WPC XIntkvpy!wI(83@#--W뎲m%Xӯ1 J"z=Mƛյ@,sY# ƾZT|M$<BFT&@Ar7x⨒5l=dEeLM1C(䖄3-ѵՒF ~2&O%n\LQxn`A8NH42 zY)@ N)?2jebg@`^~ edbpԐ B!zO wt:29NOq#.U,N %E 0:K f a ^ w 4   m f a f a f a f) a+ f? aA fU aW Nk k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k Bm D5 B* B A  D-  B HP LaserJet 4100 Series PCL,,,,0&d9 Z6Times New Roman RegularX($USUS.,]TABLE A4 54i(Backup3|xUTABLE CTABLE DTABLE ETABLE FTABLE GTABLE H dYYYY)!dxdx&0 d d  d`_&Draw Object =8C HKKKK)!dxdxLevel 1Level 2Level 3Level 4Level 5 d !USUS.,  _hX*ddd Xdd Xdd X%%,_ dd ,Fdd ,dd +  $XX $  ? XXStateofKansas d DepartmentofSocialandRehabilitation H Services | ChildrenandFamilyPolicy#XX? #UaXX '`  '#XXUa}#UaXX@RR-R #XXUa# UaXXԈ #XXUaP#VxXX@"RYOUTHNEEDSASSESSMENT #XXVx#UaXXԈ '| '#XXUa#VxXX  @z"z"F$#XXVxo#? XXCFS2004 H  @\!\!@$Rev.July2006 |  Page1of1#XX? #VxXX #` 0 #,  (    (  (   #XXVxo#,VxXX*dd_ dd _ Fdd Fdd %%,Jdd ,dd ,dd ,rdd ,,dd ,dd +  $ ,$DATE: Y @  (@Y ( $@ ,  $  0pppp@ 0 [ 1'9pppp 1InitialAssessment' *pppp9 * -#9pppp - ServiceExtension( TherapeuticFC) +!9 +%M    %*Yd dJdd Jdd dd rdd r,dd ,dd %%,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd +     ? Vx LastName:  a   ,Ya  , FirstName: +!a Y + ,Ya  , _M.I ._ 'a Y ' 'Ya  ' DOB: .Y! ) Y . ,YY ) Y , SocialSecurity#: .Y! ) YY . ,YY ) !Y , Medicaid#: .Y! ) "YY .+! ) #  Y +#Vx? 5 ## **d ddd dd dd dd dd dd dd dd dd dd dd Y%%*,ddd ,}dd ,dd ,dd ,dd ,dd +  "= #=  "? Vx Gender: 󀀀Male/Female *  I $ * Race: +! I % +Asian/Indian/_Afr.Am_Ԁ/_Cauc_./Hispanic/Other *  I & * t CurrentPlacement: 2Y! ] ' 2 *  ] (Y * .LevelofCare .Y ] ) . ' ] *Y '#Vx? #tk? Vx LegalStatus: +!e +  +JO_CINC_Ԁ_CINC_/JONon_cust_ * e ,  * ==0Disposition .Ye - .(e .  Y (#Vx? #*d dddd d}dd }dd dd dd dd %%,dd ,@dd ,dd ,dd ,=dd ,dd +  3 .3  ? Vx _CCMA_/_SRS_ԀOffice Y  /  $ 0Y $ County Y  1  $ 2Y $ CaseMgr/SocWorker Y  3 ( 4 Y (#Vx? #*d ddd @dd @dd dd =dd =dd %%,~ dd ,edd ,dd ,dd ,edd ,ddd +  (e4e ( .YYY!5 . NeedsAssessmentTool^2\Vx 5YY&s6YYY 5Behavior ;YY,!!7YY ;0Points ;YY,!!8YY ;1Point ;YY,!!9YY ;2Points ;YY,!!:YY ;3Points ?YYY,!!;YY ?4Points :YYY'!!<YYY :v@  #Vx\^2r#CompleteQuestionsBelowforAllInitialAssessments^2\Vx  ,YY?