maysi‐2 administration & referral protocol manual

MAYSI‐2Administration&ReferralProtocolManual10thJudicialDistrictProbation,StateofColorado3/28/2012 Prepared by the Spark Policy Institute

10th Judicial District, Colorado March 2012

Prepared by the Spark Policy Institute, www.sparkpolicy.com 1 | P a g e

MAYSI‐2 ADMINISTRATION AND REFERRAL PROTOCOL MANUAL

CONTENTS MAYSI‐2AdministrationandReferralProtocolManual.....................................................................................................1

Acknowledgements............................................................................................................................................................................3

10thJudicialDistrictProbation......................................................................................................................................................3

Olga............................................................................................................................................................................................................3

ProbationOfficer.................................................................................................................................................................................3


MichaelArriaga....................................................................................................................................................................................3



JanetSisneros........................................................................................................................................................................................3



Preamble:MentalHealthScreeningwithinJuvenileJustice............................................................................................4

InformationSharing...........................................................................................................................................................4

RationaleforMentalHealthScreeningofYouthsintheJudicialSystem.....................................................4

MentalHealthScreeningandMentalHealthAssessment..................................................................................4

DescriptionoftheMassachusettsYouthScreeningInstrument:Version2................................................................5

MAYSI‐2SCALES..................................................................................................................................................................5

Alcohol/DrugUse......................................................................................................................................................................5

Angry‐Irritable............................................................................................................................................................................5

Depressed‐Anxious...................................................................................................................................................................5

SomaticComplaints..................................................................................................................................................................6

SuicideIdeation..........................................................................................................................................................................6

ThoughtDisturbance(BoysOnly)......................................................................................................................................6

TraumaticExperiences............................................................................................................................................................6

MAYSI‐2AdministrationProtocols..............................................................................................................................................6

I. Mission/Purpose.......................................................................................................................................................6

II. PointsofContact.......................................................................................................................................................7

III. InitialContact.............................................................................................................................................................7



IV. AdministeringtheMAYSI‐2..................................................................................................................................8

Computer‐AdministeredthroughMAYSIWARE™........................................................................................................8

AdministeredviaPaper&Pencil.........................................................................................................................................9

MAYSI‐2ReferralProtocols..........................................................................................................................................................10

I. PostScreening.........................................................................................................................................................10

II. InformationSharing.............................................................................................................................................11

MassachusettsYouthScreeningInstrument(MAYSI‐2)Administration&ReferralProtocolSummary.....12

AppendixA:GeneralGuidelinesforMAYSI‐2YouthProtocol.......................................................................................15

PennsylvaniaGuidelinesforIntroducingtheMAYSI‐2toYouth..................................................................15

IntroducingYouthstotheMAYSI‐2..................................................................................................................................15

ListofThingstoIncludeintheIntroduction................................................................................................................15

AppendixB:MAYSI‐2Scales&QuestionsReferenceCard..............................................................................................17

AppendixC:10thJudicialDistrictAgenciesImplementingMAYSI‐2...........................................................................20

AppendixD:PublicMentalHealthServices&CommunityServicesRelevanttoMAYSI‐2inthe10thJudicialDistrict...................................................................................................................................................................................21

AppendixDContinued:PublicMentalHealthServices&CommunityServicesRelevanttoMAYSI‐2inthe10thJudicialDistrict..........................................................................................................................................................................23

AppendixE:10thJudicialDistrictReleaseofInformation...............................................................................................25

AppendixF:DepartmentalPolicy112.........................................................................Error!Bookmarknotdefined.

I.Definitions:.........................................................................................................................................................................1

II.POLICY:...............................................................................................................................................................................1

III.PROCEDURE:...................................................................................................................................................................2

AttachmentA.........................................................................................................................................................................4

AttachmentBConfidential/ProtectedInformationChecklistWithAuthorities05/17/2010...........5



ACKNOWLEDGEMENTS

Listofthepeople,title,organization,whowereinstrumentaltodevelopingthesiteprotocolsAmandaMcGowanSupervisor10thJudicialDistrictProbationDavidSimentalChiefProbationOfficer10thJudicialDistrictProbationOlgaAcosta‐DavisProbationOfficer10thJudicialDistrictProbationMichaelArriagaProbationOfficer10thJudicialDistrictProbationJanetSisnerosProbationOfficer10thJudicialDistrictProbation



PREAMBLE: MENTAL HEALTH SCREENING WITHIN JUVENILE

JUSTICE1

ByKathleenR.SkowyraandJosephJ.Cocozza,Ph.D.andValerieWilliams,M.A.,M.S.NationalCenterforMentalHealthandJuvenileJusticehttp://www.ncmhjj.com/pdfs/MH_Screening.pdf

INFORMATION SHARING

Informationsharingshouldoccurthroughanactiveexchangeofinformationtobenefitassessments,caseplanning, and service delivery. Sharing the results from the MAYSI‐2 should be done to facilitateappropriateandimprovedcoordinationofservicesforyouth.

RATIONALE FOR MENTAL HEALTH SCREENING OF YOUTHS IN THE JUDICIAL SYSTEM

“Recent research has established that a large proportion of youth involved with the juvenile justicesysteminthiscountryhavesignificantmentalhealthproblems.Findingsfromanumberofmentalhealthprevalence studies conducted within the last five years among youth in a variety of juvenile justicesettings – community‐based, detention, corrections – are remarkably consistent. Approximately 65percentto70percentofyouthinthejuvenilejusticesystemhaveadiagnosablementalhealthdisorder.Severementaldisordersarecloseto27percent,indicatingthatmorethanonequarterofallyouthinthejuvenilejusticesystemareinsignificantneedofmentalhealthtreatment.

