Project # Child/Youth Assessment and Referral Tool OMB NO. 0930-0270 

Expiration Date 08/31/2025

The Crisis Counseling Assistance and Training Program (CCP) should have protocols or procedures in place for how a crisis counselor should respond if serious

reactions are indicated while using this tool. Many CCPs have team leaders or other staff with a mental health background to administer this tool to ensure proper

assessment and referral. All crisis counseling staff using this tool should have detailed training and guidance on use of the tool and when to make a referral for more

intensive services. Prior to use of this tool, the CCP should have identified at least one organization or agency that is willing to accept referrals from the CCP for

more intensive mental health or substance use intervention services.

Please use this tool as an interview guide

1) with children receiving individual crisis counseling on the third and fifth occasions OR

2) with any child at any time if you suspect the child may be experiencing serious reactions to the disaster.

Provider Name

Date of Service

(mm/dd/yyyy)

1st Employee #

VISIT NUMBER

DURATION

2nd Employee #

First visit Second visit Third visit

15–29 minutes 30–44 minutes 45–59 minutes

ZIP Code of Service

Fourth visit

60 minutes or more

Fifth visit or later

Was a parent or caregiver present during the visit? Yes No

Was the team lead or a supervisory staff member present during administration of this tool? Yes No

school and child care (all ages through college)

community center (e.g., recreation club)

provider site/mental health agency (agency involved with the CCP)

workplace (workplace of the disaster survivor and/or first responder)

disaster recovery center (e.g., Federal Emergency Management

Agency [FEMA], American Red Cross)

place of worship (e.g., church, synagogue, mosque)

retail site (e.g., restaurant, mall, shopping center, store)

public place/event (e.g., street, sidewalk, town square, fair, festival,

sports)

temporary home (including home of friend or family, group homes, 

shelters,apartments, trailers, and other dwellings)

IF TEMPORARY HOME: PLEASE CHECK THIS BOX IF ANY

CHILDREN UNDER AGE 18 LIVE IN THIS HOME.

permanent home

IF PERMANENT HOME: PLEASE CHECK THIS BOX IF ANY

CHILDREN UNDER AGE 18 LIVE IN THIS HOME.

phone counseling (outbound calls to participants lasting 15 minutes or longer) 

hotline, helpline, or crisis line (inbound calls from participants lasting 15

minutes or longer)

medical center (e.g., doctor, dentist, hospital, mental health or substance

use disorder treatment office) 

virtual (e.g., text line, online chat service, Zoom)

other (specify in box)

family missing/dead

friend missing/dead

pet missing/dead

home damaged or destroyed

vehicle or major property loss

other financial loss

disaster un- or underemployment 

(self or household member) 

illness, injury, or physical harm (self or household member) 

life was threatened (self or household member)

witnessed death/injury (self or household member)

assisted with rescue/recovery (self or household member)

changed schools or learning format (e.g., virtual) 

prolonged separation from social network/family, physical 

isolation, or social distancing

evacuated quickly with no time to prepare

displace from home 1 week or more

sheltered in place or sought shelter due to

immediate threat of danger

past substance use/mental health problem

preexisting physical disability

past trauma

disaster-caused food insecurity

reduced or no access to reliable 

information/communication

reduced or no access to reliable transportation

ENCOUNTER INFORMATION

LOCATION OF SERVICE (select one)

RISK CATEGORIES (select all that apply)

•

Provider # 

County or Parish of Service

READ: Occasionally, we find it helpful to ask children/adolescents or their parents/caregivers a few specific questions about how they were affected by the

disaster and how they are feeling now. May I ask you these questions? My first questions are about various experiences you may have had in the disaster.
Age (select one) preschool (0–5 years) child (6–11 years) adolescent (12–17 years) Grade level in school

If you have a disability or other access or functional need, indicate the type (select all that apply).

Physical (mobility, visual, hearing, medical, etc.) Intellectual/cognitive (learning

disability, developmental delay, etc.)

Gender Male Female Transgender None of these

Mental health/substance use (psychiatric, 

substance use disorder, etc.)

Primary language spoken during this encounter (select one)

Race/Ethnicity (select all that apply) 

English Spanish Other

American Indian/Alaska Native Asian Black or African American Native Hawaiian/Other Pacific Islander White Hispanic or Latino

Did you immigrate to the United States in the past 5 years? (select one) Yes No

 RESPONSE CARD 

Prior to beginning the assessment, please give the larger version of the response card to the child or parent who will be answering your questions. This card 

willassist the child or parent in better understanding how often the child is experiencing certain reactions.

Think about your thoughts, feelings, and behavior DURING THE PAST MONTH. Use these frequency rating options to help answer how often the problem has

happened in the past month. For each question choose ONE of the following responses.

0 1 2 3 4 

“Not at all” means never in

the past month.

A “little bit” means about

two times during the past 

month.

“Quite a bit” means two to 

three times a week during 

the past month.

“Very much” means almost

every day during the past 

month.

“Somewhat” means about 

one to two times each week 

during the past month. 

