I.M.P.A.C.T. Early Childhood Program Identifying Emotional and Behavioral Needs Early Can Make a World of Difference

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1 I.M.P.A.C.T. Early Childhood Program Identifying Emotional and Behavioral Needs Early Can Make a World of Difference Application for children under age 6

2 Kentucky SEED IMPACT for Early Childhood Bluegrass Region Nomination Packet Demographic Information IMPACT ID# Child s Name: Gender: Male Female Social Security Number: of Birth: Age: of Referral: Name of Person Making the Referral: Agency/ Organization: Relationship to Child: Address: City: Zip: Phone: address: Name of Legal Guardian Relationship to the Child: Address: City: State: Zip: Phone (1) Phone (2) Name of Person Child lives with (if different) Relationship to the Child: Address: City: State: Zip: Phone (1) Phone (2) Legal Guardian is: Both Parents 1 Parent DCBS Guardian Adoptive Parent Parental Rights Terminated: Yes No; If Yes, when: Insurance Information No Insurance Medicaid / Medical Card Card Identification Number: Card Name: Private Insurance Card Identification Number: Card Name:

3 Check Yes or No to Each of the Questions below: Kentucky SEED IMPACT for Early Childhood Bluegrass Region Nomination Packet Health Information Areas of Concern No Yes If Yes, please provide details Developmental Delays Family Relational Problems Grief (death or divorce) Poor Social Skills Poor Anger Control Depression Poor/Low Compliance Trauma Victim of Physical Abuse Victim of Neglect Victim of Sexual Abuse Hyperactivity Poor Impulse Control Short Attention Span (for age) Anxiety (appears anxious) Academic Problems Low Self Esteem Attachment Issues Speech Delays Gross Motor Skill Delay Fine Motor Skill Delay Hearing Impairments Vision Impairments Problems/ Complications at Birth Ongoing Medical Concerns Aggressive towards adults Aggressive towards children Able to engage in age appropriate play Hospitalizations Multiple Daycare Placements Removed from Biological Parents Chronic Disability Behavioral Problems/Concerns Sleep Problems Sensory Problems Additional Comments/Concerns:

4 Check Yes or No to programs that the child has participated in: Programs No Yes If Yes, please provide details: when, where, what, etc HANDS PROGRAM FIRST STEPS HEAD START PRESCHOOL SCHOOL SPEICAL EDUCATION ( IEP) 504 PLAN Occupational Therapy Speech Therapy Medication Mental Health Diagnoses Current Service Providers Provider Name Phone Number Address Mental Health Daycare School DCBS worker Pediatrician Psychiatrist Occupational Physical Speech What are the needs of the child and family? (Please specify how service coordination and interagency collaboration are essential to meeting these needs): What are the strengths of the child and family? Additional Information:

5 MAP-585 (09-91) REGIONAL INTERAGENCY COUNCIL CHECKLIST FOR IDENTIFICATION OF CHILDREN WITH SEVERE EMOTIONAL DISABILITIES Child s Full Name DSM-IV Diagnosis (Required) Child s Social Security Number As stated in KRS , the child must present with one of the following conditions. PLEASE CHECK THE EXISTING CONDITIONS (1) Presents substantial limitations that have persisted for at least one (1) year or are judged by a mental health professional to be at risk of continuing for one (1) year without professional intervention in at least two (2) of the following five (5) areas: A. Self Care: Defined as the ability to provide, sustain, and protect himself at a level appropriate to his/her age. B. Interpersonal Relationships: Defined as the ability to build and maintain satisfactory relationships with peer and adults. C. Family Life: Defined as the capacity to live in a family or family type environment. D. Self Direction: Defined as the child s ability to control his/her behavior and to make decisions in a manner appropriate to his/her age and; E. Education: Defined as the ability to learn social and intellectual skills from teachers in an educational setting; or (2) Is a Kentucky resident and is receiving treatment for emotional disturbance through the interstate compact; or (3) The Department for Social Services has removed the child from the child s home and has been unable to maintain the child in a stable setting due to behavioral or emotional disturbance; or (4) A child who presents impairment/behavior of short duration yet of high intensity. Included are severe emotional problems such as suicidal or psychotic trauma reactions where prognosis regarding duration of symptoms cannot be accurately assessed. The child is certified to meet the criteria as established above. Existence of these conditions is documented in the client record. Authorized Agency Representative Based on the information cited above, this child is hereby identified by the Regional Interagency Council as a severely emotionally disturbed child in need of targeted case management services. RIAC Chairperson

6 State Interagency Council Parent / Legal Guardian Release of Information Region Child s Name SSN DOB The Kentucky Revised Statute (KRS) states that the Kentucky General Assembly finds that services to children are provided by various departments and agencies at both the state and local level, often with out appropriate policy collaboration and service coordination. The General Assembly declares that the purpose of KRS to is to establish a structure for coordinated policy development, comprehensive planning, and collaborative budgeting for services to children with an emotional disability or severe emotional disability and their families. It is further the intention of the General Assembly to build on the existing resources and to design and implement a coordinated service system for children with an emotional disability or severe disability that is community based and centered on the needs of the individual child and family. Children with a severe emotional disability who are receiving institutional care or are at risk of institutional placement shall be given priority for services pursuant KRS to I (parent / legal guardian) recognize that my child s condition requires the collaboration of care among professional service providers and agencies within and/or outside my local community. I understand that this collaboration requires disclosure of confidential information for my child to assist service providers and agencies with necessary assessments and development of service plans. I (parent / legal guardian) hereby authorize the release of the confidential information identified below to Local Resource Coordinator, designated Service Coordinator, and the Regional Interagency Council for service to children with an emotional disability or with a severe emotional disability. The information shall be used only in connection with the assessment of the child herein named above, and may be disclosed to any person actively participating with the identified plan for care or governing body. The confidential information shall not be otherwise released and shall be held confidential for any other purpose unless mandated by applicable law. Information that can be requested for release (each item must be initialed by the parent or other legal guardian) Initial Authorized Materials Initial Authorized Materials Medical History and Physical Examinations Psychiatric Hospital Psychiatric Summary/Psychological History Inpatient Records Psychological Tests Results: Substance Abuse a. Intelligence Treatment Records b. Psychomotor State of Legal Status and Custody c. Projective Court Records HANDS Program Records Court Judgments FIRST Steps Records Court Journal Entry or Entries Head Start Records Court Entry or entries Early Childhood Center Records Court Charge or Charges Court Dispositions Other information identified to be released (must be written): I understand that confidential information obtained will become part of the application for referral of the above named child and does not guarantee that services will be provided. This confidential information will be used to determine eligibility and, if my child is accepted into the program, to formulate a treatment plan. I have read, or have had read and explained to me, the above authorization and fully understand it. This release is valid for up to one (1) year from the date of my signature below. Signature Relationship (check one) Parent Guardian Child s Representative Child s Signature Child s signature is strongly encouraged for all participants. Child s signature is required when alcohol or substance abuse records are involved. Witness Signature Signature must be witnessed (Original form must be submitted)

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