Oneof themost important first steps to respond to thementalhealth treatmentneedsofyouth in thejuvenile justice system is to systematically identify themental health needs of youth as they becomeinvolvedwith the juvenile justice system. Mental health screening is now routinely preformedwithinmanyjuvenilejusticeagenciesandprogramsthroughoutthecountry.Thisisimportantprogressintheoverallefforttobetteridentifyandrespondtoyouthwithmentalhealthtreatmentneeds.”

MENTAL HEALTH SCREENING AND MENTAL HEALTH ASSESSMENT

“Mental Health Screening is a relatively brief process carried out by non‐clinical staff using astandardizedmental health screening tool. Some tools offer structured questions that youth answerabouttheircurrentorrecentthoughts,feelings,orbehaviors.Othersaskstafftomakeratingsbasedonpastrecordsorcaretakers’reportsofyouths’behavior. Inanycase,mentalhealthscreeningisatriageprocess that is employedwith every youth during an initial probation intake interview, within a fewhoursafterintakeinpretrialdetentionoruponentranceintojuvenilejusticeplacement.

Thepurposeofmentalhealthscreeningistoidentifyyouthwho’smentaloremotionalconditionssuggestthattheymighthaveamentaldisorder,mighthavesuicidepotential,ormightpresentariskofharmtoothersintheimmediatefuture.Theterm“screenedin”isusedtorefertoyouthwhoareidentifiedbythescreeningmethodasneedingfurtherattention.

1SelectedpassagescomefromSkowyra,K.R.,&Cocozza,J.J.(n.d.)Mentalhealthscreeningwithinjuvenilejustice:

Thenext frontier. Chapter 1: Introduction, andChapter 2: Procedures andPolicies. Delmar,NY:NationalCenterforMentalHealthandJuvenileJustice.http://www.ncmhjj.com/pdfs/MH_Screening.pdf



Whenyouthare“screenedin”forpossiblementalandemotionalproblems,itdoesnotnecessarilymeanthattheyhavementaldisordersorthattheyaresuicidalorlikelytoharmothers.Itindicatestheneedforafollow‐upresponsebystaff.Oftenthisinvolvesobtainingfurtherevaluation.

MentalHealthAssessmentisafollow‐upforyouthwhosescreeningscoressuggestthattheymighthavemental and emotional problems. Assessments are performed by clinicians, and the offer morecomprehensive, individualized evaluation of youth providing descriptions and recommendations thatwill be useful for longer‐range treatment and dispositional planning. The assessment process mayincludepsychological testing, clinical interviewing, andobtainingpast records fromother agencies forreviewbytheclinicalassessor.”

DESCRIPTION OF THE MASSACHUSETTS YOUTH SCREENING

INSTRUMENT: VERSION 2

The Massachusetts Youth Screening Instrument (MAYSI‐2) is a screening instrument developed fordetectingmentalhealthneedsinyouthaged12‐17. Designedasalow‐cost,easilyadministeredtool, itscreens formultiple issues and can be administered in 10‐15minutes. It is divided into seven scalescomposed of 52 questions that are designed to detect alcohol/drug use, angry‐irritable behavior,depression‐anxiety,somaticcomplaints,suicideideation,thoughtdisturbance,andtraumaticexperience.Youths answerYESorNO concerningwhether each itemhasbeen true for them "within thepast fewmonths."MAYSI‐2 requires a 5th‐grade reading level, and is designed to be self‐administered either inpaperoroveracomputer. TheMAYSI‐2isavailableinbothEnglishandSpanishaswellasinsoftwareform. TheMAYSI‐2 software is calledMAYSIWARE. MAYSI‐2 is becoming a standard feature inmanyjuvenilejusticefacilities,andisincurrentlyinusein48statesandin6countries.

MAYSI‐2 SCALES2

Alcohol/Drug Use

TheADscale is intendedto identifyyouthswhoareusingalcoholordrugs toasignificantdegree,andwhoarethereforeatriskofsubstancedependenceand/orabuse.Thescalehaseight items.Fiveoftheitemsareconcernedwithvariousnegativeconsequencesofsubstanceusedisorders,andtheremainingthreeaddresscharacteristicsofsubstanceusethatarethoughttorepresentfactorsforabuse.

Angry‐Irritable

TheAIscaleis intendedtoassessexplicitfeelingsofpreoccupyingangerandvengefulness,aswellasageneraltendencytowardirritability, frustration,andtensionrelatedtoanger.Thescalehasnineitems.Fourexplicitlyconcernangrymoodandthoughts,threeothersareconcernedwithirritabilityandriskofimpulsivereactions,andthelasttwoitemspertaintobehavioralexpressionofanger.

Depressed‐Anxious

TheDAscaleis intendedtoelicitsymptomsofmixeddepressionandanxiety.Thescalehasnineitems.

2DescriptionfromGrisso,T.&Barnum,R.(2006).MassachusettsYouthScreeningInstrumentVersion2:User’s

manualandtechnicalreport.Sarasota,FL:ProfessionalResourcePress,pp.12‐18.



Fiveitemsinquireaboutmanifestationsofanxietyandinnerturmoil,andfouritemsareconcernedwithdepressedmood.

