I. Each evaluator will have experience in diagnosing and treating the disease of chemical dependence.

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1 PREVENTION/INTERVENTION CENTER COBB COUNTY PUBLIC SCHOOL SAFE AND DRUG FREE PROGRAM CONTRACT FOR SERVICE PROVIDERS As a member of the Cobb County Schools Coalition of Treatment Providers each participant (i.e., private practitioner or treatment facility) agrees to the following: I. Each evaluator will have experience in diagnosing and treating the disease of chemical dependence. II. III. IV. Members of the Coalition will be qualified practitioners who will attend an orientation session at the Prevention/Intervention Center and will offer a 50-minute free assessment to Cobb County students or employees and families. We would like members of the Coalition to be present at all the coalition meetings; however, members should be present at a minimum of one meeting during the year. Complete and fax or mail an Assessment Form to the P/I Center within 48 hours after assessment. V. Attach a photocopy of your current license. VI. Send/fax forms to: The P/I Center for Safe and Drug Free Schools Fax # Cobb County Public Schools P.O. Box 1088 Marietta, GA Assessment form is available on our Name of Facility Phone Number Fax Number Name Street Address City, State, Zip Code Address Signature Date URL/Web address Please copy for your records and return original to P/I Center.

2 PREVENTION/INTERVENTION CENTER COBB COUNTY PUBLIC SCHOOLS SAFE AND DRUG FREE SCHOOLS PROGRAM Name of Facility Phone Number CHECK OFF YOUR TOP FIVE SPECIALITITES ONLY ADHD Anxiety Disorders Behavior Problems Blended Families Child and Adolescent Issues Child Abuse Chemical Dependency Cognitive Behavior Therapy COA Co-Dependency Conduct Disorders Cross Cultural Focus Dating and Relationship Issues Depression Developmental Disabilities Dissociative Disorders Divorce Dual Diagnosis EAP Eating Disorders Education Testing Family Dysfunction Families In Transition Family Therapy Grief Work Individual Therapy Inner Child Work

3 Learning Disabilities Loss and Separation Medication Evaluation Parenting Play Therapy Post Traumatic Stress Disorder Psychological Testing Psychosomatic Illness Rape Religious Orientation School Avoidance Self-Esteem Severely Emotionally Disturbed Sexual Addiction or Identity Sexual Abuse Social Skills Stress Management Suicidal Behaviors or Ideation Unattached or Sociopathic Children Women s/men s Issues Other Other Age 0-6 Age 6-12 Age Speak any language other than English Yes No Emergency Phone Number Pager Number Low Cost/Sliding Scale Services Yes No Are your services covered by Medicaid? Yes No

4 Are your services covered by any HMO? Yes If yes, please list. No YOUR NAME AND FACILITY PLEASE LIST INSURANCE PROVIDERS THAT YOU TAKE

5 MENTAL HEALTH ASSESSMENT FORM FOR COBB COUNTY STUDENTS Version ASSESSMENT DATE: START TIME: am / pm UPDATE: Facility Reporting: Examiner name: IDENTIFYING / INITIAL DATA: Student: DOB Age: Race Sex School: Patient lives with: Referred by: Person/s accompanying student for assessment (name/s, relationship) Interviewed for this assessment (circle all that apply): student parent other: INSTRUCTIONS: Please complete Part 1 (Self-Harm/Violence Potential) by interviewing the student, asking the questions exactly as they are written. Complete Part 2 (Current Problem Areas) and Part 3 (Recommendations for Intervention) after you complete your evaluation of the student. PART 1 Self-Harm/Violence Potential WHY HAVE YOU BEEN REFERRED FOR AN EVALUATION AT THIS TIME? Direct Quote: SUICIDAL/ SELF-INJURIOUS 1. Are you currently having thoughts or urges to harm or kill yourself? (If no, proceed to # 5) What specific thoughts are you having and how often are you having them? 2. Do you have a current plan to harm or kill yourself? (specify plan) 3. Do you have the means available to carry out your plan? (specify location of means) 4. Do you intend to follow through with your plan? When? If so, what do you expect will happen if you do carry out your plan? 5. Have you ever (in whole life) tried to kill yourself? 6. Have you ever had medical attention for a suicide attempt? 7. Have you seriously thought about killing yourself during the last year? 8. Have you thought about killing yourself many times during the last year? 9. Have you had a plan for suicide during the last year? 10. Have you tried to kill yourself in the last year? 11. Have you seriously thought about killing yourself during the last 4 weeks? 12. Has anyone in your family (or a friend) attempted or completed suicide?

