Student Assistance Program

Student Assistance/Project SUCCESS Program Assessment Form Name Grade Referred by: Reason for Referral:

D.O.B. Height Weight I. Physical Functioning: Hospitalizations, Accidents, Illness, Eating and Sleeping Habits

II.. School Functioning: (Use Cirle of Friends form) Grades, Extra Curricular Activities, Behavior, Attitude, Parents reaction to behavior, attitudes and grades Elementary: Middle School: High School: III. Peer Relationships: Quality, Duration, Numbers, Relationships that have ended, Parents & Students attitudes toward friends, what is preventing “wished” for relationships, friends leisure activities, friends AOD use.(use Circle of Friends form, Resource manual, Handout section, page 29)

IV. Family Functioning: (Use current and past living situations form, Resource manual, Handout section, page 30) Who does the student live with, Siblings, Parents, Relatives, Group Home(include ages) and What is the quality of the relationships?

Who did the student live with in the past?

Where are student’s biological parents & siblings if he/she does not live with them? And what is the quality of relationships with them?

How has the economy affected your family?

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Parent, Parenting Figures, Siblings use of AOD (Ask CASPAR four questions) Yes No 1. Do you ever worry about mom’s or dad’s drinking, use of medication or use of drugs?

2. Do you wish your mom or dad drank less or used less medication or used fewer drugs?

3. Do you wish your mom or dad didn’t drink at all, didn’t use medication, or didn’t use any drugs?

4. What makes you worry or wish……?

V. AOD History/Current Situation: (Suggested order of questioning – alcohol, marijuana, tobacco, prescription medications such as tranquilizers, barbiturates, sleeping pills, pain killers and other narcotics, stimulants, over the counter and herbal products, hallucinogens, Ecstacy, cocaine, heroin, inhalents, caffeine, energy drinks and anything else to feel better) 1. First drink (Where were you, who were you with, how did it taste, did your parent’s know? Effect and reaction from others and student’s attitude)

2. First time intoxicated, current amount, frequency, resulting behavior, reaction of others (parents, friends, school)

3. Assess tolerance, blackouts, withdrawal, loss of control, negative consequences, attempts to cut down.

4. Drug of choice/combinations: ______

D:\Docs\2018-04-27\02b2c64209ab7d5c07590dcd3e192d69.doc R 8/2012 from PS Manual 2 The CRAFFT Screening Questions Please answer all questions honestly; your answers will be kept confidential.

School:______Date:______

PIC # (OASAS only): ______Part A During the PAST 12 MONTHS, did you: No Yes

If you If you 1. Drink any alcohol (more than a few sips)?  answered  answered NO to ALL yes to (A1, A2, A3 ) ANY 2. Smoke any marijuana or hashish?  answer  (A1, to A3 ) only B1 answer below, then B1 to B6 STOP. Below. 3. Use anything else to get high?  

“anything else´includes illegal drugs, over the counter and prescription drugs, and things that you sniff or “huff”

Part B

No Yes

1. Have you ever ridden in a CAR driven by   someone (including yourself) who was “high” or had been using alcohol or drugs?

2. Do you ever use alcohol or drugs to RELAX,   feel better about yourself, or fit in?

3. Do you ever use alcohol or drugs while you   are by yourself, or ALONE?

4. Do you ever FORGET things you did while   using alcohol or drugs?

5. Do your FAMILY or FRIENDS ever tell you   tht you should cut down on your drinking or drug use?

6. Have you ever gotten into TROUBLE while   you were using alcohol or drugs?

CONFIDENTIALITY NOTICE: The information on this page may be protected by special federal confidentiality rules (42 CFR Part 2), which prohibit disclosure of this information unless authorized by specific written consent. A general authorization for release of medical information is NOT sufficient. © Children’s Hospital Boston, 2009. Reproduced with permission from the Center for Adolescent Substance Abuse Research, CeASAR, Children’s Hospital Boston. CRAFFT Reproduction produced with support from the massachusetts Behavioral Health Partnership. D:\Docs\2018-04-27\02b2c64209ab7d5c07590dcd3e192d69.doc R 8/2012 from PS Manual 3 SCORING INSTRUCTIONS: FOR CLINIC STAFF USE ONLY

CRAFFT Scoring: Each “yes” response in Part B scores 1 point. A total score of 2 or higher is a postive screen, indicating a need for additional assessment

Probability of Substance Abuse/Dependence Diagnosis Based on CRAFFT Score1,2

DSM-IV Diagnostic Criteria3 (Abbreviated) Substance Abuse (1 or more of the following): . Use causes failure to fulfill obligations at work, school, or home . Recurrent use in hazardous situations (e.g. driving) . Recurrent legal problems . Continued use despite recurrent problems Substance Dependence (3 or more of the following): . Tolerance . Withdrawal . Substance taken in larer amount or over longer period of time than planned . Unsuccessful efforts to cut down or quit . Great deal of time spent to obtain substance or recover from effect . Important activities given up because of substance . Continued use despite harmful consequences

© Children’s Hospital Boxton, 2009. This form may be reproduced in its exact form for use in clinical settings, courtesy of the Center for Adolescent Substance Abuse Research, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02115, U.S.A., (617) 355-5433, www.ceasar.org.

References: 1. Knight JR, Shrier LA, Bravender TD, Farrell M, Vander Bilt J, Shaffer HJ. A new brief screen for adolescent substance abuse. Arch Pediatr Adolesc Med 1999;153(6):591-6. 2. Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med 2002;156(6):607-14. 3. American Psychiatric Association. Diagostic and Statistical Manual of Menal Disorders, fourth edition, text revision. Washington DC, American Psychiatric Association, 2000.

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VI. Additional Information: Assess the following:

1. What maeks student angry, nervous, sad and how do they cope?

2. History of violence and fights?

3. Hallucinations

4. Suicide attempts (including family history of attempts)

VII. Financial (indebtedness, bets, earnings, need to bet more money, lying about amount of money gambled):

VIII. Sexual Activity – Have you ever been or are you currently sexually active? (screen for history ofabuse and STIs):

IX. Past or Current Involvement in Counseling Services (in school and/or outside of school):

D:\Docs\2018-04-27\02b2c64209ab7d5c07590dcd3e192d69.doc R 8/2012 from PS Manual 5