ADAPT

BEHAVIO RAL SERVIC ES

CFARS (age 0-17)

Client Name:       Intake Date:       Age:    

Instructions: Complete for all clients age 0-17 at admission, every 6 months & planned discharge

Current Evaluation Date:     

Purpose of Evaluation:
1=Admission 2=Every 6 months 3=Planned discharge (within 3 weeks after last session)

Revised 10/18
 No Minor Needs Hospitalizatio Children’s Functional Assessment Rating Scale (CFARS)
prob problem outpatient n may be
treatment (for clients age 0-17)
needed
1 2 3 4 5 6 7 8 9 Clinical Domains
Depression: Depressed Mood, Sleep Problems, Sad, Hopeless, Withdrawn, Irritable, Lacks
Energy/Interest, Anti-Depression Meds
Anxiety: Anxious/Tense, Guilt, Phobic, Worried/Fearful, Anti-Anxiety Meds,
Obsessive/Compulsive, Panic
Hyperactivity: Manic, Inattentive, Agitated, Sleep Deficit, Overactive, Impulsivity, Mood Swings,
Pressured Speech, Anti-Manic Meds, ADHD Meds
Thought Process: Illogical, Delusional, Hallucinations, Paranoid, Ruminative, Derailed Thinking,
Loose Association, Anti-Psychotic Meds, Disoriented
Cognitive Performance: Poor Memory, Low Self-Awareness, Slow Processing,
Attention/Concentration, Developmental Disability, Concrete Thinking,
Impaired Judgment
Medical/Physical: Acute Illness, Hypochondria, CNS Disorder Behavior, Chronic Illness, Need
of Med/Dental Care, Pregnant, Poor Nutrition, Enuretic/Encoperetic, Eating Disorder, Seizures,
Stress Related Illness
Traumatic Stress: Acute, Dreams/Nightmares, Chronic, Detached, Avoidance,
Repression/Amnesia, Upsetting memories, Hypervigilance
Substance Use: Alcohol, Drugs, Dependence, Abuse, Over the Counter Drugs, Craving/Urge,
DUI, Medical Control, Interferes with Functioning, IV Drugs
Interpersonal Relationships: Poor Social Skills, Overly Shy, Problems with Friends, Difficulty
Establishing./Maintaining Relationships
Behavior in Home: Defies Authority, Disregards Rules, Conflict with Relative, Conflict with
Parent/Caregiver, Conflict with Sibling/Peer
ADL Functioning: Handicapped, Permanent Disability,
Not Age Appropriate in: Communication, Self-Care, Hygiene, Mobility
Socio-Legal: Disregards Rules/Norms, Offense to Property, Offense to Persons, Firesetting,
Probation/Parole, Pending Charges, Dishonest/Lying, Gang member, Uses/Cons Others, Incompetent
to Proceed, Detention/Commitment
Work/School: Absenteeism, Skips Classes, Tardiness, Suspended, Dropped Out,
Terminated/Expelled, Poor Performance, Learning Disability, Illiterate, Defies Authority, Disruptive
Behaviors,
Danger to Self: Suicidal Ideation, Current Plan, Recent Attempt, Past Attempt, Self-Injury, Risk
Taking Behaviors, Serious Self-Neglect, Inability to Care for Self
Danger to Others: Violent/Physically Aggressive, Threats, Causes Serious Injuries, Homicidal
Ideation/Threats/Attempts, Uses Weapons, Cruelty to Animals, Sexual Assault

Security/Management Needs: Suicide Watch, No Harm Contract, Locked Unit, Protection from
Others, Seclusion, Home with Supervision, Run/Escape Risk, Restraint, Involuntary Exam, Time-
out, Monitored House Arrest,
One-to-One Supervision

Clinician Signature: ______________________________________________ Date:______________

__________________________________________________________
Signature/Credentials