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Version 1.3 March 24, 2016 1) Please enter the total number of screenings that were performed. ______

1-a) Please enter the number of students referred for assessment by age group, sex, and race/ethnicity in the chart below.

9 or younger 10 to 13 14 to 17 18 or older

Age Group Male Female Male Female Male Female Male Female

White (Non-Hispanic) Black (Non-Hispanic) Hispanic Asian American Indian Other Race

1-b) Please enter the number of students referred that received a Drug and Alcohol assessment during this reporting quarter. ______

1-c) Please enter the number of students referred that received a Mental Health assessment during this reporting quarter. ______

1-d) Please enter the number of students referred that received a Co-Occurring assessment during this reporting quarter. ______

(2)

Version 1.3 March 24, 2016

Quarterly Form (SAP Online), Page 2

Assessment Results (The information should be based on the FINAL assessment)

2-a) For each age group, state the number of students whose assessment resulted in the following PRIMARY problem categories. (Include each student only ONCE in the count.):

Age Group Primary Drug/Alcohol Primary Mental Health Primary Co-Occurring NONE

9 or younger

10 – 13

14-17

18 – older

2-b) For each age group, state the number of students whose assessment resulted in the following SECONDARY problem categories. (A student may be entered more than once):

Age Group Co-dependency Suicide Ideation Suicide Attempt Child

Abuse Bullying Grief/Loss Tobacco

GLBTQI Issues Other Trauma/Other 9 or younger 10 – 13 14-17 18 – older

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Version 1.3 March 24, 2016

Quarterly Form (SAP Online), Page 3

Assessment Results (continued)

3) Of the students who have been assessed indicate in the tables below by age group the number who were referred to each category. Include all that apply in the count. Use PRIMARY Drug and Alcohol referral category only.

Intervention Treatment Age Group School Based Group Community Based Group Other Support Services D & A Outpatient D & A Intensive Outpatient D & A Partial Hosp. D & A non-Hospital Rehab D & A

Inpatient Other None

9 or younger 10 – 13 14 – 17 18 or older

(4)

Version 1.3 March 24, 2016

Quarterly Form (SAP Online), Page 4

Assessment Results (continued)

4) Of the students who have been assessed indicate in the tables below by age group the number who were referred to each category. Include all that apply in the count. Use PRIMARY Mental

Health referral category only.

Intervention Treatment Age Group School Based Group Community Based Group Other Support Services Psychiatric Outpatient Psychiatric Partial Hospital FBMHS or BHRS Psychiatric Residential Psychiatric

Inpatient Other NONE

9 or younger 10 – 13 14 – 17 18 or older

(5)

Version 1.3 March 24, 2016

Assessment Results (continued)

5) Of the students who have been assessed indicate in the tables below by age group the number who were referred to each category. Include all that apply in the count. Use PRIMARY

Co-occurring referral category only.

Intervention Treatment Age Group School Based Group Community Based Group Other Support Services D & A Outpatient D & A Intensive Outpatient D & A Partial Hosp. D & A non-Hospital Rehab D & A

Inpatient Other None

9 or younger 10 – 13 14 – 17 18 or older Intervention Treatment Age Group School Based Group Community Based Group Other Support Services Psychiatric Outpatient Psychiatric Partial Hospital FBMHS or BHRS Psychiatric Residential Psychiatric

Inpatient Other None

9 or younger 10 – 13 14 – 17 18 or older

(6)

Version 1.3 March 24, 2016

Quarterly Form (SAP Online), Page 6

Referral Outcomes

6) Total number of students who were admitted to at least one of the Intervention or Treatment options ______

7) Total number of students who were not admitted to at least one of the Intervention or Treatment options ______

Enter the number of students who were not admitted to at least one of the intervention or treatment options by category.

8a) Lack of Funds ______ 8b) Services unavailable ______ 8c) Referral refused by student ______ 8d) Referral refused by parent ______ 8e) Referral refused by D&A provider ______ 8f) Referral refused by M/H provider ______

8g) Admission scheduled for the following quarter ______ 8h) Client waiting list ______

8i) Unknown outcome ______ 8j) Other ______

9) Enter the total number of core team consultations that the liaisons participated in the reporting quarter ______

10) Enter the total number of parent teacher consultations that the liaisons participated in the reporting quarter ______

References

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