Student Identifica Student Identification and Referral Form

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Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0286. Public reporting burden for this collection of information is estimated to average .5 hours per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

Student Identification and Referral Form

Question Numbers	Questions	Response Options
SECTION 1 – Demographics
1.1	Student/Youth ID (Assigned by site, matches NOMS ID where applicable)	[Numeric Response]
1.2	Student/Youth Age (in years)	[Numeric Response]
1.3	Student/Youth Grade level	[Numeric Response]
1.4	Which of the following best represents how the youth currently describes their gender identity?	Woman Man Transgender Youth uses a different term (please specify): Information missing Prefer not to respond
1.5	What sex was the youth assigned at birth, on their original birth certificate?	Female Male
1.6	Which of the following does the youth consider themselves to be?	Straight, that is not gay or lesbian Gay or lesbian Bisexual Youth uses a different term (please specify): Information missing Prefer not to respond
1.7	Which of the following best represents how the youth identifies their race and/or ethnicity? Select all that apply and enter additional details in the spaces below.	American Indian or Alaska Native Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc. Asian - Provide details below. Chinese Asian Indian Filipino Vietnamese Korean Japanese Enter, for example, Pakistani, Hmong, Afghan, etc. Black or African American - Provide details below. African American Jamaican Haitian Nigerian Ethiopian Somali Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc. Hispanic or Latino - Provide details below. Mexican Puerto Rican Salvadoran Cuban Dominican Guatemalan Enter, for example, Colombian, Honduran, Spaniard, etc. Middle Eastern or North African - Provide details below. Lebanese Iranian Egyptian Syrian Iraqi Israeli Enter, for example, Moroccan, Yemeni, Kurdish, etc. Native Hawaiian or Pacific Islander - Provide details below. Native Hawaiian Samoan Chamorro Tongan Fijian Marshallese Enter, for example, Chuukese, Palauan, Tahitian, etc. White - Provide details below. English German Irish Italian Polish Scottish Enter, for example, French, Swedish, Norwegian, etc. Prefer not to respond
1.8	Which of the following has the youth had in place or experienced in the past 3 months? Select all that apply.	Individualized Education Plan (IEP) 504 Plan Economic disadvantage/low-income meal status (i.e., free or reduced-price lunch eligible) Justice involvement (self) Justice involvement (caregiver or parent) Homelessness Foster care Chronic absenteeism (i.e., missed 10 or more days) In-school suspension Out-of-school suspension Failed (or failing) a core subject course (i.e., Math, English/Language Arts, Social Sciences, Science)
SECTION 2: Identification Information
2.1	Date of identification	MM/DD/YYYY
2.2	Did this identification occur virtually or in person?	Virtually In person
2.3	ZIP code where the youth was identified	[Numeric Response]
2.4	How was this youth first identified as being at risk for trauma, mental health, or substance use concerns?	Individual or gatekeeper Screening [SKIP to 2.5] Other, please specify: I don’t know
2.4a	At the time of identification, was the youth screened for trauma, mental health, or substance use risk using a screening tool?	Yes No [SKIP to 2.9] I don’t know [SKIP to 2.9]
2.5	Why was the youth screened for trauma, mental health, or substance use concerns?	Individual or gatekeeper referred youth for screening Youth self-referred for screening Youth participated in routine or scheduled screening Other, please specify: I don’t know
2.6	Was this youth identified through a group screening event or individual screenings (i.e., were multiple youths screened at one time as part of a screening event, or was the screening administered to one individual at a time)? Select one.	Individual [SKIP to 2.7] Group
2.6a	Who was screened? Select one.	All youth in attendance (e.g., all youth coming to a primary care provider’s office) [SKIP TO 2.7] Youth meeting particular criteria [COMPLETE 2.6b] I don’t know [SKIP to 2.7]
2.6b	Please describe the criteria used (e.g., youth with behavioral health history, youth seeking school support services).	[Text Response]
2.7	What screening tool was used? If multiple screening tools were used, please select all that apply.	Patient Health Questionnaire (PHQ-9) Generalized Anxiety Disorder (GAD-7) Columbia Suicide Severity Rating Scale (CSSR-S) Behavioral Health Screen (BHS) Ask Suicide Screening Questions (asQ) Beck Depression Inventory (BDI) Alcohol Use Disorders Identification Test (AUDIT) Drug Abuse Screening Tool (DAST) Brief Screening Instrument for Tobacco, Alcohol, and Drug Use (BSTAD) CAGE Questionnaire CRAFTT Screening Tool Trauma History Questionnaire (THQ) Childhood Trauma Questionnaire (CTQ) Traumatic Events Screening Inventory (TESI-C) Trauma Symptom Checklist (TSC-C or TSC-YC) Locally developed screening tool Other, please specify: I don’t know
2.8	What were the results of the screening?	The youth screened positive for trauma, mental health, or substance use risk The youth self-identified as at risk for trauma, mental health, or substance use concerns during the screening process The youth both self-identified as at risk and screened positive for trauma, mental health, or substance use risk The youth screened negative Other, please specify: I don’t know