Somatic Complaints

TheSCscaleincludessixitemsthataskaboutvariousbodilyachesandpainsthatmayaffecttheyouth,alongwithspecificbodilyexpressionsofanxiety.Anelevatedscoreonthisscalecouldoccurforavarietyof reasons. For example, somatic complaints tend to co‐occur with depression and anxiety, andsometimestheycanbeassociatedwithtraumahistoryandwiththoughtdisorderaswell.Ontheotherhand, aches, pains, and other somatic complaints may be symptoms of physical illness, and suchcomplaintsshouldnotbeoverlookedassymptomsintheirownright.

Suicide Ideation

TheSIscalehas five items.Threeof themspecificallyaddress thoughtsand intentionsaboutself‐harmandtwoinvolvedepressivesymptomsthatmaypresentanincreasedriskforsuicide.OneoftheitemsissharedwiththeDAscale.

Thought Disturbance (Boys Only)

TheTDscale is intendedto indicatethepossibilityofseriousmentaldisorder involvingproblemswithrealityorientation.Thescalehasfiveitems,fourofwhichreferexplicitlytoalteredperceptionsinrealitythat are frequently associated with psychotic disorders. The remaining item refers to a condition ofderealization ("things don't seem real") that is a more general abnormality of perception andconsciousness.Itissometimesanearlyindicationofapsychoticstate,butitmaysimplyariseinanxietyordissociativestatesaswell.InthestudywithwhichtheMAYSI‐2wasdeveloped,thevariouswaysthatwereusedtoidentifywhichitemscametogetherasscalesdidnotidentifya"thoughtdisturbance"scaleforgirlsusingMAYSI‐2items.ThustheTDscaleshouldnotbeappliedtogirls.

Traumatic Experiences

The TE scale is intended to identify whether a youth has had greater exposure to traumatic eventscomparedtootheryouths.UnlikeotherMAYSI‐2items,theTEitemsaskforresponsesregardingeventsorfeelingsovertheyouth'sentirelifetimeratherthanjustthe"pastfewmonths."ThereareseparateTEscalesforboysandgirls.

MAYSI‐2 ADMINISTRATION PROTOCOLS3

I. MISSION/PURPOSE

ByadoptingtheMAYSI‐2,itistheintentthatallyouth,ages12‐17,receivingservicesthrough10thJudicialDistrictProbationwillbeadministeredtheMAYSI‐2forearlyidentificationofpotentialbehavioralhealthissuesandearlyreferralofservices.

3ThankstoSherriEgan,ExecutiveDirector,OgleCountyJuvenileJusticeCouncil,OgleCounty,IL,whosharedtheir“Models for Change” protocol for administering the MAYSI‐2. The “Models for Change” protocol provided theoutlineofstepsforthisprotocolmanualtemplate.



II. POINTS OF CONTACT

AdministeringtheMAYSI‐2requiresfollow‐upactions.TheMAYSI‐2willbeadministeredwithsufficienttimeafterwardstofollowtheprotocolsteps.TherewillbetwotypesofinitialcontactsforadministeringtheMAYSI‐2inPuebloCounty.Theseare:

1. PuebloYouthCenter,initialin‐take,withinonehourofarrival.

2. Atthefirstformalappointmentwiththe10thJudicialDistrictProbationofficeswithinanhouroftheyouth’sarrival,butafterthestaffhastalkedwiththeyouthabouttheMAYSI‐2(seebelowforlanguage):

Ifthe10thJudicialDistrictJuvenileProbationreceivesverificationfromthePuebloYouthCenterthat a youth has completed a MAYSI‐2 screening within the last 30‐90 days, the 10th JudicialDistrict JuvenileProbationwillnotre‐administertheMAYSI‐2 totheyouth,butwill insteadgetthescreenresultinformationonthatyouthfromPuebloYouthCenter.

a. Pre‐sentenceinvestigationinterview

b. Termsandconditions

III. INITIAL CONTACT

Screenersshallinformyouthofthefollowing:

1. InstructionsofhowtointroducetheMAYSI‐2toyouth.Statethefollowing:

“Whatweareaskingyoutodonowisanswersomequestionssothatwecangettoknowyoubetterandseewhatservicesmightbehelpfultoyouandyourfamily.”

2. Instructionsonhowtocompletethesurveyareexplained.Statethefollowing:

“Thesearesomequestionsaboutthingsthatsometimeshappentopeople.Foreachquestion,pleaseanswer“yes”or“no”towhetherthatquestionhasbeentrueforyouinthepastthreemonthsorsince[nameholiday/event3monthsago]unlessotherwiseindicated. Pleaseanswerthesequestionsaswellasyoucanandchoosethebestanswerratherthanleavingthequestionsblank.”

3. Limitsonconfidentialityareexplainedintheeventthattheyouthindicatesanintentiontoharmthemselves or others; or that the youthhas indicated that he/she is a victimof child abuse orneglectorhasdisclosedthathe/shehascommittedanoffense involvingchildabuseorneglect.Statethefollowing:

“Whatyourevealwhenansweringthesequestionsisconfidential.Nothingyourevealcanbeusedagainstyouinanyjuvenileorcriminalcourthearingunlesstheresultsshowpotential,imminentdangerofself‐harminwhichcaselawenforcementwillbecontacted.Inaddition,ifyoudisclosethatyouarethevictimofchildabuseorneglectorifyoudisclosethatyouhavecommittedanoffenseinvolvingchildabuseorneglect,thatinformationmustbereportedtolawenforcementand/orPuebloCountyDepartmentofHumanServices.”

