201 Training Manual 81 APPENDIX A - University of Oklahoma

81201 Training Manual | WRAPAROUND

Nevaeh and Her Family: A Wraparound Story

Nevaeh and her fraternal twin sister, Stella, are 11-year-old girls being raised by G-Ma Dee, their paternal grandmother. The girls’ mother is in prison for manufacturing and

distributing methamphetamine. Nevaeh and Stella were born prematurely with drugs in their systems. After 2 months in the Neonatal Intensive Care Unit, DHS child welfare placed the girls with G-Ma Dee. They have lived with G-Ma Dee ever since. G-Ma Dee has legal custody.

The girls’ father has infrequent contact with them. He is not comfortable in the role of parent and says he just does not know how to be a dad. Currently, he is working on an oil rig in the Gulf of Mexico and sends money regularly to help support the girls. He stays at G-Ma Dee’s home when he is between jobs or on furlough but leaves the parenting to his mother. To Nevaeh and Stella, he seems more like an uncle than a father.

Although Stella is not having behavioral issues, Nevaeh has been acting out. Nevaeh’s school referred her to Wraparound after she was suspended for biting her teacher for the third time this semester. The teacher has difficulty keeping Nevaeh in the classroom, in her seat or focused on the task at hand. Nevaeh has also been asked not to return to her hip hop dance class after several incidents where

APPENDIX Ashe has taken things from other children in the class and has been caught tripping and kicking them as well.

Nevaeh’s primary care physician prescribed Ritalin just after she started kindergarten. G-Ma Dee says, “I don’t think it helps. I can’t tell the difference when she takes them, and when she doesn’t.” Nevaeh is generally in good health but did have several surgeries to repair a cleft palate as an infant. She will likely need additional surgeries once she has stopped growing. A DHS child welfare investigator visited the home after the school reported concerns about some bruising the school counselor noticed on Nevaeh’s arms. It turned out that one her dance classmates had punched her in the arm in order to get back a hairbrush Nevaeh took. The child welfare worker referred the family to Wraparound after hearing how frustrated G-Ma Dee was with Nevaeh’s behavior. G-Ma Dee is having difficulty finding someone to watch the girls during her dialysis three times a week. G-Ma Dee hopes to be able to get Nevaeh back into school. G-Ma Dee says, “I am too old to be running down to the school every day to pick her up and take her home. She thinks getting sent home is a prize.” G-Ma Dee fears her age and health issues will negatively impact her abililty to care for the girls.

NeVaeh’s Story/practice Forms

82 WRAPAROUND | 201 Training Manual

04/10/2019

Enter data at: systemsofcare.ou.edu. If you have questions, please email the E‐TEAM YIS Help Desk at [email protected]. 1

Oklahoma Systems of Care Assessment Worker Version

to be completed by those working with children / youth aged 5 through 15

Staff Phone #: 405‐555‐1234 Staff Name: Ben Vaughn

Assessment Date: 10/25/XX

Youth Name: Nevaeh Martin SOC ID: 81234

Completed by: XX CC/Transitions Coordinator FSP/PRSS

Assessment Type: XX Baseline 3‐Month 6‐Month 12‐Month 18‐Month 24‐month 30‐Month 36‐Month Exit

Youth Problem Scale (Copyright © January 2000, Benjamin M. Ogles & Southern Consortium for Children)

Instructions: Please rate the degree to which the child/youth has experienced the following problems in the past 30 days.

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1. Arguing with others 0 1 2 3 4 5