2.9	Who first identified the youth as being at risk for trauma, mental health, or substance use concerns? (e.g., Who first noticed that the youth was in need of assessment, or experiencing symptoms?) Select one.	School-based mental health service provider (including college or university providers) (e.g., school counselor, social worker, guidance counselor) Pupil personnel worker Family member/foster family member/caregiver Mental health service provider except school-based providers (e.g., clinician, private counselor) Classroom teacher Substitute teacher Student teacher Teacher’s aide School administrative staff School nurse School support staff Librarian Extracurricular leader (e.g., coach, club sponsor, band director) Community-based organization, recreation, religious or after school program staff Child welfare or social service staff Probation officer or other juvenile justice staff Pediatrician or primary care provider Police officer, security guard, or other law enforcement staff Peer Self (i.e., the youth themselves) Other, please specify: I don’t know
2.9a	Was this the same individual that screened or connected the youth for AWARE- and/or TISS-funded services? (e.g., Who first conducted the screening that identified the youth, or who enrolled the youth in grant-funded services?)	Yes [SKIP TO 2.10] No I don’t know [SKIP TO 2.10]
2.9b	Who first screened or connected the youth for AWARE- or TISS-funded services? (e.g., Who first conducted the screening that identified the youth, or who enrolled the youth in grant-funded services?)	School-based mental health service provider (including college or university providers) (e.g., school counselor, social worker, guidance counselor) People personnel worker Family member/foster family member/caregiver Mental health service provider except school-based providers (e.g., clinician, private counselor) Classroom teacher Substitute teacher Student teacher Teacher’s aide School administrative staff School nurse School support staff Librarian Extracurricular leader (e.g., coach, club sponsor, band director) Community based organization, recreation, religious or after school program staff Child welfare or social service staff Probation officer or other juvenile justice staff Pediatrician or primary care provider Police officer, security guard, or other law enforcement staff Peer Self (i.e., the youth themselves) Other, please specify: I don’t know
2.10	Has the identifying individual received training to help recognize trauma, mental health, or substance use risk in students?	Yes No [SKIP TO SECTION 3] I don’t know [SKIP TO SECTION 3]
2.11	Please select the type of training the identifying individual has received. Select all that apply.	Adverse Childhood Experiences Youth Mental Health First Aid Applied Suicide Prevention Intervention Skills Training (ASIST) QPR (Question, Persuade, Refer) Lifelines SafeTALK SafeZONE Signs of Suicide (SOS) Locally Developed, please specify: Other, please specify: I don’t know
2.12	Please enter the approximate month and year this individual was most recently trained. If the individual has received more than one training, please indicate the date of their most recent training.	MM/YYYY
SECTION 3: Referral Information
3.1	Was the youth determined to be in need of a referral as a result of the identification process described in the previous section?	Yes [SKIP to 3.2] No [ANSWER 3.1a and then END FORM] I don’t know [SKIP to 3.2]
3.1a	Why not?	Youth was already receiving services or supports Youth or parent refused additional services Other, please specify: I don’t know
3.2	Was the youth referred to a service or support as a result of the identification process described in the previous section?	Yes [SKIP to 3.2b] No [ANSWER 3.2a and then END FORM] I don’t know [ANSWER 3.2a and then END FORM]
3.2a	Why not?	Youth was already receiving services or supports Youth or parent refused referral/services Unable to obtain information needed about youth to make a referral Unable to obtain information needed about providers or resources to make a referral Appropriate referral resources not available in area Attempted to make a referral, but provider did not have capacity or youth wait-listed for at least 3 months Other, please specify: I don’t know
3.2b	What was the date of the first referral received as a result of the identification process described in the previous section?	MM/DD/YYYY
3.2c	How many total referrals were made for this youth following identification?	[Numeric Response]
3.3	How were referrals made?	Appointment(s) set up for youth Youth/parent given referral information, but must schedule their own appointment Both Other, please specify: I don’t know
3.4	To which of the following mental health or substance use services was the youth referred as a result of the identification process described in the previous section? Select all that apply.	Public mental health agency or provider (e.g., tribal or state sponsored mental health agency) Private mental health agency or provider Psychiatric hospital/unit Emergency department Substance use treatment center School counselor (e.g., any school-based mental health service provider, including school counselor, school social worker, school psychologist, or other school-based mental health clinician) Mobile crisis unit School-based health clinic Tribal or cultural services (e.g., traditional healing practices, talking circles, sweat lodge) Non-hospital crisis stabilization unit Youth was not referred to mental health or substance use services, but was referred to other supports Other, please specify: I don’t know