4. Informationsharing.Statethefollowing:



“A summary of these resultsmay be sharedwith the agencies indicated on the Release ofInformationform.”

IV. ADMINISTERING THE MAYSI‐2

Computer‐Administered through MAYSIWARE™

Takingthesurvey

1. At the10th JudicialDistrict JuvenileProbationoffices therewill beonededicated computerthathastheMAYSI‐2softwareprograminstalled.Thecomputerwillbelocatedinanareaorroomthatisfreeofdistractions.

2. ComputeraccesstotheMAYSI‐2atthe10thJudicialDistrictProbationofficeswillbeprovidedto a selected number of Probation staff to include Probation Officers, Supervisors, ChiefProbationOfficer,InformationTechnologySpecialist(s),andInternProbationOfficers.Eachpersonwilluseastandardizedpasswordandindividualusernamestologin.

3. Youthwillbeprovidedwithverbalinstructions(see“InitialContact”onpreviouspageorseeMAYSI‐2ProtocolSummaryfortalkingpoints).

4. ScreeneropensMAYSIWARE™andenterspersonalusernameandstandardpassword.

5. Screenerselects“StartMAYSI‐2.”

6. Screenerentersdemographicdata fromyouth’s intakesheet. Use firstnameand lastnameonly.EachyouthwillhaveapersonalID#thatthescreenerwillenter.

7. YouthbeginsMAYSI‐2(headphonesprovided).Theyouthshouldselectthelanguage(Englishor Spanish) that is best for him/herself. Screener shoulddefinewith youth that questionsapplytothelast3months(ornameaholiday).Screenerwaitsoutsidetheroomornearbyifthecomputerislocatedinanopenareaincasequestionsarise.

Scoringthesurvey

8. AftertheyouthcompletestheMAYSI‐2,thescreenerwillentertheirusernameandpasswordagainandthenwillcheck“reviewreport”toaccessscreeningresults.

9. Personalized2ndscreeningformsforthatyoutharecreatedwhenayouthscoresatoraboveCAUTIONontheSuicideIdeationscaleandatoraboveWARNINGonallotherscales. Whenthese scores are reached, the computer will automatically generate secondary screeningquestions. When the software asks the screener if they want to review the report, thescreener can simply click “yes” to see the youth’s report and any generated secondaryscreening questions. Both the screen results and secondary screening questions can beprinted out for manual note‐taking. In addition, a summary form is provided where thescreener can document any action taken. The screener can later go into theMAYSIWARECasesoptionandthenselecttheyouth(youthwillbelistedundercasesbyMAYSIWAREID,lastandfirstnameanddateofbirth)inthetopboxandontheappropriateMAYSIscreeningoption(“Add/Edit2ndScreeningAnswers”)locatedatthebottomofthescreen.TheScreenercanenteranswersdirectlyintothesoftware.Thescreenerwillneedtoselecttheirownnamefrom the drop‐down box located at the top right hand corner of the page as the person



enteringtheform.Thescreenershouldattempttotypeanswersusingtheyouth’slanguageorwords.ThescreenerwillfindtheSummaryformaftertheSecondScreeningformswherethe screener can recordwhat actionwas taken (and a description) or if an actionwas nottakenandwhyanactionwasnottaken.Pleasenote:Ifthescreenerbelievesthatthesenotesarenot finalized, theyshouldclick “cancel”. If thenotesare final, thescreenershouldclick“done”.Once“done”isclickedthescreenerwillnotbeabletogobackandmakechanges.

10. Manual (paper and pencil) secondary screening forms are available in the full MAYSI‐2manual.TheseshouldbeusedforyouththatscoreatorabovetheCAUTIONonindividualscales at the supervising officer’s descretion. Because the computer will only generatesecondaryscreeningquestionsforWARNING(exceptforSuicideIdeation),thescreenerwillneedtoreferencethepaperandpencilversionforms.

Administered via Paper & Pencil

Takingthesurvey

1. Theyouthshouldbeplacedinaroomorareawithoutdistractions.

2. Staff hands the youth the MAYSI‐2 Questionnaire appropriate for their gender and languagepreference (similar to the electronic version, the paper screen is available in both English andSpanish), and provides instructions (see “Initial Contact” on previous page or see MAYSI‐2ProtocolSummaryfortalkingpoints).

3. Staffensuresyouthcanreadtheitemswithminimalhelpbyaskingtheyouthtoreadthefirstfewitems aloud. If the youth’s preferred language is Spanish and they need reading assistance,Spanish‐speakingstaffshouldbeavailable.

a. Ifyouthcannotreadthequestionnaire,staffmember letsyouthknows/hewillhelpbyreadingtheitemsfromtheirowncopy.

b. Staffreadseachitem,includingtheitemnumberandyouthplacesanswerbythecorrectitem.Staffshouldnotwatchhowtheyouthanswerseachiteminordertoeasethelevelofpotentialdiscomfort.

4. Whensurveyiscompleted,staffcheckstoconfirmallquestionshavebeenanswered.Ifnot,staffencouragesyouthtocompletemissingitems.

a. Ifyouthishavingtroubledecidingwhetheritemistrueornotforhim/her,promptyouthtoanswer“yes”ifithas“probablybeentrue”orifitis“alittletrue.”

