Hawaii Family Guidance Center
Child and Adolescent Mental Health Division
Initial SEBD Mental Health Assessment
Name:
Date of Birth:
Age:
School information:
Date of Report:
Legal Guardian:
Examiner: Your Name and Degree
Referral Source and Reason for Referral
Xxx has referred XXX and his/her family to the Hawaii Family Guidance Center for
services. This mental health assessment is part of the SEBD eligibility process.
Sources of Information
Interviews with…on… Interview and testing of…on… Collateral interviews with XXX on
XXX.
Presenting Problems and Psychosocial History
[Presenting problems, when each started, severity, getting better or worse. Get concrete,
descriptive information.
Family composition, family history as it relates to the child’s difficulties – eg.,
separations, CWS or other agency involvements, domestic violence, multiple
relationships/fathers, incarcerations, family trauma, etc, etc].
School History
[Schools attended, grades, grades repeated and why, attitude towards school,
attendance, disciplinary actions.]
Sexual History
[Any victimization or sexual perpetration? Sexually active? Understanding of pregnancy,
sexually transmitted diseases]
Substance Abuse History
[Child’s SA history]
Legal History
[Child’s legal history, and, if a PO is involved, who he/she is, when first violation
occurred, list of current charges – information obtained from PO]
Past Mental Health History
[Treatment the youth or family has had in relation to the youth]
Family Psychiatric History
[Biological family’s psychiatric history, substance abuse and problems with the law].
Medical and Developmental History
Confidential Report:
Examiner: Jeffrey W. Cumes, PhD
Page 1 of 4
[Birth, delivery and early development. Prenatal factors if relevant (eg., substance
abuse, physical or emotional abuse of parent, high stress, any notable illnesses, injuries,
accidents, hospitalizations, allergies, drug allergies during the pregnancy. Postnatal
health problems in the infant/child, early separations from the child. Child’s
developmental progression – when did the child start walking, talking, relating
reciprocally to others. Any unusual behavioral characteristics – eg. sensitivity to light or
sound or certain clothing. Any unusual physical features – eg facial features associated
with FAS].
Parent’s (Guardian’s) Theory on the Cause of the Problems
[What the parent/guardian believes are the reasons the child has his/her problems]
Cultural or Transcultural Issues
[Length of residence in Hawaii, other residence out of state, language spoken by youth
and family members at home, cultural factors that may affect treatment.]
Child’s Perspective on the Issues
Establish rapport. Engage in testing to build a connection. Child’s perspective on his/her
life and challenges. If necessary, use Incomplete Sentences and Thematic Apperception
Test to get at underlying dynamics. Get the child’s understanding of his/her problems
and their causes, motivation for change, hopes and plans for the future. Three wishes.
Mental Status Examination
[Appearance, attitude, behavioral observations:
Orientation: (time, place, person).
Sensorium (degree of wakefulness)
Motor Behavior: (E.g., fidgety, distractible, impatient, slowed).
Speech: (articulation, style, speed).
Expressive and receptive language abilities: (an impression).
Affect and Mood: Engagement pattern, eye contact, reported mood, observed affect,
Anxiety: expressed and visible signs of.
Thought content: Rational, hallucinations, delusions.
Thought processes: Estimated cognitive abilities and intelligence.
Suicidal thoughts, plan. Previous ideation. Homicidal thoughts or plan. Previous ideation.
If anything positive emerges here, it needs to be further explored].
Judgment and Insight:
Assessment Tools
[Child and Adolescent Functional Assessment Scale (CAFAS), Achenbach Checklists
(optional), Wechsler Abbreviated Intelligence Scale (WASI), Wide Range Achievement
Test, 4th Edition (WRAT4), Incomplete Sentences (optional), Thematic Apperception
Test (TAT), other measures as needed.
Cognitive Assessment
Wechsler Abbreviated Test of Intelligence (WASI)
Sum of T Scores
IQ
Percentile
Confidence
Interval
Verbal IQ
Performance IQ
Confidential Report:
Examiner: Jeffrey W. Cumes, PhD
Page 2 of 4
Full Scale IQ
Wide Range Achievement Test: Fourth Edition (WRAT4)
Subtest/Composite
Raw Score
Score Summary Table
Standard
Confidence
Score
Interval
Percentile
Rank
Optional
Scores
Word Reading
Sentence
Comprehension
Spelling
Math Computation
Reading
Composite
Comment on test findings:
Personality and Functional Status
Child and Adolescent Functional Assessment Scale (CAFAS)
Subscale
Scores
(0 – 30)
CAFAS Scale
Impairment Level
(Minimal, mild, moderate, severe)
School/Work Role Performance
Impairment
Home Role Performance
Impairment
Community Role Performance
Impairment
Behavior Toward Others
Impairment
Moods/Emotions
Impairment
Self-Harmful Behavior
Impairment
Substance Use
Impairment
Thinking
Impairment
YOUTH TOTAL based on 8 scores
[Comment on the results here in one or two sentences]
Objective Checklist (eg: Achenbach CBCL)
[Note: You can integrate the findings of the TAT and incomplete sentences into your
Summary and Clinical Formulation rather than discussing them separately under the
above headings].
Client’s and Family Strengths
[What does the parent/guardian describe here? What do you see? What are indications
of the child’s resilience? You can discuss this under Protective Factors below].
Confidential Report:
Examiner: Jeffrey W. Cumes, PhD
Page 3 of 4
Summary and Clinical Formulation
Brief one paragraph summary of who the child is, who referred, and why (presenting
problems).
Use a description and/or the 4 Ps to capture key information covered in the body of the
report above:
Predisposing Factors: [What were the conditions that predisposed this family and this
child to have these problems?]
Precipitating Factors: [Why did the problems emerge now? Or, if they started earlier,
what triggered their increase in severity?]
Perpetuating Factors: [What’s keeping the problems going?]
Protective Factors: [What strengths does the child and his/her family have that can
help?]
Any additional narrative your feel the report requires should go in here.
Diagnostic Impressions
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Current GAF:
Past year:
Recommendations
Indicate whether you believe the child and his/her family could benefit from our services,
i.e., from interventions and providers identified through a coordinated services plan
involving a multidisciplinary team. Follow with other recommendations. Do not
recommend a specific program (eg, MST, Intensive In-Home services. Rather identify
the need (eg: This youth is in need of close supervision and structure, with education as
a part of the program providing this oversight). Individualize the recommendations to fit
the specific child and family.
Your Name and Degree
Your Agency
This report and its recommendations are offered to assist in treatment planning, and
represent one perspective. They are based on the information obtained at the time of the
assessment and could change in the light of additional data.
Confidential Report:
Examiner: Jeffrey W. Cumes, PhD
Page 4 of 4