2. Getting into fights 0 1 2 3 4 5

3. Yelling, swearing, or screaming at others 0 1 2 3 4 5

4. Fits of anger 0 1 2 3 4 5

5. Refusing to do things teachers, parents, or employers ask 0 1 2 3 4 5

6. Causing trouble for no reason 0 1 2 3 4 5

7. Using drugs or alcohol 0 1 2 3 4 5

8. Breaking rules or breaking the law (out past curfew, stealing) 0 1 2 3 4 5

9. Skipping school, classes, or work 0 1 2 3 4 5

10. Lying 0 1 2 3 4 5

11. Can’t seem to sit still, having too much energy 0 1 2 3 4 5

12. Hurting self (cutting or scratching self, taking pills) 0 1 2 3 4 5

13. Talking or thinking about death 0 1 2 3 4 5

14. Feeling worthless or useless 0 1 2 3 4 5

15. Feeling lonely and having no friends 0 1 2 3 4 5

16. Feeling anxious or fearful 0 1 2 3 4 5

17. Worrying that something bad is going to happen 0 1 2 3 4 5

18. Feeling sad or depressed 0 1 2 3 4 5

19. Nightmares 0 1 2 3 4 5

20. Eating problems 0 1 2 3 4 5

TOTALS 00 22 44 1155 2200 00

TOTAL 4411

Problems Score of 25 and above = Critical Impairment


04/10/2019


Youth Functioning Scale

(Copyright © January 2000, Benjamin M. Ogles & Southern Consortium for Children)

Instructions: Please rate the degree to which the child’s / youth’s problems affect his or her current ability in everyday activities. Consider the child’s / youth’s current level of functioning.

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1. Getting along with friends 0 1 2 3 4

2. Getting along with family 0 1 2 3 4

3. Developing relationships with boyfriends or girlfriends 0 1 2 3 4

4. Getting along with adults outside the family (teachers, principal, employer) 0 1 2 3 4

5. Keeping neat and clean, looking good 0 1 2 3 4

6. Caring for health needs and keeping good health habits (taking medicines or brushing teeth) 0 1 2 3 4

7. Controlling emotions and staying out of trouble 0 1 2 3 4

8. Being motivated and finishing projects 0 1 2 3 4

9. Participating in hobbies 0 1 2 3 4

10. Participating in recreational activities (sports, swimming, bike riding) 0 1 2 3 4

11. Completing household chores (cleaning room, other chores) 0 1 2 3 4

12. Attending school and getting passing grades in school 0 1 2 3 4

13. Learning skills that will be useful for future jobs 0 1 2 3 4

14. Feeling good about self 0 1 2 3 4

15. Thinking clearly and making good decisions 0 1 2 3 4

16. Concentrating, paying attention, and completing tasks 0 1 2 3 4

17. Earning money and learning how to use money wisely 0 1 2 3 4

18. Doing things without supervision or restrictions 0 1 2 3 4

19. Accepting responsibility for actions 0 1 2 3 4

20. Ability to express feelings 0 1 2 3 4

TOTALS 00 44 88 1122 2200

TOTAL 4444

Functioning Score of 44 and below = Critical Impairment Outcome

In the past 90 days, how many times has the youth been:

arrested ____0_______ Stopped/questioned by the police ____0_______

In the past 90 days, how many times has the youth attempted suicide? ____0_______

School / Trade School / College

Which grade did the child / youth most recently complete? ____4_______

Is the child / youth homeschooled? Yes (If yes, skip the remaining questions in this section.) No

Is the child / youth in school? (If summer, report the situation at end of most recent school term.)

XX Yes No (If no, skip the remaining questions in this section.)

In the last 90 days (of the school year), how many times, if any, has the child / youth been:

tardy? ____0_______ absent? 3

referred to office for discipline? ____15_______ in detention? 1


04/10/2019


in‐school suspended? ____0_______ out‐of‐school suspended? ____3_______

During the current or most recent school year, has the child / youth been expelled? Yes XX No

During the current or most recent school year, did the child / youth adult have an IEP or 504 plan?

XX IEP (Individualized Education Plan) 504 Neither IEP or 504

Placements

Please specify the number of days the child / youth spent in each of the following over the last 90 days.

Jail Therapeutic Foster Care Juvenile Detention Center Youth Shelter Inpatient Psychiatric Hospital Foster Care Drug/Alcohol Rehab Supervised Independent Living Residential Treatment Independent Living by Self Crisis Stabilization Unit 90 Guardians/Parents Residential Job Corp / Voc Center Homeless Group Home __9900_____TOTAL DAYS (Must be 90)

Indicate which of the substances listed below the youth has used for recreational purposes – and how often – in the past 90 days.