Scoringthesurvey

5. ThemanualMAYSIScreenscorescanbeentereddirectlyintotheMAYSIWAREsimplybythestaffmember filling out the youth’s Race and Ethnicity information screen and clicking ”next” tocontinue, selecting“ManualEntry”andentering theyouth’sanswers fromthepaperandpencilform.ThestaffmembershouldselectthelanguagetheMAYSI‐2wastakeninandleaveblankanyquestions that theyouthdidnotanswer. Following theentryof information, thestaffmemberwillbeaskediftheywishtoverifytheanswers.Aftertheverificationofresponses,thescreenwillbeautomaticallyscoredandthestaffmemberwillthenbewillbeaskediftheywishtoviewthe



MAYSI‐2report.Theycanprintoutthereportand,ifapplicable,proceedwiththesecondscreeninformation.

6. Ifastaffmembercannotusethemanualentryoptiononthesoftwaretogeneratescreenscores,thestaffmembercanalsousetheMAYSI‐2ScoringKeytohandscoretheQuestionnaire.

a. AlignthearrowontheleftsideoftheScoringKeywiththearrowontherightsideofpage1oftheQuestionnaire.

i. CirclethenumbersontheScoringKeythattheyouthmarked“Yes”andplaceanXoneachitemontheScoringKeyforwhichtheyouthdidnotprovideananswer.

ii. Twoscalesaregender‐specific:

1. ThoughtDisturbancescaleisforBOYSONLY.

2. TraumaticExperiencesscalehasaseparateScoringKeyforboysandgirls.

b. Repeataboveprocedurewithpagetwoof theMAYSI‐2Questionnaire,aligningtherightsideoftheScoringKeywiththearrowonpagetwooftheQuestionnaire.

7. UsetheMAYSI‐2ScoringProfiletorecordtheinformationfromtheScoringKey.

a. Firstidentifythescales,ifany,forwhichthenumberofX’sindicateaninvalidscore:

i. Forscaleswitheighttonineitems,morethantwounanswereditemsinvalidatesthescale.

ii. For scalewith five to six items,more thanoneunanswered item invalidates thescale.

b. TransferfromtheScoringKeytotheScoreProfilethenumberofitemscircledforagivenscale(ifitisvalid,see“a”above).

i. Remember,twoscalesaregender‐specific:

1. ThoughtDisturbancescaleisforBOYSONLYsoonlyboyswillhaveascoreforTD.

2. TraumaticExperiencesscalehasseparateScoringKeysforboysandgirls.Besureyouusedtheappropriatekeybeforeenteringthescore.

8. Undernocircumstancesshouldthestaffchangeanyoftheyouth’sanswersontheMAYSI‐2.Ifsecondscreeningquestionsrevealtheyouthmisunderstoodaquestion,thisinformationcanbewritten in response to the second screening question to thereby “correct” or clarify the initialanswer.

9. FollowupsecondaryscreeningformsareavailableinthefullMAYSI‐2manual.

MAYSI‐2 REFERRAL PROTOCOLS

I. POST SCREENING

1. Ifyouthscoresatorabovethe“Caution”levelonthe“SuicideIdeation”scale

a. Asksecondscreeningquestionsoftheyouth.



b. If it is determined that the youth is in imminent danger to him/herself, call lawenforcement and law enforcementwill determine appropriate action includingpossibletransporttoParkviewMedicalCenterand/orSt.Mary‐CorwinHospital.

c. Ifdeterminedyouthisnotinimminentdangertohim/herself:

i. Complete a Safety Contract with the youth and his/her family/legalguardian/fosterparent.

ii. Advise responsible parties (his/her family/legal guardian/foster parent) thatYouthneedstobemonitored.

iii. ConductCollateralInterviewswithfamilymembersand/orpastserviceproviders.

iv. Dependingontheinformationcollected,thescreenermayneedtodooneormoreofthefollowing:

FollowproceduresinSectionII.InformationSharing

Determineifyouthiscurrentlyreceivingmentalhealthcare.ContactandconfirmwithproviderthatservicesarecurrentandinformproviderthatyouthisatProbationandabehavioralhealthscreenhasbeenconducted.

SeekaClinicalConsultationfromamentalhealthprofessional(pleaseseeattachedProviderListlocatedinAppendixD).

ArrangeacomprehensiveMentalHealthEvaluationfromcommunity‐basedserviceproviderfromProviderList(seeAppendixD)orfromaprivateproviderifyouthandfamilyhaveprivatehealthinsurance.

2. The Traumatic Experiences section will not create 2nd screening questions, so the screenerneedstopaycloseattentiontotheMAYSI‐2summaryscoresheetandusetheinformationtohelpdetermineifyouthshouldbereferredforafurtherassessment.

3. “Warning”onanyotherscale

a. AskMAYSI‐2secondscreeningquestionsofyouth.

b. Set service response plan according to section III. Massachusetts Youth ScreeningInstrument(MAYSI‐2)Administration&ReferralProtocolSummary.

4. SeeAppendixDforalistofallpublichealthandcommunityorganizationswithinthe10thJudicialDistrictthatprovidebehavioralhealthservicestoyouth.

II. INFORMATION SHARING

1. Sharing the results of the MAYSI‐2 with other providers, including mental healthproviders, is subject to regulations. Results can be shared based on any of theseprotocols:

a. The10thJudicialDistrictProbationReleaseofInformation(ROI)(SeeAppendixEforacopy).

b. TherulessetforthinstatestatuteandDepartmentalPolicy112(SeeAppendixFforacopyofDepartmentalPolicy112).



