Date
Status
Initials
FIRST 5 Santa Clara County Prioritization Worksheet (Internal Use Only)
Child’s Full Birth Name
Child’s Primary Language
Child’s Date of Birth
Child’s Current Age
mm / dd
/ yyyy
_____ Years _____ Months
Primary Caregiver Language
Primary Caregiver Name
1: REFERRAL SOURCE
PRIORITY REFERRAL SOURCES OTHER REFERRAL SOURCES
High Priority
Yes
No
PoP Differential Response Family Court Family Wellness Court
High Risk Infant Clinic Head Start (non-PoP) Pediatricians Referrals Monitoring Early Childhood Autism (MECA) Other: _____________________________
2: CHILD ASQ
Risk Level: Version: Date of administration:
High Priority Low Moderate Months / Low / Moderate Months / / High High
Yes
No
ASQ/SE
Risk Level: Version: Date of administration:
Child Concerns and Risk Factors Physical Health/Development Oral Health Nutrition/Obesity Lack of health insurance No medical provider Known Developmental Delays/Disabilities Late pre-natal care Low birth weight Positive Tox Infant Blood lead levels Speech/Language Development Social/Emotional Development Behavioral Problems Violent Behavior Exposure to trauma In Poverty Other:___________________________
Prioritization Worksheet v7.doc 02.05.08
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FIRST 5 Santa Clara County Prioritization Worksheet (Internal Use Only)
3: FAMILY / ENVIRONMENT (check all that apply) Strengths Stable employment during last 12 months Adequate income last 12 months Stable housing last 12 months Caregiver provides basic needs and care Able to protect child from further harm Adequate parenting skills Concerns and Risk Factors Domestic Violence Parental Conflict Incarcerated Parent Criminal History Gang exposure Substance Abuse Prior CPS Referrals (inc. siblings) Prior Child Welfare case (inc. siblings) Teenage Mother Single Parent Low maternal education Grandparents as primary caregiver Young family caregiver Multiple young children in home Parenting skills/practices that do not foster healthy development 4: COMMENTS
High Priority
Yes
No
Positive relationship with extended family Currently receiving services (school, social service) Knowledge and use of community resources Supportive network of friends and neighbors Community Participation (i.e. faith, cultural or interest) Other: _______________________________ Caregiver Physical health Caregiver Chronic illness Caregiver Mental Health (inc. maternal depression) Disabled caregiver (Mental/ Physical) Basic Needs (Food, adequate shelter, clothing) Lack of quality daycare High level of family stress Lack of support network Inability to access essential services/resources Other:__________________________
Prioritization Worksheet v7.doc 02.05.08
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