ASSESSMENT 

QUESTIONS INTRODUCTION: I want to talk to you about your (your child’s) feelings and thoughts about the disaster and how much they are causing problems now. Think

about your thoughts, feelings, and behavior DURING THE PAST MONTH (please remind child/parent of this for each question). Use the frequency rating

options on the previous page and on the response card to help the child answer how often the problem has happened in the past month. For each question

choose ONE of the following responses and check the appropriate box for that question.

0 = not at all 1 = a little bit 2 = somewhat 3 = quite a bit 4 = very much

QUESTIONS TO BE READ RESPONDENT ANSWERS

1. Do you get upset, afraid, or sad when something makes you think about the disaster? 0 1 2 3 4 

2. Do you have bad dreams or nightmares about what happened? 0 

0

1 

1

2 3 4 

3. Do you have upsetting thoughts or pictures that come into your mind about what happened? 0 1 2 3 4 

4. Do you try not to think about or talk about what happened? 0 1 2 3 4 

5. Do you stay away from places, people, or things that make you remember the disaster? 0 1 2 3 4 

6. Do you have difficulty falling asleep or wake up often because of what happened? 0 1 2 3 4 

7. Do you feel jumpy or nervous? 0 1 2 3 4 

8. Do you find it harder to concentrate or pay attention to things than you usually do? 0 1 2 3 4 

9. Do you feel irritable or grouchy? 0 1 2 3 4 

DEMOGRAPHIC INFORMATION

S M T W T F S S M T W T F S 

X 

X 

S M T W T F S 

X X 

X 

X 

X X 

S M T W T F S 

X X X 

X X X 

X X X 

X X 

S M T W T F S 

X X X X X X X 

X X X X 

X X X X 

X X X X X X X 
QUESTIONS TO BE READ RESPONDENT ANSWERS

10. Do you feel sad, down, or depressed? 0 1 2 3 4 

11. Have you had more aches and pains, such as stomachaches or headaches? 0 1 2 3 4 

12. If in school: Do you find it harder to get your schoolwork done? 0 1 2 3 4 

13. Do you worry about something else bad happening to you/your family/your friends? 0 1 2 3 4 

14. Are you having a harder time getting along with family or your friends? 0 1 2 3 4 

15. Are you finding it harder to do or enjoy activities that you used to enjoy? 0 1 2 3 4 

ADDITIONAL QUESTIONS FOR PARENTS (required for parents of children ages 0–7; recommended

for parents of all children and adolescents)

0 1 2 3 4 

0 1 2 3 4 

0 1 2 3 4 

0 1 2 3 4 

16. Has your child been more clingy or worried about separation?

17. Has your child been quieter and more withdrawn?

18. Has your child talked repeatedly or asked questions about the disaster?

19. Has your child’s play been about the disaster?

20. Have you noticed changes in your child’s behavior or development (e.g., bed-wetting, baby talk, fighting 

or risk-taking behavior, or decline in school performance)?

0 1 2 3 4 

COUNT THE NUMBER OF ENTRIES IN THE LAST TWO COLUMNS ABOVE THAT HAVE A SCORE OF 3 

OR 4. IF TOTAL NUMBER IS 4 OR MORE, DISCUSS THE POSSIBILITY OF A REFERRAL FOR SERVICES.

TOTAL NUMBER

FOR CHILDREN OVER THE AGE OF 10 OR IF YOU ARE CONCERNED ABOUT A YOUNGER CHILD, YOU MAY ASK:

21. In the past few weeks, have you wished you were dead?

YES NO

22. In the past few weeks, have you felt that you or your family would be better off if you were dead?

YES NO

23. In the past week, have you been having thoughts about killing yourself?

YES NO

24. Have you ever tried to kill yourself?

YES NO

If the patient answers "Yes" to any of the above, ask the following acuity question:

25. Are you having thoughts of killing yourself right now?

YES NO

IF THE ANSWER TO ANY OF THE ITEMS ABOVE IS "YES," REFER FOR IMMEDIATE PSYCHIATRIC INTERVENTION. The CCP should have protocols or

procedures in place for how a crisis counselor should respond or react if the response if "YES." 

other crisis counseling program services (e.g., group counseling, 

referral to a team leader, follow-up visit)

mental health services (e.g., professional, longer-term counseling,

treatment, behavioral, or psychiatric services)

substance use services (e.g., professional, behavioral, or medical treatment

or self-help groups, such as Alcoholics Anonymous or Narcotics Anonymous)

Was the referral accepted by the child? YES NO

community services (e.g., FEMA, loans, housing, employment, social

services)

resources for those with disabilities or other access or functional needs

other (specify in box)

Was the referral accepted by the parent/caregiver? YES NO

ASSESSMENT QUESTIONS (continued)

REFERRAL (select all that were communicated)
INSTRUCTIONS: 

CHILD/YOUTH ASSESSMENT AND REFERRAL TOOL

When To Use This Form:

It is recommended that this form be used with all children or youth who are intensive users of services. Intensive users are people who are participating in 

their third individual crisis counseling visit with any crisis counselor from the program or who continue to suffer severe distress that may be having an 

impact on their ability to perform routine daily activities. This form should beused as an interview guide (1) with children receiving individual crisis 

counseling on the third and fifth occasions OR (2) with any child at any time if you suspect the child may be experiencing serious reactions to the disaster.