2. SharingtheresultsoftheMAYSI‐2withfamilymembers/legalguardiansissubjecttoanyofthefollowing:

a. The10thJudicialDistrictProbationReleaseofInformation(SeeAppendixEforacopyoftheROI).

b. TherulessetforthinstatestatuteandDepartmentalPolicy112(SeeAppendixFforacopyofDepartmentalPolicy112).

MASSACHUSETTS YOUTH SCREENING INSTRUMENT (MAYSI‐2)

ADMINISTRATION & REFERRAL PROTOCOL SUMMARY4

MAYSI‐2ProtocolSummaryisaquickreferencesheetofthestepstobefollowedwhenadministeringtheMAYSI‐2mentalhealthscreeninginstrumenttoyouths12‐17yearsofage.Thefirstpageprovidesstepsforhowtoadministertheinstrument. Thesecondpageprovidesdirectionsforrecommendedservicesbased on the youth’s MAYSI‐2 scores. For detailed information, consult the manual, MAYSI‐2Administration&ReferralProtocolManual:10thJudicialDistrict,StateofColorado.

BeforeAdministeringtheInstrument

DuringAdministration AfterAdministration

IntroducetheTestbysaying:

“Whatweareaskingyoutodonowisanswersomequestionssothatwecangettoknowyoubetter and see what servicesmight be helpful to you andyourfamily.”

Give instructions on how tocompletethesurveybysaying:

“These are some questionsabout things that sometimeshappen to people. For eachquestion, please answer “yes”or “no” to whether thatquestion has been true foryouinthepastthreemonthsor since [name holiday 3monthsago]unlessotherwiseindicated.Pleaseanswerthesequestions as well as you canand choose the best answerrather than leaving thequestionsblank.”

Monitor and supervise theroom/area where the youth iscompletingtheinstrument.

Answer questions by the youthas necessary and ensure thatyou are available for anyassistance needed tosuccessfully complete thequestionnaire.

When using the MAYSIWARE(computerized version ofMAYSI‐2), please ensure thatyouhavecompletedthesection“TO BE COMPLETED BY STAFFONLY”priortoadministration.

Runtheanalysisoftheanswers.

Printoffthereport.

Conduct appropriate follow‐upactionsandprocedures

Enter action taken in “Results”field. (Indicate which of the post‐scoring services described belowwere done.) If a youth’s MAYSIscoredoesnot indicateapotentialmental health problem, enter “NoActionRequired.”

Protectconfidentialityofresultsbyfollowing the Information SharingProtocol.

4ManythankstotheTexasJuvenileJusticeSystemthatdesignedthesummarymatrixformat.Moreinformation

canbe foundatSkowyra,K.R.,&Cocozza, J.J. (n.d.)Mentalhealthscreeningwithin juvenile justice:Thenextfrontier. Appendix C: TexasMAYSI‐2 Protocol Reference Card, p.26. Delmar, NY: National Center forMentalHealthandJuvenileJustice.Accessedfromhttp://www.ncmhjj.com/pdfs/MH_Screening.pdf



Give the confidentiality warningsbysaying:

“What you reveal whenanswering these questions isconfidential unless the resultsshow potential imminentdanger of self‐harm in whichcase law enforcement will becontacted. Nothingyourevealcanbeusedagainstyouinanyjuvenile or criminal courthearing.However,thereisoneexception to this. If youdisclosethatyouarethevictimof child abuse or neglect or ifyou disclose that you havecommitted an offenseinvolving child abuse orneglect, that informationmustbe reported to lawenforcement and/or PuebloCounty Department of HumanServices.”

Stipulate how information issharedbysaying:

“A summary of these resultsmay be shared with theagencies indicated on theReleaseofInformation.”

TakethefollowingactioninresponsetoMAYSI‐2scoresinthesecombinations:

MAYSI‐2POST‐SCORINGRECOMMENDEDSERVICESSECONDARYSCREENING

(byJuvenileJusticeStaff)PRIMARYSERVICES

(byMentalHealthProfessionals)A. MonitortheYouth.Staffshouldadvise

families/legalguardians/fosterparentstoexercisegreatervigilanceandattentiontotheyouthinordertoconductrelevantbehavioralobservations.Ifyouthisatimminentdangerofself‐harmfamilies/legalguardians/fosterparentsshouldcontactlawenforcement.CompleteSecondScreeningQuestionsforayouthwhoscoresatorabovetheCAUTIONscoreforSuicideIdeationscaleandtheWARNINGscoreforallotherscales.

E. ClinicalConsultation.Staffshouldseekexpertisefromclinicalprofessionals/mentalhealthprofessionalswhocanintervenetoprovidebriefevaluationoremergencycare.

B. InterviewingandCollateralContacts.Staffshouldengageinfocuseddiscussionswiththeyouth,orwiththeyouth’sfamilyand/orpastserviceproviders.Thefocusshouldexplorethereasonsforthejuvenile’sresponsesonrelevantitemsoftheMAYSI‐2,aswellasoutsideinformationthatcontradictsorisconsistentwithwhattheyouthreportedontheinstrument.CompleteSecond

F. EvaluationReferral.Staffshouldarrangeforamorecomprehensivepsychiatricorpsychologicalevaluationtodeterminethenatureandsourceoftheyouth’sself‐reporteddistressordisturbance.



ScreeningQuestionsforayouthwhoscoresatorabovetheCAUTIONscoreforSuicideIdeationscaleandtheWARNINGscoreforallotherscales.

