Charlie Harper is a 12-year-old boy in the sixth grade who has been referred following multiple reports by his school of increased signs of withdrawal and frequency in truancy. Charlie’s teacher, Mrs. Ward, who has been concerned about Charlie. It was about a month ago that Mrs. Ward had noticed the change in Charlie’s participation, enthusiasm for learning, and his social skills deteriorate. Coinciding with these changes is the fact that Charlie’s father had been arrested and sent to jail. After speaking briefly with Charlie, Mrs. Ward was able to assess that he was experiencing multiple issues. First, he started getting negative comments, and being bullied by his peers. Most importantly, he expressed that his mother has not been able to spend time with him as in the past and states “my Mom has to work all the time because she said that she has a lot of bills to pay.” When asked who takes care of him when is Mom is working, Charlie replied to Mrs. Ward “I take care of myself.” On the day of the referral, Charlie had missed the bus after school. After failed attempts to contact his mother and emergency contacts, Principal Roberts had taken Charlie home and found that Mom was not home. A neighbor had seen them outside and stated that Charlie’s Mom asked her if she could keep an eye on him until she returned home from work. As Mr. Roberts was unaware of the arrangement, he did not feel comfortable leaving Charlie with the neighbor and explained that he would handle the situation. Being a mandatory reporter, Mr. Roberts called child protective services who took Charlie into custody, interviewed Mr. Roberts and Mrs. Ward and eventually was able to reach and interview Mrs. Harper. Evaluation of the home revealed that Mrs. Harper was not neglectful, and there were no signs of abuse or maltreatment of any kind. Appropriate amount of food was present in the home and the home environment appeared to be safe and clean. There is still the question of how Charlie has an increase of truancy. It turns out that Mrs. Harper would drop Charlie off at the bus stop, a block away, and after she drove off, Charlie would walk back home and climb into his bedroom window that he left unlocked. Mrs. Ward was unaware of this and seemed genuinely surprised at the revelation. It seems clear that Charlie’s issue is bullying and embarrassment as a result of his father’s arrest and incarceration. Mrs. Ward admits that this is something that they have not spoken about, and agrees that in retrospect this has had a significant effect on Charlie emotionally, physically due to lack of appetite, and psychologically. Mrs. Ward agrees that Charlie would benefit from counseling. Case Management Intake and Assessment Form Client Information Client Name: Service Point #: Date: Last Address: Age: How long here? DOB: Race: /_ /_ SSN: Cell Phone #: Ethnicity:  Hispanic or Latino Emergency Contact(s):  Non-Hispanic or Non-Latino or Relationship: Phone #: DL or ID? Y  N  Birth Certificate? Y N SS Card? Y N How long have you been homeless? Anyone here with you?  Yes: What is your current marital status? :  No Do you have children with you:  Yes If yes, List Below  No Name: Age: DOB: Gender: SSN: Name: Age: DOB: Gender: SSN: Name: Age: DOB: Gender: SSN: Name: Age: DOB: Gender: SSN: Veteran Information Are you a veteran?  Yes  No Copy of your DD214: Yes No Discharge Status: Honorable Dishonorable Military benefits in past? Yes  No  Education Special education, behavioral problems or disabilities? Yes  No  Highest level of education completed? Employment Are you working?  Yes  No Where?:  Temp Wage: What was your last job? When?  Permanent Reason for leaving? What type of work experience do you have? Have you ever been fired?  Yes  No When: Have you applied for any jobs recently?  Yes Reason:  No Where: Physical limitations?  Yes  No What: Mental health /substance abuse affected work?  Yes  No Legal Have you ever been convicted of a crime?  Yes What?  No Are you on probation?  Yes When was this? Do you have any legal actions pending currently?  Yes  No What? When was this?  No Jail/Prison?  Yes  No Income and Resources Debts/Financial Responsibilities Are you receiving any of the following? Do you have to pay on the following in the next 90 days? • • • • • • • • • • • • • • • • • • • • • • • SSI(Child) SSI/SSDI/Retirement FIP (TANF) Child Support Alimony/spousal support Employment Unemployment Disability/Work Comp Pension Medicaid or Medicare Food Stamps or WIC Section 8, public housing or ongoing rental assistance TANF Child Care, Transportation, Other VA Medical, Iowa Care, MH/DS Credit card(s) Loans(s) Past due rent Cell phone Vehicle Utility bills Child support Court fees or fines Storage units Other Physical Health Do you have access to health care?  Yes Do you take any medications?  Yes Pregnant?  Yes Due date: _  No  No Any current health concerns/diagnosis? Do you need any refills on medications?  Yes  No Physical limitations?  Yes Do you need referrals for HIV/AIDS/Hepatitis testing or services?  Yes Do you need glasses?  Yes  No  Yes  No  No  No  No Hearing loss or difficulty?  Yes  No Allergies:  Yes  No Mental Health Have you ever been seen by someone for mental health?  Yes Have you had any inpatient treatments?  Yes  No  No If yes, your diagnosis: Have you had outpatient treatments?  Yes Any current treatment?  Yes  No If no, would you like to be seen?  Yes  No  No Case Manager: Complete additional Mental Health and Wellness Form Substance Abuse Have you ever used drugs or alcohol?  Yes Inpatient Treatment?  No  Yes Current  Yes If yes, list type and date last used:  No  No Outpatient?  Yes Clean UA today?  Yes Case Management Is there anything else I should know about you and/or your family?  Yes  No Client Signature: Date: Case Manager Signature: Date:  No  No
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