6 MENTAL HEALTH ASSESSMENT, page 2 Students Name: HOMICIDAL / VIOLENT / THREATENING BEHAVIOR 13. Are you currently having thoughts or urges to harm or kill someone else? (If no, proceed to # 17) What specific thoughts are you having? 14. Do you have a current plan to harm someone else? If so, what is the name of the person you wish to harm and what is their relationship to you? 15. Do you have the means available to carry out your plan? (Specify location of means) 16. Do you intend to carry out your plan? When? 17. Have you ever made an attempt to harm someone else? When? Describe briefly: THREAT TO PERSONAL SAFETY 18. Has anyone harmed you recently? (Describe) 19. Are you currently afraid for your own safety? (Specify why) SAFETY CONCERNS OF PARENTS / SIGNIFICANT OTHERS 20. Are parents/others afraid for student s safety currently? (Explain) PSYCHOSIS you? 21. Are they afraid for their or anyone else s safety during assessment? (Explain) 22. Are they afraid student will try to leave during assessment? 23. Are you having any thoughts that are currently causing you distress or feel out of control to (Describe) 24. Are you having fears that other people are out to get you in any way? 25. Have you been hearing voices or having any kind of hallucinations? (Describe) SUBSTANCE ABUSE / DEPENDENCE / WITHDRAWAL 26. Do you believe you are having any problems with substance abuse? 27. Do you use any substances or medications? (specify) When did you last use this/these substance/s? substance? 28. Are you currently intoxicated? If yes, did you drive yourself here? If so, are you willing to allow staff to hold your keys for you while you are being assessed? 29. Do you believe you are currently experiencing physical withdrawal symptoms from a If so, briefly describe:

7 MENTAL HEALTH ASSESSMENT, page 3 Students Name: PART 2: CURRENT PROBLEM AREAS (Circle specific problems) U = Unknown/Not Assessed 0 = No Problem 1 = Mild 2 = Moderate 3 = Severe 1. ACADEMIC: DROP IN GRADES / FAILING / SUSPENSION / EXPULSION 2. SCHOOL AVOIDANCE / SOMATIC COMPLAINTS 3. LEARNING / SPEECH DISORDERS (Specify) 4. BULLIED BY OTHERS - COMMUNITY / SCHOOL 5. DEVELOPMENTAL / TIC DISORDERS 7. ATTENTION-DEFICIT / HYPERACTIVITY 8. DIFFICULTY WITH PARENTAL/AUTHORITY FIGURES 9. EATING DISORDERS ANOREXIA / BULIMIA 10. DIFFICULTY WITH PEER RELATIONSHIPS 11. LYING / STEALING (Specify) 12. RUNAWAY BEHAVIOR (Specify) 13. DESTRUCTION OF PROPERTY 14. VERBALLY ABUSIVE / THREATENING 15. PHYSICALLY THREATENING / VIOLENT / BULLY 16. CRUELTY TO CHILDREN / ANIMALS / FIRE SETTING (Specify) 17. ABUSE: PHYSICAL / SEXUAL / EMOTIONAL 19. GANG PARTICIPATION 20. JUVENILE COURT / DFCS INVOLVEMENT 21. ALCOHOL, DRUGS, (Specify) 22. SELF-MUTILATION (DATE ) 23. DEPRESSION 24. ANXIETY 25. MAJOR LIFE CHANGE / DIVORCE / DEATH IN FAMILY

8 MENTAL HEALTH ASSESSMENT, page 4 Students Name: TREATMENT HISTORY Dates Provider / Description Special Ed. Resource Self-contained Mental Health tx. outpt inpt Alcohol & Drug tx. outpt inpt Psychopharmaceuticals PART 3: RECOMMENDATIONS FOR INTERVENTION Indicate which referrals were made and check reasons that apply: YES/NO Outpatient Services Individual Family Group Substance Use Intervention Parenting Intervention/Education YES/NO Inpatient/Partial Hospitalization Suicidal Homicidal Substance Use Medical Evaluation YES/NO Psychoeducational Academic/LD testing Tutoring Describe specific referrals given Comments Number of free assessments family has received Likelihood family will follow up (1=no, 7=yes) Record Follow-ups: Send to: Prevention/Intervention Center Fax # Cobb County Public Schools Phone # P.O. Box 1088 Marietta, GA 30061

9 RELEASE OF INFORMATION I hereby authorize (Assessment Center) to disclose to Cobb County Public Schools Prevention/Intervention Center and (School) the following items of information: Information obtained from assessment; medical records; psychological test results; Other regarding (Student Name) This release permits single continuing (check one) disclosure. This consent is given on (Date) This consent is subject to revocation at any time except to the extent that action has been taken in reliance thereon. Signature of Student Signature of Parent Witness Date Date Date

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