COMMUNITY UNIT SCHOOL DISTRICT 300 2550 HARNISH DRIVE ALGONQUIN, IL 60102 PHONE: 847.551.8300 Fax: 847.551.8314 FREEDOM OF INFORMATION February 1, 2017 Ms. Paulina Loza Re: FOIA Request Received January 31, our Record #980 Subject: A copy of the administration instruction to staff Level of care assessment procedures Dear Ms. Loza: I am responding to your January 31, 2017 request(s) under the Freedom of Information Act (5 ILCS 140/1 et seq.), in which you asked for the above referenced information. Enclosed is a copy of D300 s Level of Care Referral Process. Per your request, I will email this response to you. This responsive document will be posted online at the District s website by end of day on February 3, which is two business days from today. To access it, go to www.d300.org, then click Our District > Freedom of Information Act > View the FOIA Archive. Please let me know if you have additional questions. Thank you. Everlean Dodson Everlean Dodson Archives Manager
Level of Care Referral Process Teacher or staff member becomes aware of potential problem or behavior (Self-Injurious, Suicidal Ideation, Homicidal Behavior, Serious Risk of Health, Safety, Welfare of Self or Others) Individual will contact Social Worker, Counselor, or Psychologist and Building Administrator Assess Student Risk No Immediate Threat Mild to No Risk Immediate Threat Moderate to High Risk Imminent Threat Life-Threatening Call Parent as team deems appropriate Contact parent or Emergency Contact Person Call 911 Can recommend Level of Care Assessment SASS Referral Level of Care referral and complete school referral form and obtain release of information Contact Parent or Emergency Contact to inform them of situation Complete school referral form and obtain release Building principal is notified Building principal is notified of information and must complete the and must complete the Person Determined to Pose Person Determined to Pose a Clear and Present danger a Clear and Present danger Form within 24 hours of the Form within 24 hours of the referral and turn into the referral and turn into the District Safety Officer District Safety Officer Communicate outcomes with team and individual who Repeated made initial referrals referral to social worker, counselor, or psychologist should seriously be considered for a Level of Care Assessment. Remember to consider Child Find responsibilities.
Level of Care Assessment What is it? It is a formal referral to a mental health professional to determine if a student is a danger to himself or others. The team approach is the best way to handle it. 1) Principal, Assistant Principal, Psychologist, Social Worker, Nurse, Guidance Counselor, Teacher and Education Specialist as appropriate. 2) Anyone who has pertinent information to the situation that can assist. 3) Once the Level of Care Recommendation has been given, the staff member must communicate to the Principal or a building administrator by the end of the current school day. When do I refer a student? When a teacher or staff member becomes aware of a potential problem or behavior that may include: When a student is a danger to others in a building i.e. bringing a knife to school, threatening drawings, writings or statements, acts of violent physical aggression. Or When a student is harmful to self i.e. This may include threatening suicide, self-injurious behavior such as burning, cutting etc., highly agitated, at risk behaviors, severely depressed. Who do I refer to? Psychologist, Social Worker, or Guidance Counselor and Principal Who contacts the parent? Team decision- Most likely the administration for discipline related matters, or for social/emotional matters, the social worker, guidance counselor or psychologist. Stress that ONLY the assessment is free by some providers and that any type of treatment, therapy or services are the parents responsibility.
Level of Care Assessment Where can we refer the student for a level of care assessment? Alexian Brothers Behavioral Health Hospital- Hoffman Estates free Aunt Martha s Carpentersville Community Health Center Centegra health System Woodstock Kane County Community Crisis Center free Linden Oaks Behavioral Health McHenry County Crisis comes to building free Presence Saint Joseph Hospital - Elgin SASS- Cares Services (All kids or uninsured) Streamwood Behavioral Health Center- free Other facilitates as information becomes available. Family s Psychiatrist or Family Mental Health Provider- at parent s expense Proper forms must be filled out. (attach) o Have parent sign District Release of Information o Complete appropriate School Referral Form o Referral forms and evaluation results are to be kept in the nurse s file o The building principal must complete the Person Determined to Pose a Clear and Present Danger Form and give it to the District Safety Officer within 24 hours of the assessment being recommended. The person who contacts the parent (psychologist, social worker, or principal) will update the team on the outcome. Revised: March 2016
Screening Assessment and Support Services SASS What is SASS? SASS is a multi-department (DMH, HFS, DCFS) crisis intervention program for children and adolescents, who are experiencing a psychiatric emergency, which may result in a psychiatric hospitalization or intensive community based services. What is the Referral Process? Crisis and Referral Entry Service (CARES): The single point of entry to the Screening Assessment and Support Services Program that handles calls for children and youth in Illinois. CARES is a 24 hours a day, seven days a week hotline 1-800-345-9049,TTY 1-866-794-0374 CARES should be called when a child is a risk to himself or others and at any time you or others think a child is having a mental health crisis. CARES purpose is to ask questions of the child s parents, caregivers, or other callers about the child s behavior. CARES will then either send the local area SASS agency to see the child and guardian, or refer the child the guardian to community mental health or other services. Who Can Receive SASS Services? Any child or youth in a mental health crisis who qualifies or may qualify for public funding. Ex: Medicaid, DCFS wards or Illinois All Kids If the Child is Eligible for SASS services: SASS will work with the guardian and child for at least 90 days. If the child is hospitalized SASS will join the hospital team to care for the child. SASS will help the hospital team plan for the child s return home and will provide services when the child is home. If the child is not hospitalized, SASS will provide mental health services and supports to help the child stay at home. How Will Families Be Involved in Their Child s Care? To assure that services in the State of Illinois are both family-driven and youth-guided, families are the primary decision makers for their child s treatment. SASS will work closely with families to learn about the child s strengths and needs. Families/parents/guardians collaborate in the child s treatment.