=YYY ,v]AgeaFirstAdjudication )YYI>YY )9andunder )YYI?YY )16yrsandup )YYI@YY )1415yrs )YYIAYY )13yrs -YYYIBYY -1012yrs )YYICYYY )NumberofAdjudications )YYgDYY ) )YYgEYY )One )YYgFYY )Two )YYgGYY )Three -YYYgHYY -Fourormore ,YYgIYYY ,PreviousOutofHomePlacements ,YY-JYY ,None ,YY-KYY ,One ,YY-LYY ,TwoorMore ,YY-MYY , 0YYY-NYY 0 ,YY-OYYY ,ParentalDrug/AlcoholorMentalHealthIssues ,YYKPYY ,No ,YYKQYY , ,YYKRYY ,Yes ,YYKSYY , 0YYYKTYY 0 4YYY!KUYYY 4 @||#Vx\^2#CompleteQuestionsBelowforAllInitialAssessments.For d_TFC_ԀServicedExtensions, iV @uuanswerONLYforbehavioroccurringduringthisplacement,orsincelastassessment.^2\Vx  /YY e WYYY /6"SettingFires ,YYEXYY ,Never ,YYEYYY ,Once ,YYEZYY ,Severaltimes ,YYE[YY ,Convicted 0YYYE\YY 0Multipleconvictions ,YYE]YYY ,NumberofNewAdjudications(NotforInitial) ,YYc^YY , ,YYc_YY ,One ,YYc`YY ,TwoorMore ,YYcaYY , 0YYYcbYY 0 ,YYccYYY ,Drug/AlcoholUse ,YYdYY ,None ,YYeYY ,Experimental ,YYfYY ,Abuse ,YYgYY ,Pasttreatment 0YYYhYY 0Multipletreatments ,YYiYYY ,ParentalControl/StaffControl ,YYjYY ,Effective ,YYkYY ,Noteffective ,YYlYY ,None ,YYmYY , 0YYYnYY 0 ,YYoYYY ,PhysicallyAggressive/AssaultiveBehavior ,YY pYY ,Never ,YY qYY ,Familyonly ,YY rYY ,Peers ,YY sYY ,Authority 0YYY tYY 0Adjudicatedforassault ,YY uYYY ,SchoolPerformance ,YY3!vYY ,Regularlyattending ,YY3!wYY ,Behaviorproblems ,YY3!xYY ,Severebehaviorproblems ,YY3!yYY ,Truant 0YYY3!zYY 0Expelled ,YY3!{YYY ,PeerRelationships ,YYQ"|YY ,Positive ,YYQ"}YY ,Negative ,YYQ"~YY ,Gangmember ,YYQ"YY , 0YYYQ"YY 0 ,YYQ"YYY ,NumberofRuns ,YYo#!YY ,None ,YYo#!YY ,One ,YYo#!YY ,Twoormore ,YYo#!YY , 0YYYo#!YY 0 ,YYo#!YYY ,Emotional/MentalHealthProblems ,YY$5"YY ,None ,YY$5"YY ,Pastoutpatienttherapy ,YY$5"YY ,Onpsych_meds_ ,YY$5"YY ,Pastpsychhospital 0YYY$5"YY 0Multiplehospitalizations ,YY$5"YYY ,PastReject/EjectfromLevel5,#Vx\^2##,[,VxTherapeuticFC#Vx,,[70#^2\Vx ,YY%S#YY ,No ,YY%S#YY , ,YY%S#YY , ,YY%S#YY ,Once 0YYY%S#YY 0Morethanonce ,YY%S#YYY ,VictimofPhysical/Sexualabuse ,YY&q$YY ,No ,YY&q$YY ,Suspected ,YY&q$YY ,Yes ,YY&q$YY , 0YYY&q$YY 0 ,YY&q$YYY ,SexualOffender ,YY'%YY ,No ,YY'%YY , ,YY'%YY ,Yes ,YY'%YY , -YYYY'%YY -RepeatOffender /YYY'%YYYY / 3@TOTALPOINTS#Vx\^20#&%VxԀ +#Vx%&u4#^2\VxԈ 3YYY )&YYY 3()&  YYY (*d d~ dd ~ edd edd dd edd eddd d%%, dd ,9dd ,dd +  *C(*C(  `#Vx\^24#UaVx dddPlacement/ServicedRecommendation:  *(   *(  ddd_TFC_ԀServiced ExtensionApproval:  *(   05 󀀀0 @ Level4orFosterHome +)@@   +)  04 󀀀NoExtension  +)  614 0 @ Level5orTherapeuticFosterHome ,*@@   ,*  5up 󀀀RequestExtension orConsortiumReScreenforLevel6  ,*  15up 0 @ Level6 -+@@   -+   -+ #VxUa6#`6t_ _.w,   t9SupervisoryApproval:_____________________________________ 70-