I-4. Adjustment to Past Trauma – Increased Arousal (PAST 30 DAYS) No evidence of increased arousal. Concerns are age / developmentally appropriate or this information is unknown to me. Infant / child may have a history of increased arousal or currently shows this behavior on an infrequent basis. Infant / child demonstrates increased arousal most of the time. Infants appear wide eyed, over reactive to stimuli, and have exaggerated startle response. Older children may have all of the above with behavioral reactions such as tantrums. Severe problems with attachment. A child who is unable to separate or a child who appears to have severe problems with forming or maintaining relationships with caregivers. If the child’s needs / functioning fall within a shaded box, explain why: I-5. Adjustment to Past Trauma – Numbing Response (PAST 30 DAYS) No evidence of numbing response. Concerns are age / developmentally appropriate or this information is unknown to me. Child exhibits some problems with numbing. Child may have a restricted range of affect or an inability to express or experience certain emotions (e.g., anger or sadness). Child has moderate difficulties with numbing responses. Child may have blunted or flat emotional state or have difficulty experiencing intense emotion or feel consistently detached or estranged from others. Child has significant numbing responses or multiple symptoms of numbing. Diminished interest or participation in activities. If the child’s needs / functioning fall within a shaded box, explain why: I-6. Regulatory (PAST 30 DAYS) Child has no evidence of regulatory problems including ability to control bodily functions such as eating, sleeping, eliminating, sensitivity to external stimulation, etc. or this information is unknown to me. Some problems with regulation. Infants may have unpredictable patterns and be difficult to console. Older children may require a great deal of structure and need more support than other children in coping with frustration and difficult emotions. Moderate problems with regulation. Children may have severe reactions to stimuli and emotions that interfere with their functioning and ability to progress developmentally. Unpredictable patterns in eating and sleeping routines that disrupt the rest of the family. Profound problems with regulation are present that place the child’s safety, well being and / or development at risk. If the child’s needs / functioning fall within a shaded box, explain why: A. EMOTIONAL CHARACTERISTICS (Ages Birth to 5) (Continued) I-7. Eating (PAST 30 DAYS)
aggressive out of frustration). child. If the child’s needs / functioning fall within a shaded box, explain why: I-11. Sleep – Child Must be 12 Months or Older (PAST 30 DAYS) Child gets a full night’s sleep each night. Any concerns are age / developmentally appropriate or this information is unknown to me. Child has some problems sleeping. Toddlers resist sleep and consistently need a great deal of adult support to sleep. Preschoolers may have a history of poor sleep or continued problems 1-2 nights per week. Child is having problems with sleep that might include difficulty falling asleep, night waking, night terrors or nightmares on a regular basis (4 or more times per week). Child is experiencing significant sleep problems that result in sleep deprivation that affects the child’s functioning. Parents have exhausted numerous strategies for assisting child. If the child’s needs / functioning fall within a shaded box, explain why: I-12. Attachment (PAST 30 DAYS) No evidence of problems with attachment. Any concerns are age / developmentally appropriate or this information is unknown to me. Mild problems with attachment. Children may be overly reactive to separation or seem preoccupied with parent. Boundaries may seem inappropriate. Moderate problems with attachment and may fail to demonstrate stranger anxiety or have extreme reactions to separation resulting affecting development, may avoid caregivers and have inappropriate boundaries putting them at risk. Severe attachment problems. Children attachment to anyone or no one in an extreme manner. Child meets criteria for Reactive Attachment Disorder. If the child’s needs / functioning fall within a shaded box, explain why: A. EMOTIONAL CHARACTERISTICS (Ages Birth to 5) (Continued) I-13. Depression (PAST 30 DAYS) No evidence or concern about depression. Any concerns are age / developmentally appropriate or this information is unknown to me. Child may be depressed or has experienced situations that may lead to depression. Infants may appear withdrawn and slow to engage at times. Older children are irritable or do not demonstrate a range of emotional response / affect. Moderate problems with depression are present. Children may have negative verbalizations, no emotional response, dark / sad play and demonstrate little enjoyment in play and interactions. Clear evidence of a disabling level of depression that makes it virtually impossible for the child to function in any life domain. If the child’s needs / functioning fall within a shaded box, explain why:
II-3. Recreational Play (PAST 30 DAYS) No evidence that the child has problems with recreational play. Any concerns are age appropriate or this information is unknown to me. Child is doing adequately with recreational or play activities although some problems may exist. Child may be uninterested or poorly able to sustain play. Child is having moderate problems with recreational activities, may resist play, show little enjoyment or interest in activities. Child has no interest in play or recreational activities. May spend most of time non-interactive or cannot demonstrate enjoyment or use play to further development. If the child’s needs / functioning fall within a shaded box, explain why: II-4. Preschool / Child Care (PAST 30 DAYS) No evidence of problem with functioning in current preschool or child care environment. Any concerns are age appropriate or this information is unknown to me. Mild problems with functioning in current preschool or child care environment. Moderate to severe problems with functioning in current preschool or child care. Child has difficulties maintaining his / her behavior creating significant problems for others. Profound problems with functioning in current preschool / child care. Child is at immediate risk of being removed from program due to his / her behaviors or needs. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages Birth to 5) (Continued) II-5. School – Attendance (PAST 30 DAYS) Child attends preschool / child care regularly. Any concerns are need / age appropriate or this information is unknown to me. Child has some problems attending preschool / child care, but generally is present. Child is having problems with preschool attendance and is missing at least 2 days / week on average. Child is absent most of the time and this causes a significant challenge in achievement, socialization and following routine. If the child’s needs / functioning fall within a shaded box, explain why: II-6. School – Compatibility (PAST 30 DAYS) Infant / child’s preschool / child care meets the needs of the infant / child or this information is unknown to me. Child’s preschool / child care is marginal in its ability to meet the unusual needs of the child and / or the environment may be weak in areas. Child’s preschool / child care does not meet the unusual needs of the child in most areas and the environment may not support the child’s growth or promote further The child’s preschool / child care is contributing to problems for the child in one or more areas.
II-10. Relationship with Peers Child has good relations with peers. Any concerns are age appropriate or this information is unknown to me. Child has occasional difficulties relating with at least one peer. Child has difficult relations with peers that notably interferes with his / her education. Child has very difficult relations with all peers. Relations with peers currently prevents child from learning. If the child’s needs / functioning fall within a shaded box, explain why: B. BEHAVIORAL CHARACTERISTICS (Ages Birth to 5) (Continued) II-11. Atypical Behaviors (PAST 30 DAYS) (repetitive head banging, spinning, hand flapping, finger-flicking, rocking, toe walking, staring at lights, repetitive speech) Child has no evidence of atypical behaviors. Any concerns are age appropriate or this information is unknown to me. History or reports of atypical behaviors from others that have not been observed by the individual completing this form. Clear evidence of atypical behaviors reported by caregivers that are observed on an ongoing basis. Clear evidence of atypical behaviors that are consistently present and interfere with the infants / child’s functioning on a regular basis. If the child’s needs / functioning fall within a shaded box, explain why: II-12. Impulsivity / Hyperactivity (PAST 30 DAYS) No evidence of impulsivity / hyperactivity. Any concerns are age appropriate or this information is unknown to me. Child is under the age of 3. Some problems with impulsive, distractible or hyperactive behavior. Clear evidence of problems with impulsive, distractible or hyperactive behavior that is interfering with the child’s ability to function. Clear evidence of a dangerous level of impulsive behavior that can place the child at risk of physical harm. If the child’s needs / functioning fall within a shaded box, explain why: II-13. Oppositional Behaviors (PAST 30 DAYS) No evidence of oppositional behaviors. Child displays age appropriate resistance towards adults or this information is unknown to me. History or recent onset (past 6 weeks) of defiance towards authority figures. Clear evidence of oppositional and / or defiant behaviors which are interfering with the child’s functioning and/or causing emotional harm to others. Clear evidence of a dangerous level of oppositional behavior involving the threat of physical harm to others which interferes with child’s social and emotional development. If the child’s needs / functioning fall within a shaded box, explain why:
III-4. Communication (PAST 30 DAYS) Child’s ability to communicate is age appropriate or this information is unknown to me. Child is able to understand others but may have limited ability to express him / her self. Child has limited abilities to understand others and express him / her self. Child is unable to communicate. If the child’s needs / functioning fall within a shaded box, explain why: III-5. Self Care and Daily Living Skills (PAST 30 DAYS) Child’s self care / daily living skills appear to be age appropriate or this information is unknown to me. Child requires excessive verbal prompting on self care tasks or daily living skills. Child requires assistance (physical prompting) on multiple self care tasks or complete assistance on one self care task. Child requires complete assistance on more than one self care task (eating, bathing, dressing, toileting). If the child’s needs / functioning fall within a shaded box, explain why: C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-6. Medical Needs (PAST 30 DAYS) Child is healthy or this information is unknown to me / does not apply. Child has some medical problems that require medical treatment. Child has chronic illness that requires ongoing medical intervention (diabetes, severe / uncontrolled asthma, life threatening allergies, HIV). Child has life threatening illness or medical condition. (active cancer, AIDS, etc). List medical condition (within the last 30 days): If the child’s needs / functioning fall within a shaded box, explain why: III-7. Medical Needs – Life Threatening (PAST 30 DAYS) Child’s medical condition has no implications for shortening his / her life or this information is unknown Child’s medical condition may shorten life, but not until later in adulthood. Child’s medical condition places him / her at some risk of premature death before he / she reaches adulthood. Child’s medical condition places him / her at eminent risk of death.
