Wellness Assessment – Youth – Family Connections

We respect your privacy. Your answers are confidential and will not be given to your employer or any clinician who has not provided care to you.

We will review your answers to see if we can offer you additional resources or support. We may also review your answers with your clinician if doing so could help you.

We encourage you to complete this form and discuss with your clinician.

If you have questions about this form, please call the number on the back of your enrollee card.

INSTRUCTIONS FOR COMPLETING THE WELLNESS ASSESSMENT

This form is for clients younger than 18
Select one answer per question.

Directions for parents/guardians completing a form for a child under age 18:

Please complete the "Wellness Assessment - Youth" form for your child.
Answer each question as best you can based on your personal observation and knowledge of your child.

Directions for Clinicians:

Please review the completed assessment with your client.
Check to be sure that all member and clinician identifying information
at the top of the form is complete and accurate.
Clinician ID refers to your tax id.
In the event that a member is unable to complete this form, please complete both the patient and clinician information and fill in the "MRef" option next to "Clinician ID".
Submit this form This form is a secure, confidential assessment.

Completing this brief questionnaire will help us provide services that meet your child's needs. Answer each question as best you can and then review your responses with your child's clinician.

Child's Name *

First

Last

Child's Date of Birth

Subscriber ID

Authorization #

Clinician Name *

First

Last

Today's Date

Clinician ID/ Tax ID

Clinician Phone Number

MRef

MRef

State

Visit Number

1 or 2
3 to 5
Other

Relationship to child

For questions 1-21, please think about your experience in the past week.

Please select an answer that best describes your child

1. Destroyed property

Never
Sometimes
Often

2. Was unhappy or sad

Never
Sometimes
Often

3. Behavior caused school problems

Never
Sometimes
Often

4. Had temper outbursts

Never
Sometimes
Often

5. Worrying prevented him/her from doing things

Never
Sometimes
Often

6. Felt worthless or inferior

Never
Sometimes
Often

7. Had trouble sleeping

Never
Sometimes
Often

8. Changed moods quickly

Never
Sometimes
Often

9. Used alcohol

Never
Sometimes
Often

10. Was restless, trouble staying seated

Never
Sometimes
Often

11. Engaged in repetitious behavior

Never
Sometimes
Often

12. Used drugs

Never
Sometimes
Often

13. Worried about most everything

Never
Sometimes
Often

14. Needed constant attention

Never
Sometimes
Often

How much have your child's problems caused:

15. Interruption of personal time?

Not at All
A little
Somewhat
A Lot

16. Disruption of family routines?

Not at All
A little
Somewhat
A Lot

17. Any family member to suffer mental or physical problems?

Not at All
A little
Somewhat
A Lot

18. Less attention paid to any family member?

Not at All
A little
Somewhat
A Lot

19. Disruption or upset of relationships within the family?

Not at All
A little
Somewhat
A Lot

20. Disruption or upset of your family's social activities?

Not at All
A little
Somewhat
A Lot

21. How many days in the past week was your child's usual routine interrupted by their problems?

Answer the following only if this is your first time completing this questionnaire for this child.

22. In general, would you say your child's health is

23. In the past 6 months, how many times did your child visit a medical doctor?

24. In the past month, how many days were you unable to work because of your child's problems? (answer only if employed)

25. In the past month, how many days were you able to work but had to cut back on how much you got done because of your child's problems? (answer only if employed)