C. CompleteaSafetyContract.Workingwiththeyouthandhis/herfamily/legalguardian/fosterparent,acontracttoensuretheyouthwillnotharmhim/herselfwillbewrittenup.

G. ContactandconfirmMentalHealthServices.Staffreviewscasefileandconfirmswithhis/hermentalhealthproviderthatyouthiscurrentlyreceivingmentalhealthservices.Providerisinformedofcurrentsituation.Ifnotreceivingcurrentmentalhealthservices,areferralshouldbecompleted.

D. FollowReleaseofInformationProcedures.Ifmentalhealthservicesareneeded,staffwillfollowappropriateInformationSharingprocedures.

H. TransporttoSecureFacility.Ifyouthisinimminentdangerofharminghim/herself,lawenforcementwillbecalledandlawenforcementwilldetermineappropriateactionincludingpossibletransporttoParkviewMedicalCenterand/orSt.Mary‐CorwinHospital.

RecommendedActionsbyJuvenileJusticeStaffSuicideIdeationScaleOnly

CAUTION A&B&CwiththeoptionofEither(EorF)and (GorH)with D

WARNING D+Either(EorF)andH

AnyCombinationofScales(ExceptSuicideIdeationScale)

CAUTION WARNING Either(AorBorBoth)+Dand G

WARNINGWARNING

+ Both(A&B)+DandEither(EorForG)

CAUTION CAUTION CAUTION Either(AorBorBoth)+Dand G

CAUTION CAUTION WARNING Both(A&B)+DandEither(EorForG)

CAUTION CAUTION CAUTION CAUTION Either(AorBorBoth)+Dand Either(EorForG)



APPENDIX A: GENERAL GUIDELINES FOR MAYSI‐2 YOUTH

PROTOCOL5

PENNSYLVANIA GUIDELINES FOR INTRODUCING THE MAYSI‐2 TO YOUTH

Introducing Youths to the MAYSI‐2

Instruments liketheMAYSI‐2mustbeintroducedtoyouthsappropriately. Howyouthsrespondtothequestionsdependsalotonwhattheythinktheinstrumentisassessing.Therefore,thepersongivingtheMAYSI‐2shouldtakeoneortwominutestointroducetheyouthtoit.

Thereisnoonewaydotheintroduction.Itcertainlycallsformorethanhandingtheformtotheyouthandsaying“pleasecompletethis.”Ontheotherhand,itdoesnotrequirealengthyordetaileddescription.Whatisneededissomebasicinformation,offeredinanonthreateningmannerandinawaythatyouthscanunderstand.

BelowisalistofguidelinesdescribingthetypesofinformationthatshouldbeincludedwhenintroducingyouthstotheMAYSI‐2.

List of Things to Include in the Introduction

1.Thatthequestionswillhelpstaffunderstandtheyouthbetter

Let youths know that youwould like to give them a set of questions to answer thatwill help staff tounderstand thembetter. Describethemasquestionsaboutwhotheyare– their thoughtsand feelingsabout thingsor themselves. Tell themthis includesabout50yes/noquestions. Theyouthsshouldbetoldthatthishelpsthestaff learnwhethertheymighthavespecialneedsthatstaffshouldknowabout.ReferencestotheMAYSI‐2asatestshouldbeavoidedasayouthmaythinkthismeanstherearerightandwronganswerstothequestions.

2.Whowill(orwillnot)seetheyouth’sanswersandusethemforcertainpurposes

Youthsshouldbetoldwhowillseetheiranswersand/orscores. Thismaydifferacrossprograms.Forexample, one probation department might only allow probation staff to see the youths’ answers andscoressothattheycandeterminewhethertheyouthhasspecialneeds.Whateverthepotentialuses,theyouthshouldbe toldabout them. Thisdoesnothave tobedetailed,but it shouldbehonest. Itmightinclude indicatingwhowillnotseetheresults,e.g., “theresultswillnotgotothe judgeortheD.A.,”aswellaswhowillseetheresults.

3.VoluntarynatureoftheMASYI‐2

TakingtheMAYSI‐2isalways“voluntary”inthattheyouthsmaychoosenottoanswerthequestions.Itisinappropriatetomaketheirparticipationmandatoryortopunishthemfornotanswering.TheMAYSI‐2is routine (likeotherhealthand identityquestions)and intendedonly for theyouth’sprotection. Theinformationisintendedtohelpstaffintheprogramattendtoyouths’immediatesafetyandneeds.

5 Adapted from Skowyra, K.R., & Cocozza, J.J. (n.d.)Mental health screeningwithin juvenile justice: The next

frontier.AppendixB:PennsylvaniaGuidelinesforIntroducingtheMAYSI‐2toYouth,pp.22‐23.Delmar,NY: National Center for Mental Health and Juvenile Justice. Accessed fromhttp://www.ncmhjj.com/pdfs/MH_Screening.pdf



4.Checkforspecialneedsofyouthincompletingtheprocedure

Once the youth is ready to take the MAYSI‐2, staff should assist the youth in getting started. If theprogram uses MAYSIWARE, this is a matter of entering the youth’s background information in thecomputerandthen,afterputtingtheheadphonesontheyouth,sittingwiththeyouthwhilethecomputerprogramminggives theyouth initial instructionsaboutanswering thequestionson thekeyboard. Thestaffpersonthenstepsasidewhentheyouthbeginstorespondsothattheyouthdoesnotfeelthatthestaffpersonislookingattheresponses.