PROJECT #—FEMA disaster declaration number, e.g., State-XXXX. PROVIDER NAME—The name of the program/agency. 

PROVIDER #—The unique number under which your program/agency is providing services.

1st EMPLOYEE #—YOUR employee number issued by ODCES. 

2nd EMPLOYEE #—Employee number issued by ODCES for your teammate during this encounter.

DATE OF SERVICE—The date of the encounter in the format mm/dd/yyyy, e.g., 01/01/2021. 

COUNTY OR PARISH OF SERVICE—The county or parish where the encounter occurred.

ZIP CODE OF SERVICE—The ZIP code of the location where the encounter occurred.

VISIT NUMBER—Is this the first, second, third, fourth, fifth, or later visit for this person to your program? All visits did not have to be with you.

SELECT ONLY ONE.

DURATION—How long did your encounter last? SELECT ONLY ONE. If the encounter was under 15 minutes, record it on the Weekly Tally Sheet.

LOCATION OF SERVICE—Where did the encounter occur? SELECT ONLY ONE.

RISK CATEGORIES—These are factors than an individual may have experienced or may have present in his or her life that could increase his or her need 

for services. MORE THAN ONE CATEGORY MAY APPLY. SELECT ALL CATEGORIES THAT APPLY. 

DEMOGRAPHIC INFORMATION:

AGE—What age does the person or his or her parent indicate he or she is? SELECT ONLY ONE. 

GRADE LEVEL IN SCHOOL—Please enter the number, e.g., 4 = fourth grade.

PEOPLE WITH DISABILITIES OR OTHER ACCESS OR FUNCTIONAL NEEDS—If the participant or his or her parent considers the participant to 

have a disability or an access orfunctional need, what type is indicated (physical, intellectual/cognitive, or mental health/substance use)? SELECT

ALL THAT APPLY.

• Physical: includes disorders that impair mobility, seeing, or hearing, as well as medical conditions, such as diabetes, lupus, Parkinson’s, acquired

immunodeficiency syndrome (AIDS), or multiple sclerosis (MS).

• Intellectual: includes a learning disability, birth defect, neurological disorder, developmental disability (e.g., Down syndrome), or traumatic brain

injury.

• Mental health/substance use: includes psychiatric disorders, such as bipolar disorder, major depressive disorder, posttraumatic stress

disorder (PTSD), schizophrenia, and substance use disorder.

GENDER—The gender the person reports him- or herself to be. SELECT ONLY ONE.

PRIMARY LANGUAGE SPOKEN DURING ENCOUNTER(S)—What language did you actually and primarily use to speak with this individual

during the encounter? This may bedifferent from the preferred language. If “OTHER” (not English or Spanish), fill in the other language that the

person used (may include sign language). SELECT ONLY ONE.

RACE/ETHNICITY—What race does the person identify as being? SELECT ALL THAT APPLY.

IMMIGRATED TO THE UNITED STATES IN THE PAST 5 YEARS—Indicate if any participant immigrated to the United States in the past 5 

years from any country and for any reason. SELECT ONLY ONE.

ASSESSMENT QUESTIONS—GIVE THE RESPONSE CARD TO THE INDIVIDUAL.

For each question, put a check mark in the appropriate box based on the individual's responses. COUNT THE NUMBER OF ENTRIES IN THE

LAST TWO COLUMNS THAT HAVE A SCORE OF 3 OR 4. EACH ITEM WITH A SCORE of 3 or 4 COUNTS AS 1. IF THE TOTAL IS 4 OR

MORE, DISCUSS THE POSSIBILITY OF A REFERRAL FOR SERVICES.

For questions 21–24, indicate "yes" or "no" based on the individual's responses. SELECT ONLY ONE.

If the child responds "yes" to any of these questions (21–24), ask question 25 and indicate "yes" or "no" based on the individual's response. SELECT

ONLY ONE.

REFERRALS—Based on your conversation with this individual, you may have referred him or her for other services. In the REFERRAL box, select all of

the types of services to whichyou referred the person.

REFERRALS ACCEPTED—This refers to whether or not the child or parent took the information you offered, not whether they followed up on the referral.

SELECT ONLY ONE.

Thank you for taking the time to complete this form accurately and fully!

Paperwork Reduction Act Statement This information is being collected to assist the Substance Abuse and Mental Health Services Administration

(SAMHSA) with program monitoring of FEMA’s Crisis Counseling Assistance and Training Program. Crisis counselors are required to complete this form

following the delivery of crisis counseling services to disaster survivors (44 CFR 206.171 [F][3]). Information collected through this form will be used at

an aggregate level to determine the reach, consistency, and quality of the Crisis Counseling Assistance and Training Program. Under the Privacy Act of

1974, any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person

is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number.

The OMB control number for this project is 0930-0270. Public reporting burden for this collection of information is estimated to average 15 minutes per

assessment, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing

and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including

suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57B, Rockville, MD 20857.