ABLE Forms and Handouts

Forms and Handouts

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Category	Description
Personal Strengths Assessments	Useful before talking about problems and includes measures of what's working and going right with the child and family.
Health and Problem Assessments	Child mental and physical problems and concerns in relation to family, school and community.
Data Collection	Observe and record information on positive and negative activities of living, such as sleep, stress, eating, toileting, energy, etc.
Team Building	Expand the focus from the child to the cultural community.
Resiliency: Your Changing Stories	View what's important and valued by everyday coping or balancing life and to build purpose, direction or change using restoring of experience.

I. Personal Strengths Assessments

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FORMS

Child Reinforcement Survey (likes and dislikes)

Ages 2 to 6

Ages 6 - 12 (expanded form)

Ages 6 to 13

Ages 13 to 18

Child Assets Scale (a Practioner's guide of risks and protections)

Parent Summary of Child Health Asset (a parent's guide to the child's interaction in the environment)

Child's Strengths Checklist (for parent or provider to complete)

Daily Strength Scale (child's self-report)

Family Support and Natural Ecology Chart (parent environmental support)

Family Global Health and Well-being (how families function)

Past Weeks' Quality of Family Life (1 - 10 scale of parent/family significance of everyday functioning)

Play Observation Checklist A guide to observing childs play

Family Strengths Assessment - prepared by the LINCS Program for use by Able Families

HANDOUTS

Promise to Families (letter of welcoming to the program)

Letter to Child

Solution Focus Handout (use of positive talk as a way to change)

Enhancing Family Functioning (create special time for children)

OUTSIDE WEBSITES SCREENING TOOLS

The Holmes-Rahe Life Stress Inventory (Initial assessment of parent's stress)

Casey Life Skills (Life skills assesment tools for youth and young adults)

A useful multi sensory rating of under and over sensitivities reported by the care giver.

Parent Care Needs (parent form for assessing interests and needs using family centered care coordination)
If you can not access this website, it will require signing in to publish this pdf document instead of a link.

Pediatric Care Plan (sample summary care plan with listed conditions, medications and other health requirements for child)

Youth Needs Assessment (teen questions of needs and wishes).

II. Health and Problem Assessments

FORMS

Child Development and Family Life Experiences (history form)

Supplement A: School

Supplement B: Pre-School

Four Generation Family Genogram (family history, relationships and significant events)

Combined Health/Risk Checklist (disability illness rating and maybe helpful in determining child and family functional behaviors)

Sleep Apnea Questionnaire Screening for sleep problems in childhood

HANDOUTS

Guidelines for Physician Evaluation (Developmental Pediatrics)

Extended Health Care Provider Assessment of Special Needs Children
(proposed use of nurse for collaborating with teams)

OUTSIDE WEBSITES SCREENING TOOLS

Anxiety Moods

Child Anxiety/PTSD Symptom Rating Scale

Bipolar Mood Screening (standardized screening questionaire)

Mood Regulating Symptom Checklist (rating scale for bipolar behaviors)

Young Mania Scale (mania or for bipolar like moods)

Young Mania Scale (interpretation of the scale)

Depression Module - Self Help Report - Reading age children for screen

Depression Symptom Rating Scale

Depression Tool Kit a complete tool package for health practitioners for treating child depression

Obsessive Compulsive Screening Checklist

Spence Children's Anxiety Scale - Home Web Site Page Includes: materials on the scales reliability, validity, and availability for use. Linked are the child and parent scored versions, plus the pre-school version. Links are also found for directions and instruction for scoring.

Scared Anxiety Screen for Children: (includes scoring)

Scared Anxiety Screen parent Form: (includes scoring)

Autism

Asperger Screening Scale for Autism

Informal Screening for Autism Spectrum Disorders

Rating scale and scoring for adolescent screening for autism

Rating scale for childhood Asperger Syndrome including scoring

Friendship and relationship quotient for children

2-5 y/o M Chat screening for autism

scoring for M Chat for autism

Attention

Vanderbilt Checklist for ADHD (for parents to complete)

Vanderbilt Checklist for ADHD (for teachers to complete)

Side effects to stimulant medication questionnaire (PDF)

12 question rating scale for frequent probes in the classroom helpful for fine tuning ADHD with medication titration.