Recreational Use

Never A Few Times Weekly Daily

Tobacco products (e‐cigarettes, cigarettes, chewing tobacco, cigars, etc.) 0 1 2 3

Alcoholic beverages (beer, wine, liquor, moonshine, etc.) 0 1 2 3

Cannabis (marijuana, pot, grass, hash, etc.)? 0 1 2 3

Cocaine (coke, crack, etc.) 0 1 2 3

Cough syrup 0 1 2 3

Prescription Stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) 0 1 2 3

Methamphetamine (speed, crystal meth, ice, etc.) 0 1 2 3

Inhalants (nitrous oxide, glue, gas, paint thinner, etc.) 0 1 2 3

Sedatives or sleeping pills (Valium, Ativan, Librium, Xanax, Rohypnol, GHB, etc.) 0 1 2 3

Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) 0 1 2 3

Street Opioids (heroin, opium, etc.) 0 1 2 3

Synthetic marijuana (T‐K‐2) 0 1 2 3

Prescription opioids (Fentanyl, Oxycodone, OxyContin, Percocet, Hydrocodone, Vicodin, Methadone, Buprenorphine, etc.)

0 1 2 3

Anti‐freeze 0 1 2 3

Other – specify 0 1 2 3


08/15/2018


Oklahoma Systems of Care Assessment Caregiver Version

to be completed by caregivers of children, youth, and young adults aged 5 through 25

Staff Name: Ben Vaughn Staff Phone #: 405-555-1234

Assessment Date: 10-23-XX


Completed by: Mother Father Step‐Mother Step‐Father Foster Parent Sibling Aunt / Uncle XX Grandparent Other



Instructions: Please rate the degree to which your child has experienced the following problems in the past 30 days.

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4. Fits of anger 0 1 2 3 4 5






10. Lying 0 1 2 3 4 5









19. Nightmares 0 1 2 3 4 5


TOTALS 00 22 1122 1122 44 00

TOTAL 3300



08/15/2018




Instructions: Please rate the degree to which your child’s problems affect his or her current ability in everyday activities. Consider your child’s current level of functioning.

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TOTALS 00 55 88 1122 1166

TOTAL 4411

Functioning Score of 44 and below = Critical Impairment


08/15/2018


Hopefulness Scale (Copyright © January 2000, Benjamin M. Ogles & Southern Consortium for Children)

1. Overall, how satisfied are you with your relationship with your child right now? 6 Extremely satisfied 5 Moderately satisfied 4 Somewhat satisfied 3 Somewhat dissatisfied 2 Moderately dissatisfied 1 Extremely dissatisfied

2. How capable of dealing with your child’s problems do you feel right now? 6 Extremely capable 5 Moderately capable 4 Somewhat capable 3 Somewhat incapable 2 Moderately incapable 1 Extremely incapable

3. How much stress or pressure is in your life right now? 6 Very Little 5 Some 4 Quite a bit 3 A moderate amount 2 A great deal 1 Unbearable amounts

4. How optimistic are you about your child’s future right now? 6 The future looks very bright. 5 The future looks somewhat bright. 4 The future looks ok. 3 The future looks both good and bad. 2 The future looks bad. 1 The future looks very bad.

Family Assessment

Please tell us how well each statement below describes your family

(on a scale from 0 to 5).

Not at all like my

family

Very much like my family

1. My family spends too much time arguing. 0 1 2 3 4 5 2. We don’t know how to work problems out. 0 1 2 3 4 5 3. I don’t feel safe in my home. 0 1 2 3 4 5 4. It is hard to know what the rules are in my family. 0 1 2 3 4 5 5. We don’t trust each other. 0 1 2 3 4 5 6. You can’t say what you really think in my family. 0 1 2 3 4 5 7. My family is there for me. 0 1 2 3 4 5 8. I never know what to expect from my family. 0 1 2 3 4 5 9. It’s ok to talk about my feelings with my family. 0 1 2 3 4 5 10. My family doesn’t spend enough time having fun. 0 1 2 3 4 5


08/15/2018


Oklahoma Systems of Care Assessment Youth Version

to be completed by youth aged 9 through 15

Staff Name: Ben Vaughn Staff Phone #: 405-555-1234

Assessment Date: 10-23-XX




Instructions: Please rate the degree to which you have experienced the following problems in the past 30 days.

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4. Fits of anger 0 1 2 3 4 5






10. Lying 0 1 2 3 4 5









19. Nightmares 0 1 2 3 4 5


TOTALS 00 55 66 99 44 00

TOTAL 2244



08/15/2018




Instructions: Please rate the degree to which your problems affect your current ability in everyday activities. Consider your current level of functioning.

