sexual behavior.

No evidence of victimizing others is identified. All parties in sexual activity appear to be consenting. No power differential is present. Although parties appear to be consenting, there is a significant power differential between parties in the sexual activity with this individual being in the position of authority. Individual is clearly victimizing at least one other individual with sexually abusive behavior. Individual is severely victimizing at least one other individual with sexually abusive behavior. This may include physical harm that results from either the sexual behavior or physical force associated with sexual behavior.

Check
0 1 2 3

PHYSICAL FORCE/THREAT Please rate the highest level from the most recent episode of sexual behavior. No evidence found of the use of any physical force or threat of force in either the commission of the sex act or in attempting to hide it. Individual used the threat of force in an attempt to discourage the victim from reporting the sex act. Individual used mild to moderate force in the sex act. There is some physical harm or risk of physical harm. Individual used severe physical force in the commission of the sex act. Victim was harmed or at risk for physical harm from the use of force. PLANNING Please rate the highest level from the most recent episode of sexual behavior.
No evidence is found of any planning. Sexual activity appears entirely opportunistic. Some evidence indicates efforts to get into situations where likelihood of opportunities for sexual activity is enhanced. Evidence indicates some planning of sex act. Considerable evidence documents predatory sexual behavior in which victim is identified prior to the act, and the act is premeditated.

Check
0 1 2 3

Check
0 1 2 3

AGE DIFFERENTIAL Please rate the highest level from the most recent episode of sexual behavior.
Ages of the perpetrator and victim and/or participants are essentially equivalent. Age differential between perpetrator and victim and/or participants is substantial, but the victim(s) are older than 17 years. Age differential between perpetrator and victim at least 5 years, but the victim is 13 to 17 years old. The victim is 13 years old or younger.

Check
0 1 2 3

TYPE OF SEX ACT Please rate the highest level from the most recent episode of sexual behavior.
Sex act(s) involve touching or fondling only. Sex act(s) involve fondling plus possible penetration with fingers or oral sex. Sex act(s) involve penetration into genitalia or anus with body part. Sex act involves physically dangerous penetration due to differential size or use of an object.

Check
0 1 2 3

RESPONSE TO ACCUSATION Please rate the highest level from the past 30 days.
Individual admits to behavior and expresses remorse and desire to not repeat. Individual partially admits to behaviors and expresses some remorse. Individual admits to behavior, but does not express remorse. Individual neither admits to behavior nor expresses remorse.

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CRIME MODULE
Coding Definitions

Check
0 1 2 3

SERIOUSNESS Please rate the highest level from the past 30 days.
Individual has engaged only in status violations (e.g. curfew). Individual has engaged in delinquent behavior. Individual has engaged in criminal behavior. Individual has engaged in criminal behavior that places other citizens at risk of significant physical harm. HISTORY Please rate using time frames provided in the anchors. Current criminal/delinquent behavior is the first known occurrence. Individual has engaged in multiple criminal/delinquent acts in the past one year. Individual has engaged in multiple criminal/delinquent acts for more than one year, but has had periods of at least 3 months where he/she did not engage in criminal/delinquent behavior. Individual has engaged in multiple criminal/delinquent acts for more than one year without any period of at least 3 months where he/she did not engage in criminal/delinquent behavior. ARRESTS Please rate the highest level from the past 30 days. Individual has no known arrests in past. Individual has history of arrests, but no arrests past 30 days. Individual has 1 to 2 arrests in last 30 days. Individual has more than 2 arrests in last 30 days. PLANNING Please rate the highest level from the past 30 days. No evidence found of any planning. Criminal/delinquent behavior appears opportunistic or impulsive. Evidence suggests that individual places him/herself into situations where the likelihood of criminal/delinquent behavior is enhanced. Evidence indicates some planning of criminal/delinquent behavior. Considerable evidence indicates significant planning of criminal/delinquent behavior. Behavior is clearly premeditated. COMMUNITY SAFETY Please rate the highest level from the past 30 days. Individual presents no risk to the community. He/she could be unsupervised in the community. Individual engages in behavior that represents a risk to community property. Individual engages in behavior that places community residents in some danger of physical harm. This danger may be an indirect effect of the individuals behavior. Individual engages in behavior that directly places community members in danger of significant physical harm. LEGAL COMPLIANCE Please rate the highest level from the past 30 days. Individual is fully compliant with all responsibilities imposed by the court (e.g. school attendance, treatment, restraining orders), or no court orders are currently in place. Individual is in general compliance with responsibilities imposed by the court (e.g. occasionally missed appointments). Individual is in partial noncompliance with standing court orders (e.g. individual is going to school, but not attending court-order treatment) Individual is in serious and/or complete noncompliance with standing court orders (e.g. parole violations).

Check
0 1 2 3

Check
0 1 2 3

Check
0 1 2 3

Check
0 1 2 3

Check
0 1 2 3

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PEER INFLUENCES Please rate the highest level from the past 30 days. Individual's primary peer social network does not engage in criminal/delinquent behavior. Individual has peers in his/her primary peer social network who do not engage in criminal/delinquent behavior but has some peers who do. Individual predominantly has peers who engage in delinquent behavior but individual is not a member of a gang. Individual is a member of a gang whose membership encourages or requires illegal behavior as an aspect of gang membership. ENVIRONMENTAL INFLUENCES Please rate the environment around the individuals living situation. There is no evidence that the individual's environment stimulates or exposes the individual to any criminal/delinquent behavior. Mild problems in the individual's environment might expose the individual to criminal/delinquent behavior. Moderate problems in the individual's environment clearly expose the individual to criminal/delinquent behavior. Severe problems in the individual's environment stimulate the individual to engage in criminal/delinquent behavior. RECOVERY SUPPORT IN COMMUNITY Please rate the individuals participation in recovery programs such as AA, NA, or other types of recovery groups or activities that are community based. No problems with maintaining social connectivity through recovery support groups or activities. Individual attends recovery support groups regularly and has no problems in attending the meetings. Mild problems with maintaining social connectivity through recovery support groups or activities. Individual may attend meetings irregularly. Moderate problems with maintaining social connectivity through recovery support groups or activities. Individual has attended recovery support groups in the past but is no longer attending meetings. Severe problems with maintaining social connectivity through recovery support groups or activities. Individual has never participated in recovery support groups or activities.

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712011(2)

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