Golf Fundraiser CHRISTMAS IN JULY is July 22nd! - Click HERE for more information!»

MST Referral Questionnaire

Multi-Systemic Therapy(MST) Eligibility Determination Screening Tool(EDST)

Please Answer the Following Questions to the Best of Your Ability to Assist in Determining Clients Eligibility for MST services. A yes for some portions does not always disqualify a youth, in some cases a youth can be assessed on a case by case basis by the MST clinician meeting with the family with consultation from supervisor and MST expert for final determination.

What is the youth's full name?
Is the youth actively psychotic? (unless temporary and due to drug use)
 Yes
 No
According to records or parent report; Has the youth been diagnosed with Schizophrenia or another psychotic disorder?
 Yes
 No
Is the youth actively threatening suicide? (Suicidal statements in the last 2 weeks)
 Yes
 No
Has the youth attempted suicide in the last 6 months?
 Yes
 No
If so, how many attempts?
When did the attempt(s) occur? (Please specify dates)
Was the youth hospitalized or sent to crisis?
 Yes
 No
Is the youth actively threatening Homicide?(Statements in the last 2 weeks)
 Yes
 No
Has the youth attempted Homicide in the last 6 months?
 Yes
 No
If so, how many attempts?
When did the attempt(s) occur? (Please specify dates)
Were there weapons involved? (Please indicate type)
Any injuries?
Are the youth's presenting problems primarily psychiatric(rather than behavioral) problems?
 Yes
 No

For example: a domestic violence charge due to a psychiatric break resulting in rescue crisis involvement rather than assault due to defiance

8. Standard MST programs may not accept referrals for primarily sex offending behaviors. (Youth with sexual offenses in the context of other delinquent behaviors may be an appropriate referral.) Is there a referral behavior that is of a sexual nature?
 Yes
 No

For example: Rape, Gross Sexual Imposition, Exposure

Has the youth been diagnosed with Autism?
 Yes
 No
 Unknown
Does the youth have a Level 1 Autism diagnosis?
 Yes
 No
 Unknown
Of the following, what is the youth's problem behaviors primarily due to?
 Level 1 Autism
 Willful defiance
 Unknown
Does the youth have a Level 2 or Level 3 Autism diagnosis?
 Level 2
 Level 3
 Neither
 Unknown
Is the Youth's IQ currently known?
 Yes
 No
If so, what is the youth's IQ score?
  1. IQ scores are often included in most schools Evaluation Team Report (ETR)
  2. IQ scores below 70 will be evaluated on a case by case basis

Examples of Appropriate Referrals

Sexual-Related Example Below:

  1. Example of an appropriate referral of youth with sex offending behaviors: A 16-year-old male has a history of criminal charges for shoplifting and breaking and entering.  He is chronically truant from school, and there is a strong suspicion that he abuses marijuana and alcohol.  There are also two reported incidents of inappropriate sexual behavior by this youth, including touching the breasts of a classmate and attempting to force sexual relations with the younger sister of a neighborhood peer.  These two incidents occurred in close proximity to one another and there have been no further allegations for the past year.

Autism Example Below:

  1. Example of an appropriate referral: MA is a 16 year-old-male who has been diagnosed with Autism Spectrum Disorder (Social Communication and Repetitive Behaviors both Level 1). MA was recently referred to MST because of charges of burglary and shoplifting. He has also been observed smoking marijuana. Due to significant difficulty relating to youth his age, MA has been hanging out with a group of 13- year-old males who seem to be the instigators of the recent burglary and shoplifting and of the marijuana use. MA told his mother that he went along with the shoplifting plans because he wants to have friends. His mother states that following ongoing interventions he has recently shown some success in being able to interact with other youth but is more comfortable with younger children. MA has been unsupervised after school and some evenings because his mother works late.

Psychiatric Example Below:

  1. Example of an appropriate referral of a youth with co-morbid psychiatric problems: TL is a 16-year-old female with a history of depression, past suicidal ideation and past suicide attempt, who was hospitalized for an overdose 2 years prior to the current referral.  She was referred by the juvenile courts for shoplifting, truancy and runaway behavior.  She is not currently suicidal and has had no suicide attempts since the hospitalization.

 

Examples of Inappropriate Referrals

Psychiatric Example Below:

  1. Example of an inappropriate referral of a youth with co-morbid psychiatric problems:  JM is a 15-year-old male referred by the juvenile courts for domestic violence.  He is currently trying to harm his mother and himself.  He has ongoing suicidal ideation and has been diagnosed with bipolar affective disorder.  He is intermittently homicidal toward family members.  He has experienced these problems periodically for the past 2 years.

Sexual-Related Example Below:

  1. Example of an inappropriate referral of a youth with sex offending behaviors: A 15-year-old male has just been charged with a third sexual offense, molesting a 4-year-old neighbor.  This youth has a history of two similar offenses with other children in the past year.  The youth has no other reported behavior problems.  He attends school regularly, functions at grade level, and has only been involved with the courts for allegations of sexual misconduct.  The referral indicates there are reports of verbal conflict between parents and the youth and within the marital dyad.

Autism Example Below:

  1. Example of an inappropriate referral: AM is a 13-year-old male who has been diagnosed with Autism Spectrum Disorder (Social Communication and Repetitive Behaviors both Level 1). He has shown significant difficulty in relating to other youth at school. His teacher reports that he does not seem to understand how to play with others, avoids contact with classmates, and becomes disruptive or aggressive when in unavoidable proximity to other youth or when having to wait. His classmates view AM as odd, and he is frequently teased and bullied. As a result, he has been refusing to attend school. His mother has been trying to force AM to attend school, which has increased his anxiety and resulted in AM using physical aggression to resist his mother’s efforts. Consequences for this behavior have not been effective and seem to increase his aggression. During a recent morning when his mother tried to get AM to go to school, he became extremely aggressive and assaulted his mother. He was subsequently arrested for domestic violence.

ZEPF
INTEGRATED
CARE

Integrated care is the coordination of general and behavioral health care needs in an effort to treat not just the body but the mind.

ZEPF NEWS & EVENTS

Zepf Centerís Staff Overwhelmingly Ratify Contract

Zepf Center is pleased to announce the staff represented by Service Employees International Union 1199 (SEIU), overwhelmingly ratified a three-year collective bargaining agreement on June 19, 2019. The agreement merges two bargaining units and unifies the mental health and substance use disorder sides of Zepf Center under one contract.

 

VIEW MORE

Annual Golf Outing - Christmas in July 2019

SAVE THE DATE

JULY 22, 2019

Toledo Country Club, 3949 River Rd., Toledo, OH

VIEW MORE

Dr. Angela Best and Katie Beach CNP Join Zepf Center in Bowling Green

Zepf Center has added providers to our Wood County office to expand our Mental Health Services.

VIEW MORE