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TOTALS 00 11 66 2211 2288

TOTAL 5566

Functioning Score of 44 and below = Critical Impairment


08/15/2018


Hopefulness Scale (Copyright © January 2000, Benjamin M. Ogles & Southern Consortium for Children)

1. Overall, how satisfied are you with your life right now? 6 Extremely satisfied 5 Moderately satisfied 4 Somewhat satisfied 3 Somewhat dissatisfied 2 Moderately dissatisfied 1 Extremely dissatisfied

2. How energetic and healthy do you feel right now? 6 Extremely energetic and healthy 5 Moderately energetic and healthy 4 Somewhat energetic and healthy 3 Somewhat unenergetic and unhealthy 2 Moderately unenergetic and unhealthy 1 Extremely unenergetic and unhealthy

3. How much stress or pressure is in your life right now? 6 Very Little 5 Some 4 Quite a bit 3 A moderate amount 2 A great deal 1 Unbearable amounts

4. How optimistic are you about your future right now? 6 The future looks very bright. 5 The future looks somewhat bright. 4 The future looks ok. 3 The future looks both good and bad. 2 The future looks bad. 1 The future looks very bad.

Family Assessment

Please tell us how well each statement below describes your family

(on a scale from 0 to 5).

Not at all like my

family

Very much like my family

1. My family spends too much time arguing. 0 1 2 3 4 5 2. We don’t know how to work problems out. 0 1 2 3 4 5 3. I don’t feel safe in my home. 0 1 2 3 4 5 4. It is hard to know what the rules are in my family. 0 1 2 3 4 5 5. We don’t trust each other. 0 1 2 3 4 5 6. You can’t say what you really think in my family. 0 1 2 3 4 5 7. My family is there for me. 0 1 2 3 4 5 8. I never know what to expect from my family. 0 1 2 3 4 5 9. It’s ok to talk about my feelings with my family. 0 1 2 3 4 5 10. My family doesn’t spend enough time having fun. 0 1 2 3 4 5


Strengths, Needs, and Cultural Discovery (SNCD)

GENERAL INFORMATION:

REFERRAL INFORMATION:

LONG RANGE VISION:

STRENGTHS & NEEDS FOR LIFE DOMAINS:

Youth Name Parent/Guardian

Date of Initial Review with Family Date of Update

Care Coordinator Family Support Provider

Referral Source:

Referral Reason::

Person(s) Providing Information::

Name & Relationship Name & Relationship

Residence:

Family:

Social:

Behavioral/Emotional



POTENTIAL FAMILY TEAM MEMBERS AND RELATIONSHIP TO CHILD/YOUTH/YOUNG ADULT AND FAMILY

PRIORITY NEEDS OR CONCERNS OF THE FAMILY, CHILD/YOUTH/YOUNG ADULT, AND/OR PROFESSIONALS:

STRENGTHS & NEEDS FOR LIFE DOMAINS:

Name Relationship

Education/Vocational:

Financial/Economic:

Safety::

Legal:

Health:

Spiritual:

Leisure/Recreation:

Name Relationship

Name Relationship



SIGNATURES:

Youth Name Care Coordinator

Youth Signature Parent/Guardian SignatureDate Date

Care Coordinator Family Support ProviderDate Date

Team Member Team MemberDate Date





Family Support Provider


Crisis/Safety Plan

Youth Name Care Coordinator Family Support ProviderDate:

Describe issue or behavior:

Speci�c Action Steps (making environment safe, plan for the 24-hour day, etc.):

Professionals, Agencies, or Supports I can contact during a crisis:

Care Coordinator


Clinician

Family Team Member

Family Team Member

Children’s Crisis Line Statewide 833-885-2273.