General

Pediatric Symptom Checklist (child and youth self-report for emotional and behavioral screening, ages 6 - 16)

The Holmes-Rahe Life Stress Inventory (Initial assessment of parent's stress)

Developmental Disorders Symptom Rating Scale (1 - 10 functional scale)

Attachment questionnaire completed by care giver which promotes a sense of child's relationship security.

Child attachment Checklist (Well organized questions about reactive children's attachment using scaling)

Questionnaire for Child and Adult Chronic fatigue with scoring

Side effect medication list. General questionnaire assessing side effects to non specific medications

Family psychosocial Screening by Kathi Kemper (important questions for highly stressed families for interviewing with scoring criteria.)

Social emotional Behaviors Rating Ratings of Social emotional behaviors for individuals with severe Developmental disabilities.

Parent-Family Scale

Family Impariment Scale

Strengths and Difficulities Questionnaire Brief Questionnaire accessing state of teens (11-17) mental health. Younger childre, (4 and up) have parent and teacher complete forms. Score on line and compare print outs for alignment.

III. Data Collection

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FORMS

Weekly Log Summary

for Depression

for Stress

for Worries

Daily Mood Chart (feelings experienced through out the day)

Self-Monitoring How I Feel Chart (happy, sad, mad faces for the child to discriminate)

Self-Monitoring Event Calendar (30 day recordings of negative or positive events)

Self-Monitoring by a Student for single class period

Self-Monitoring by a Student for a single school day

Self-Monitoring by a Student for a single school week.

Functional Behavior Assessments (Scatter plot and ABC Behavior)

OUTSIDE WEBSITES SCREENING TOOLS

Monthly Mood Chart (in relation to sleep and school performance)

Mood Chart for Manic Depression (self-recording of 30 day mood cycles)

The Ottawa-Georgia Mood Scales (1 - 10 scales for mood, anger, and anxiety)

Stress Thermometer (stress related to behavior and coping strategies in a crisis)

Sleep Diary (child's self-monitoring, with help, sleep hygiene)

IV. Team Building

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FORMS

Core Team Satisfaction Survey (for rating on-going group functions)

Community Meeting Feedback Form

School District Health Care Plan

Family Health Promotion Plan (goals for child, school, family and community needs)

Team Management Rating Scale (useful for parent at any group meeting to identify the team process)

Medical Home Form for Evaluation and Service Recommendations (a way to input health provider concerns)

HANDOUTS

Collaborative Coordination for Team Building (steps toward working together over time)

A Model for Home Meetings (family talking and spending time together)

School and Community Conference Arrangements (worksheet for community conference notes)

Health Providers Promotion Prevention Matrix (prevention basis for the Family Health Promotion Plan)

Guide to Conferencing (action steps to successful consultation)

OUTSIDE WEBSITES

Family input may be obtained using these three sources of information from the families assessment of needs:

www.pediatricmedhome.org/pdfs/3_Assessment_of_Care_Needs.pdf
parents summary of the pediatric care plan and

www.pediatricmedhome.org/pdfs/3_Pediatric_Care_Plan.pdf
the child’s expressed needs

www.pediatricmedhome.org/pdfs/3_YouthCareCoordination_HRTW.doc

V. Resiliency: Your Changing Stories

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FORMS

Family Health Promotion Plan (weaves meaningful story threads that promote child-family strengths)

Quality-of-Life Outcome Measures (QOM) (cumulative parent's opinion of child's progress over time that includes the following four QoLM)

Comfort/Hassle Scales (1 - 10 scales of both soothing and stressful moments)

Confidence/Progress Scales (1 - 10 scales of both feeling strong and positive change examples)

Past Weeks' Quality of Family Life (1 - 10 scale of parent/family significance of everyday functioning)

A Family Focus (initial story stem from reflective family meanings)

Life Quality Change Survey (story lines created from family qualities)

Team Management Rating Scale (empowers a family's goals communicating together)

HANDOUTS

Negotiating Resources for Resilience Handout (building resilient stories from the following forms: Comfort/Hassles Scales, Confidence/Progress Scales, Child Assets Scale, Child's Strengths Checklist and Daily Strength Scale)

Perceiving Change Handout (ready, able and willing scale)

Family Health Promotion Concept Plan (ideas supporting changes for child/family well-being)

What is Narrative Practice? (basis for changing stories)

Note: All outside websites are public domain access.

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