SASS will provide and/or link the child and family to services, resources and supports to address the immediate crisis and begin to assist with building resilience. Parents will be offered the services of a Family Resource Developer (FRD). A FRD is a parent or guardian who has previously navigated the mental health system successfully for a child who has been diagnosed with a Serious Emotional Disturbance (SED).
Level of Care Referral Agency Contacts Information Alexian Brothers Behavioral Health Hospital 1650 Moon Lake Boulevard Hoffman Estates, IL 60169 Phone: 800-432-5005 Phone: 847-882-1600 For intake information or to speak with a counselor anytime, one call is all it takes. Available 24 hours a day, 7 days a week. 1-800-432-5005 Aunt Martha s Carpentersville Community Health Center 3003 Wakefield Drive Carpentersville, Illinois 60110 Phone: 847-851-8600 Call or visit for comprehensive diagnostic evaluation and assessment. Centegra Health System 527 W. South Street Woodstock, IL 60098 Phone: (800) 765-9999 Centegra Behavioral Health Services is located at Centegra Specialty Hospital-Woodstock. For urgent assessments, to schedule an appointment with a qualified mental health professional, or to schedule a FREE chemical dependency screening, call (800) 765-9999 Kane County Community Crisis Center Available 24 Hours a Day
Crisis Line 847-697-2380 Business Line 847-742-4088 En Espanol 847-697-9740 Domestic Violence- Sexual Assault- Economic Crisis- Shelter Linden Oaks Behavioral Health 852 South West Street Naperville, IL 60540 Phone: 630-305-5027 www.eehealth.org McHenry County Crisis Provides assessments like SASS but for privately insured individuals 1-800-892-8900. Presence Saint Joseph Hospital, Elgin 77 North Airlite Street Elgin, IL 60123 Phone: 847-695-3200 Behavioral Health Intake/Referral Line - A 24 hour intake and information line for mental health services both through the hospital and in the community for adults and adolescents call 847-931-5521. In crisis situations, if unable to speak directly to a clinician, call 800.784.2433 SASS 1-800-345-9049 Screening, Assessment and Support Services (SASS) program for children and adolescents experiencing a mental health crisis. If you are in need of SASS Services or experiencing a mental health crisis, please contact the CARES line at 1-800-345-9049. If CARES determines that a client meets criteria, a crisis worker will be sent out to your location to perform an assessment on the client in crisis to determine the level of care needed. Streamwood Behavioral Healthcare System 1400 East Irving Park Road Streamwood, IL 60107 Phone: 630-837-9000
Clinical assessment and referral staff are available 24 hours a day, 7 days a week. Call (630) 837-9000 or (800) 272-7790 and ask for the Assessment and Referral Department. The Department of Health and Human Services provides a free 5-step Risk Assessment resource to the mental health community. Information available at the following: http://store.samhsa.gov/product/suicide-assessment-five-step-evaluation-and-triage-safe-t-pocket-cardfor-clinicians/sma09-4432
RISK OR THREAT ASSESSMENT GUIDE Warning Signs: A sign or indicator that causes concern for safety A. Imminent Warning Sign: A sign which indicates that an individual is very close to behaving in a way that is potentially dangerous to self or others. Imminent Warning Signs call for immediate action by school authorities and law enforcement. Imminent Warning Signs can include the following: Possession and/or use of firearm or other weapon Suicide threats or statements Detailed threats of lethal violence (time, place, method) Severe rage for seemingly minor reasons Severe destruction of property Serious physical fighting with peers, family, others. B. Early Warning Signs: Certain behavioral and emotional signs that when viewed in a context, may signal a troubled individual. Early Warning Signs call for a parent notification and possible Level of Care Referral. Early Warning Signs can include the following: Social withdrawal or lacking interpersonal skills Excessive feelings of isolation and being alone Excessive feelings of rejection Being a victim of violence, teasing or bullying Feelings of being picked on Expressions of violence in writings and drawings Uncontrolled anger History of discipline problems Drug and alcohol use Affiliation with gangs Talking about weapons or bombs General statements of distorted, bizarre thoughts Depression Marked change in appearance