Phone:

Phone:

Phone:

Phone:

Phone:

Who are we trying to protect? Youth Siblings Other Children

Other:Property

Pets

This Safety Plan will be reassessed: Weekly Bi-Weekly Monthly

This Safety Plan will be in place from to

Date Date


Family Team Meeting Form

Youth Name:

Date:

Location:

Time:

Team Mission:

Team Members Present:

Family’s Long-Range Vison:

Initial Family Team Meeting: Yes NoCare Coordinator Family Support Provider

Agenda Items Presenter Time Allotted

Introductions:

Development and Review of Ground Rules. Ground Rules include:

Prioritization of Needs

Brainstorm Action Steps to Address Prioritized NeedsAction Step Selection (Family and youth make �nal selection.)Action Steps: Who, What, When, and How Often

Discussion of Family Team Membership

Discussion of Potential Crises/Review of Crisis Plan if necessary

Schedule Follow-Up Meeting and AdjournFollow-Up Meeting Scheduled for:

Review and Discussion of Long-Range Vision and Team Mission:


Wraparound Plan Form

Youth Name:

Date: Location:Time:

Addendum to Family Team Meeting held on


Need/GoalWhat?

Action StepWho? Person Responsible

When?How Often Strength Outcome


Wraparound Plan

SIGNATURES:

Youth Name Care Coordinator








I/We (youth/guardian) have actively participated in the development of this plan and understand the treatment goals and plan. I/We have the following response:

I have been oered a copy of my wraparound plan, and I/we

with this Wraparound Plan.I/We Agree Disagree

Accept Decline


Functional Assessment

Youth Name:


Date:

Behavior • Describe the crisis behavior or scenario in detail such as what exactly they are doing when it’s at its worst? What’s happening – including verbal and physical aggression behaviors, suicidal behaviors, etc.

• Make your description very clear and spell it out

Rate It • How often does this behavior occur at its worst? How do they behave during lesser outbursts and how often do those occur?

• How long does the behavior or sit-uation last? How long at its worst and when it is resolved quickly?

• Intensity on a scale of 1 to 10; 1 being the lowest and 10 results in self harm, harm to others, where does it fall?

• What are the consequences?

How does it start?

• Are there people, situations or events that trigger or set off the behavior?

• Are there certain people that these occur with? Places? Certain words that are said? Situations such as times of change?

What’s different?

• Under what situations are things better or less likely to occur?

• What is different about these spe-

answers into how to prevent the behavior or address it better?

• Why they are not experiencing crisis under these circumstances?


Functional Assessment (continued)

Youth Name:


Date:

Warning signs • What behaviors are signs that a crisis may soon occur?

• What physical signs, facial expres-sions, actions, that the crisis may be beginning to happen?

• lead up to a crisis?

What’s worked?

• What has made a difference before?

• How did it work?• What makes it better?• What makes it worse?

• What happens as a result of the behavior or situation?

• Is there something received or gained from it?

• What are they trying to communi-cate?

• What is the underlying, unmet need?

Positive Alternatives

• What could be done instead?• What’s something as rewarding or

Better/Worse • Are there people that make the situation better or worse?

• Are there certain things that situa-tion better or worse?

• Are things that can help better the situation regardless of location?

After • What does the person do?• How does their body feel? (Tense,

shaky, hot or cold?)• Are their punishments or rewards?• What does everyone else do?



Youth Name:


Date:

Prevent it • List the: what, who, when, how often?

• Who are the formal and natural supports?

During • List the: what, who, when, how often?

• Who are the formal and natural supports?

• Include helpful phone numbers.



Youth Name:


Date:






SIGNATURES:


Transition Plan

Youth Name:


Date:

Referring to/Continuing Services with:

Longe Range Vision/Goal:

Team Mission:

Strength:

Lessons Learned:

Achievements during Wraparound:

Continuing Needs:

What to do if symptoms come back or if additional services are needed?

Updated SNCD (within last 3 months).

Family has facilitated Family Team Meeting.

Family has developed a Functional Assessment/Crisis Plan.

Updated Functional Assessment/Crisis Plan.

Date of Last Update:

Date of Last Update:

Address Phone Appointment Date Appointment Time

Medications Dosage Special Instructions


Transition Plan

Youth Name:


Date:






SIGNATURES:


What is the plan to ensure that family is contacted 1 time per month for three months after discharge/ graduation?

Participating in services at discharge/graduation. Yes No

Person Responsible Date of Follow-up

201 Training Manual 81 APPENDIX A - University of Oklahoma

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Transcript of 201 Training Manual 81 APPENDIX A - University of Oklahoma