to me / does not apply. If the child’s needs / functioning fall within a shaded box, explain why: III-8. Medical Needs – Chronicity (PAST 30 DAYS) Child is expected to fully recover from his / her condition within the next 6 months or this information is unknown to me / does not apply. Child is expected to fully recover from his / her condition after at least 6 months but less than 2 years. Child is expected to fully recover from his / her condition but not within the next 2 years. Child’s medical condition is expected to continue throughout his / her lifetime. If the child’s needs / functioning fall within a shaded box, explain why: C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-9. Medical Needs – Diagnostic Complexity (PAST 30 DAYS) Child’s medical diagnoses are clear and correct or this information is unknown to me / does not apply. Some evidence exists to say that the child’s symptoms are complex and the diagnosis may not be entirely accurate. There is substantial concern about the accuracy of the child’s medical diagnoses due to the complexity of symptoms. It is currently not possible to accurately diagnose the child’s medical conditions. If the child’s needs / functioning fall within a shaded box, explain why: III-10. Medical Needs – Emotional Response (PAST 30 DAYS) Child is coping well with his / her medical condition or this information is unknown to me / does not apply. Child is experiencing some emotions related to the medical condition, but these are not affecting other areas of life. Child’s emotional response to his / her condition is interfering with treatment and other areas of life. Child is having severe emotional response to his / her condition that is interfering with treatment and functioning. If the child’s needs / functioning fall within a shaded box, explain why: III-11. Medical Needs – Impairment in Functioning (PAST 30 DAYS) Child’s medical condition is Child’s medical condition is Child’s medical condition is Child’s medical condition
not interfering with his / her functioning in other life domains or this information is unknown to me / does not apply. having a limited impact on functioning in one other life domain (self care, social interaction, communication, etc). interfering with functioning in more than one life domain or is disabling in at least one domain. has disabled him / her in all other life domains. If the child’s needs / functioning fall within a shaded box, explain why: C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-12. Medical Needs – Treatment Involvement (PAST 30 DAYS) Child and family are actively involved in treatment or this is not applicable or this information is unknown to me / does not apply. Child and / or family are generally involved in treatment but may struggle to stay consistent. Child and / or family are generally uninvolved although they are sometimes compliant with recommendations. Child and / or family are currently resistant to all efforts to provide medical treatment. If the child’s needs / functioning fall within a shaded box, explain why: III-13. Medical Needs – Intensity of Treatment (PAST 30 DAYS) Child’s medical treatment involves taking daily medications or visiting a medical professional no more than weekly, or this information is unknown to me / does not apply. Childs medical treatment involves taking multiple medications or visiting a medical professional multiple times per week. Child’s treatment is daily but non-invasive. Treatment can be administered by a caregiver. Child’s medical treatment is daily and invasive and requires either a medical professional or trained caregiver to administer. If the child’s needs / functioning fall within a shaded box, explain why: III-14. Medical Needs – Organizational Complexity (PAST 30 DAYS) All medical care is provided by a single medical professional or this information is unknown to me / does not apply. Child’s medical care is generally provided by a coordinated team medical professionals who work for the same organization. Child’s medical care requires collaboration of multiple professionals who work for more than one organization. Child’s medical care requires the collaboration of multiple professionals who work for more than one organization and are not able to communicate effectively. If the child’s needs / functioning fall within a shaded box, explain why:
C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-15. Physical Needs (PAST 30 DAYS) Child has no physical limitations. Any concerns are age appropriate or this information is unknown to me. Child has some physical condition that places mild limitations on activities (hearing, vision impairment). Child has physical condition that notably impacts activities (blindness, deafness or significant motor difficulties). Child has severe physical limitations due to multiple physical conditions. If the child’s needs / functioning fall within a shaded box, explain why: III-16. Dental Needs (PAST 30 DAYS) No evidence of any dental health needs or this information is unknown to me. Child may have some dental health needs but they are not clearly known at this time. Dental health is interfering with functioning in at least one life domain (eating, social interaction, etc.). Child has serious dental health needs that require intensive and / or extended treatment / intervention. If the child’s needs / functioning fall within a shaded box, explain why: III-17. Daily Functioning (PAST 30 DAYS) Child has age appropriate self care skills. No indication of deficits or this information is unknown to me. Child has minor indications of problems in self care compared to same age peers, but is generally self reliant. Child demonstrates moderate or routine problems in self care skills and relies on others for help more than is expected for his / her age group. Child has severe or constant problems in self care skills and relies on others for help much more than is expected for his / her age group. If the child’s needs / functioning fall within a shaded box, explain why: III-18. Motor (PAST 30 DAYS) No evidence of fine or gross motor development problems. Any concerns are age appropriate or this information is unknown to me. Child has some indicators that motor skills are challenging and there may be some concern that there is a delay. Child has either fine or gross motor skill delays. Child has significant delays in fine or gross motor development or both. Delay causes impairment in functioning. If the child’s needs / functioning fall within a shaded box, explain why:
C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-19. Communication (PAST 30 DAYS) No evidence of communication problems exists. Any concerns are age appropriate or this information is unknown to me. Child has a history of communication problems but currently is not experiencing problems. Child has difficulty understanding or expressing self through language / gestures which interfere with functioning, including trouble interpreting facial gestures or initiating gestures to communicate needs. Toddlers may not follow simple 1-step commands. Preschoolers may be unable to understand simple conversations or carry out step commands. Child has serious communication difficulties and is unable to communicate in any way including pointing and grunting. If the child’s needs / functioning fall within a shaded box, explain why: III-20. Failure to Thrive (PAST 30 DAYS) No evidence of failure to thrive or this information is unknown to me. Child may have experienced past problems with growth and ability to gain weight and is currently not experiencing problems. Child is experiencing problems in their ability to maintain weight or growth. Child may be below the 5th percentile for age and sex and may weigh less than 80% of their ideal weight for age, have depressed weight for height. Child may have one or more of the symptoms listed and is currently at serious medical risk. If the child’s needs / functioning fall within a shaded box, explain why: III-21. Labor and Delivery Child and biological mother had a normal labor and delivery or this information is unknown to me. Child or mother had some mild problems during delivery, but child does not appear affected by problems. Child or mother had problems during delivery that resulted in temporary functional difficulties for the child or mother. Child had severe problems during delivery that have resulted in long term implications for development. If the child’s needs / functioning fall within a shaded box, explain why:
C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-22. Parent / Sibling Exposure Child’s parents have no developmental disabilities. The child has no siblings or existing siblings are not experiencing any developmental or behavioral problems or this information is unknown to me. Child’s parents have no developmental disabilities. Child has siblings who are experiencing some mild developmental or behavioral problems. Child’s parents have no developmental disabilities. Child has a sibling who is experiencing a significant developmental or behavioral problem. One or both of the child’s parents have been diagnosed with a developmental disability, or the child has multiple siblings who are experiencing significant developmental or behavioral problems. If the child’s needs / functioning fall within a shaded box, explain why: D. ADDITIONAL DETAILS OF CHILD’S LEVEL OF NEED (OPTIONAL) Attach school, medical, psychological or other evaluations that document the child’s current special care needs and / or attach signed ‘Confirmation of Needs’ forms. SECTION III. AUTHORIZATION