Level of Care - Risk For Harm Categories 1. Imminent Risk for Harm: An individual is, or is very close to, behaving in a way that is potentially dangerous to self or others. Examples include: detailed threats of lethal violence, suicide threats, possession and/or use of firearms or other weapons, serious physical fighting, etc. Most of these individuals will need immediate hospitalization or arrest. 2. Moderate High Risk for Harm: An individual has displayed significant Early Warning Signs, has significant existing Risk Factors and/or Precipitating Events. There may be evidence of emotional distress (depression, social withdrawal, etc.) or of intentional infliction on others (bullying, intimidation, seeking to cause fear, etc). Most of these individuals will need to be referred for a Level of Care Assessment. 3. Mild-Low Risk for Harm: An individual has displayed Early Warning Signs, reveals little history of serious Risk Factors or dangerous behavior. There may be evidence of the unintentional infliction of distress on others (insensitive remarks, teasing taken too far). There may be evidence of poor decision making, false accusations. Most of these individuals will need to have their parent/guardian contacted and possibly recommend a Level of Care Assessment.
School Referral Form Date: Referring Person/Title: Student Name: DOB: School: Home Address: Phone: Parent/Guardian: Emergency Assessment or Scheduled Appointment (Please Circle) Release Signed: Yes or No (Please Circle) If no, Verbal permission: Yes or No (Please Circle) Reason for Referral: Significant statements, information or background which may assist in the assessment: Do you wish information on the disposition? (If release are signed by parent/guardian and/or student?) Yes or No If Yes: Via Phone In Writing or Both (Please circle) Doctor Use Only Assessment Completed By: Date: Feedback to Referral By: Date: Revised: March 2016
Community Unit School District 300 2550 Harnish Drive Algonquin, IL 60102 P - 847.551.8300 F 847-551-8433 Authorization for Use and Disclosure of Protected Health Information and Education Records Patient/Student Name: Date of Birth: I hereby authorize: To disclose protected health information and/or educational records to (include first and last name): For the purpose of: The receiving/sending agency or person shall agree to comply with the provisions of the Family Educational Rights and Privacy Act as it relates to the indicated records. I have been advised as to my rights to inspect copy and challenge the contents of the records that are to be released and to limit consent to designated records or designated portions of information within the records. I further realize that I can revoke authorization for release at any time. This release is valid for one year from date signed. Pertinent information within the initialed areas is sought: Students Temporary Records Outside Agency Records Psycho-educational Records Special Education Files Anecdotal Records Disciplinary Record Social History Other Intake/Discharge Summaries Medical Records Diagnostic Information Developmental Records Psychological/Psychiatric Other Parent/Guardian Signature Date Witness Signature (Required to release Mental Health Records) Date Student Signature (Required if student is 12 years or older) Date 03/2016 Revised
Community Unit School District 300 2550 Harnish Drive Algonquin, IL 60102 P - 847.551.8300 F 847-551-8433 Autorización para el Uso y Divulgación de Información de Salud y Expedientes Educativos Protegidos Nombre del Paciente/Estudiante: Fecha de Nacimiento: Por la Presente Autorizo a: Para revelar información médica confidencial y / o expedientes educativos a (incluir nombre y apellido): Para el propósito de: La agencia o persona recibiendo/enviando deberá aceptar cumplir con la disposiciones de los Derechos Educativos de la Familia y Ley de Privacidad tal como refiere expedientes indicados. Se me ha informado de mis derechos a inspeccionar la copia y cuestionar el contenido de los documentos que se darán a conocer y limitar mi aprobación a los archivos designados o ciertas partes de información dentro de los expedientes. También se que puedo revocar la autorización de divulgación de información en cualquier momento. Este documento es válido por un año a partir de la fecha que se firmo. Pertinent information within the initialed areas is sought: Expedientes Temporales Estudiantiles Expedientes de Agencia Exteriores Expediente Psico-Educativos Archivos de Educación Especial Expediente Anecdótico Expediente Disciplinario Historial Social Otro Firma del Padre/Tutor Resumen de Admisión / Alta Expediente Medico Información de Diagnósticos Expedientes de Desarrollo Psicológica / Psiquiátrica Otro Fecha Firma del Testigo (Necesaria para divulgar expediente de salud mental) Firma del Estudiante (Necesaria si el estudiante tiene más de 12 años) Fecha Fecha