3.5	To which of the following other supports was the youth referred as a result of the identification process described in the previous section? Select all that apply.	School or academic organization (e.g., school club, academic counseling, tutoring) Family or extended family (e.g., parent, foster parent, grandparent, aunt, uncle) Community based organization, recreation religious, afterschool program (e.g., Boys & Girls club, faith-based organization, Alcohol/Narcotics Anonymous, job training programs) Physical health provider (e.g., pediatrician, primary care provider) Law enforcement/Juvenile justice agency (e.g., pre-trial services, mental health court, police) Social service agency (e.g., child welfare, supportive housing) Crisis hotline (i.e., 988, local crisis hotline, text message hotline) Other, please specify: I don’t know
SECTION 4: Mental Health and Support Service Information
4.1	In the 3 months following the date of referral, did the youth receive mental health or other support services as a result of the referral?	Yes [SKIP to 4.2] No [ANSWER 4.1a then END FORM] I don’t know [ANSWER 4.1b then END FORM]
4.1a	Why did the youth not receive a mental health or other support service? [END FORM after responding]	No action was taken following the referral (e.g., information sent to referral resource or parent/guardian but an appointment was not made directly) Made an appointment but the youth did not attend the appointment Attempted to make an appointment, but provider did not have capacity or youth was wait-listed for at least 3 months Appropriate referral resources not available in area Parent/caregiver refused service or could not be contacted Other, please specify: I don’t know
4.1b	Why do you not know if the youth received services? [END FORM after responding]	Parent/guardian permission for tracking required but not granted No tracking system in place Tracking system requires an agreement to share data but the agreement is not in place Tracking system prohibits data sharing Other, please specify: I don’t know
4.2	From which of the following mental health or substance use services/support agencies did the youth receive services in the 3 months following the date of the referral? Select all that apply.	[Selected response options carried forward from 3.4 and 3.5, excluding “Other, please specify” and “I don’t know” options. In addition, exclude “Youth was not referred to mental health or substance use services, but was referred to other supports” from 3.4 items] Other, please specify: I don’t know
4.3	In the 3 months following the date of the referral, which of the following services did the youth receive as a result of the referral? Select all that apply.	Mental health assessment (e.g., assessment of psychosocial needs and conditions) Substance use assessment Mental health counseling (e.g., outpatient group or individual counseling) Substance use counseling (e.g., inpatient or outpatient, group or individual) Inpatient or residential psychological services Medication Suicide risk assessment (e.g., initial risk assessment or re-assessment) or safety planning Tribal or cultural services (e.g., traditional healing practices, talking circles, sweat lodge) Case management Crisis stabilization Trauma-specific services Medical care Employment services Family services Legal services Childcare Transportation Education services Housing support Social or recreational activities/supports Peer services Other, please specify: I don’t know [END FORM]
4.4	Were any of these services provided via telehealth or virtual appointments?	Yes No [SKIP to 4.5] I don’t know [SKIP to 4.5]
4.4a	Which of the services were provided via telehealth? Select all that apply.	[Selected response options carried forward from 4.3] Other, please specify: I don’t know
4.5	Were any of these services provided via in-person or hybrid appointments?	Yes No [SKIP to 4.6] I don’t know [SKIP to 4.6]
4.5a	Which of the services were provided via in-person or hybrid appointments? Select all that apply.	[Selected response options carried forward from 4.3] Other, please specify: I don’t know [SKIP to 4.6]
4.5b	What is the ZIP code where the first in-person service occurred after referral in each of the following categories? (Leave blank if ZIP code is not known)	[Selected response options carried forward from 4.5a, with numeric responses] EXAMPLE: ___ Mental Health Assessment EXAMPLE: ___ Substance Use Assessment
4.6	In the 3 months following the date of the referral, approximately how many total appointments did the youth attend in each of the following categories as a result of referral? (Leave blank if the number of appointments is not known)	[Selected response options carried forward from 4.3, with numeric responses] EXAMPLE: ___ Mental Health Assessment EXAMPLE: ___ Substance Use Assessment EXAMPLE: ___ Other, please specify: [If total number of appointments across all categories is 0, END FORM] [ANSWER 4.6a for all categories where the total number of appointments is 1, then END FORM] [ANSWER 4.6a and 4.6b for all categories where the total number of appointments two or greater, then END FORM]
4.6a	What was the date of the first service related to [CATEGORY carried forward from 4.6] received as a result of the referral? (Leave blank if the date is not known)	MM/DD/YYYY
4.6b	What was the date of the second service related to [CATEGORY carried forward from 4.6] received as a result of the referral? (Leave blank if the date is not known)	MM/DD/YYYY

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