Date of CAT ASSESSMENT (MM/DD/YYYY): _____ / _____ / ______

For each section, refer to CAT Scoring Manual for detailed Scoring Instructions

1. CHILD RISK BEHAVIORS
0 = No evidence of any needs
1 = History, watch/prevent, mild
2 = Moderate, recent, act
3 = Severe, acute, act immediately
0 / 1 / 2 / 3
Suicide Risk
Self Mutilation
Other Self Harm
Danger to Others
Sexual Aggression
Runaway
Judgment
Fire Setting
Social Behavior
Bullying
2. CHILD BEHAVIORAL/ EMOTIONAL SYMPTOMS
0 = No evidence of problems
1 = History mild, watch/prevent
2 = Causing problems, consistentwith diagnosable disorder
3 = Causing severe/dangerous problems
0 / 1 / 2 / 3
Psychosis
Impulse Control
Depression
Anxiety
Oppositional
Conduct
Adjustment to Trauma
Anger Control
Substance Use
3. LIFE DOMAIN FUNCTIONING
0 = No evidence of problems
1 = History, mild
2 = Moderate
3 = Severe
0 / 1 / 2 / 3
Living Situation
Community
School
Peer Functioning
Developmental
Sleep
Medication Compliance
/ 4. JUVENILE JUSTICE
0 = No evidence of problems
1 = History, watch/prevent
2 = Moderate
3 = Severe
0 / 1 / 2 / 3
Juvenile Justice Status
Community Safety
Delinquency
5. CHILD PROTECTION
0 = No evidence of problems
1 = History, mild
2 = Moderate
3 = Severe
0 / 1 / 2 / 3
Abuse or Neglect
Domestic Violence
6. CAREGIVER STRENGTHS & NEEDS
Not applicable – no caregiver identified
0 = No evidence of needs, is a strength
1 = Minimal needs
2 = Moderate needs
3 = Severe needs
0 / 1 / 2 / 3
Health
Supervision
Involvement with Care
Social Resources
Residential Stability
Access to Child Care
Family Stress
IDENTIFICATION(age, gender, living situation, legal status, ethnicity, preferred language, diagnosis if known and document if using an interpreter or speaking to child in another language)
Presenting Problem (circumstances of presentation)
HISTORY (describe details of past mental health treatment of youth and their family members, suicidal ideation, and/or dates, methods, severity of past attempts, outcomes of past attempts, past psychiatric medication use, therapy, hospitalizations, out-of-home placements, past medical issues, developmental hx issues)
A. Per Client:
B. Per Collateral Info:
CURRENTMEDICATIONS(names, doses, last use, herbs and non-Rx meds. Include source of info e.g. client, family, etc.
CURRENTHealth Issues (include allergies/drug reactions)
VIOLENCE HX (Include if victim of violence; violence toward others/property; arrests; access to weapons)
SUBSTANCE ABUSE(Include type, first/last use, route of administration, longest/latest sobriety, hx of alcohol, tobacco, caffeine, illicit, prescribed & over the counter drugs)
Brief Mental Status Evaluation:
ORIENTATION: / Person / Place / Time / Circumstances / Purpose
LEVEL OF CONSCIOUSNESS: / Alert / Hyper vigilant / Lethargic / Clouded / Comment:
ABILITY TO ATTEND/FOLLOW: / Clear / Preoccupied / Auditory hallucinations / Visual hallucinations
Lucid / Confused / Disorganized / Delirious / Comment:
INTELLECT: / Above average / Average / Below average / Comment:
MEMORY: / Immediate: / Good / Fair / Poor
Recent: / Good / Fair / Poor
Remote: / Good / Fair / Poor
THOUGHT PROCESSES: / Coherent / Rambling / Circumstantial / Tangential / Loose / Incoherent / Idiosyncratic
THOUGHT CONTENT: / Normal / Obsessive / Delusional / Paranoid / Grandiose
Bizarre / Impoverished / Ideas of reference / Blocking
JUDGEMENT: / Good / Fair / Poor / Grossly impaired
INSIGHT: / Good / Fair / Poor / Denial / Nil
SPEECH: / Normal / Slow / Rapid / Pressured / Loud / Soft / Articulate / Slurred
MOOD: / Appropriate / Euphoric / Expansive / Euthymic / Dysphoric / Angry / Fearful
AFFECT: / Appropriate / Incongruent / Broad / Elevated / Labile / Hypomanic / Anxious
Restricted / Blunt / Flat / Irritable / Depressed / Hostile
COMMENTS:
CLINICAL IMPRESSIONS(incl. rational for dx, if applicable):
Signature and License Type of Staff:______
Print Staff Name:______Date:______
COUNTY OF SONOMA DEPARTMENT OF HEALTH SERVICES
BEHAVIORAL HEALTH DIVISION
CRISIS ASSESSMENT TOOL (CAT) of the
CHILD AND ADOLESCENT NEEDS AND STRENGTHS (CANS) / Client Name: ______
Client Number: ______

MHS 821 (01-12)CONFIDENTIAL INFORMATION –See California Welfare & Institutions Code, Section 5328Page 1 of 3