APPENDIX B: MAYSI‐2 SCALES & QUESTIONS REFERENCE CARD6

TheMAYSI‐2 is composedof seven scales. Each scale ismadeupof a set of questions. For all scalesEXCEPT Traumatic Experiences, the questions refer to the “last fewmonths.” Traumatic Experiencesquestionsreferto“everinyourlife.”

MAYSI‐2ScaleDescriptionof

Scale/MeasurementComponents

QuestionsonScale

Alcohol/DrugUse Frequentuseof

alcohol/drugs

Riskofsubstanceusedisordersorpsychologicalreactiontolackofaccesstosubstances

10.Haveyoudoneanythingyouwishyouhadn’t,whenyouweredrunkorhigh?

19.Haveyourparentsorfriendsthoughtyoudrinktoomuch?

23.Haveyougottenintroublewhenyou’vebeenhighorhavebeendrinking?

24.Ifyes[to#23],hasthetroublebeenfighting? 33.Haveyouusedalcoholordrugstohelpyoufeelbetter?

37.Haveyoubeendrunkorhighatschool? 40.Haveyouusedalcoholanddrugsatthesametime?

45.Haveyoubeensodrunkorhighthatyoucouldn’trememberwhathappened?

Angry‐Irritable Experiencesfrustration,lastinganger,moodiness

Riskofangryreaction,fighting,aggressivebehavior

2.Haveyoulostyourtempereasily,orhada“shortfuse”?

6.Haveyoubeeneasilyupset? 7.Haveyouthoughtalotaboutgettingbackatsomeoneyouhavebeenangryat?

8.Haveyoubeenreallyjumpyorhyper? 13.Haveyouhadtoomanybadmoods? 35.Haveyoufeltangryalot? 39.Haveyougottenfrustratedeasily? 42.Whenyouhavebeenmad,haveyoustayedmadforalongtime?

44.Haveyouhurtorbrokensomethingonpurpose,justbecauseyouweremad?

6 Adapted from Skowyra, K.R., & Cocozza, J.J. (n.d.)Mental health screeningwithin juvenile justice: The next

frontier. Appendix C: TexasMAYSI‐2 Protocol Reference Card, pp.24‐25. Delmar, NY: National Center forMentalHealthandJuvenileJustice.Accessedfromhttp://www.ncmhjj.com/pdfs/MH_Screening.pdf





QuestionsonScale

Depressed‐Anxious Experiences

depressedandanxiousfeelings

Riskofimpairmentsinmotivation,needfortreatment

3.Havenervousorworriedfeelingskeptyoufromdoingthingsyouwanttodo?

14.Haveyouhadnightmaresthatarebadenoughtomakeyouafraidtogotosleep?

17.Haveyoufeltlonelytoomuchofthetime? 21.Hasitseemedlikesomepartofyourbodyalwayshurtsyou?

34.Haveyoufeltthatyoudon’thavefunwithyourfriendsanymore?

35.Haveyoufeltangryalot? 41.Hasitbeenhardforyoutofeelclosetopeopleoutsideyourfamily?

47.Haveyougivenuphopeforyourlife? 51.Haveyouhadalotofbadthoughtordreamsaboutabadorscaryeventthathappenedtoyou?

SomaticComplaints Experiencesbodily

discomfortsassociatedwithdistress

Riskofpsychologicaldistressnototherwiseevident

Whenyouhavefeltnervousoranxious… 27.…haveyoufeltshaky? 28.…hasyourheartbeatveryfast? 29.…haveyoufeltshortofbreadth? 30.…haveyourhandsfeltclammy? 31.…hasyourstomachbeenupset? 43.Haveyouhadbadheadaches?

SuicideIdeation Thoughtsandintentionstoharmoneself

Riskofsuicideattemptsorgestures

11.Haveyouwishedyouweredead? 16.Haveyoufeltlikelifewasnotworthliving? 18.Haveyoufeltlikehurtingyourself? 22.Haveyoufeltlikekillingyourself? 47.Haveyougivenuphopeforyourlife?

ThoughtDisturbance (BoysOnly)Unusual

beliefsandperceptions

Riskofthoughtdisorder

9.Haveyouseenthingsotherpeoplesayarenotreallythere?

20.Haveyouheardvoicesotherpeoplecan’thear? 25.Haveotherpeoplebeenabletocontrolyourbrainoryourthoughts?

26.Haveyouhadabadfeelingthatthingsdon’tseemreal,likeyou’reinadream?

32.Haveyoubeenabletomakeotherpeopletothingsjustbythinkingaboutit?





QuestionsonScale

TraumaticExperiences Lifetimeexposureto

traumaticevents(e.g.,abuse,rape,observedviolence).Questionsreferyouthto“everinthepast”not“pastfewmonths”

Riskoftrauma‐relatedinstabilityinemotion/perception

Girls

48.HaveyouEVERINYOURWHOLELIFEhadsomethingverybadorterrifyinghappentoyou?

49.Haveyoueverbeenbadlyhurt,orbeenindangerofgettingbadlyhurtorkilled?

50.Haveyoueverbeenraped,orbeenindangerofgettingraped?

51.Haveyouhadalotofbadthoughtsordreamsaboutabadorscaryeventthathappenedtoyou?

52.Haveyoueverseensomeoneseverelyinjuredorkilled(inperson–notinmoviesoronTV)?

Boys

46.Havepeopletalkedaboutyouwhenyou’renotthere?

48.HaveyouEVERINYOURWHOLELIFEhadsomethingverybadorterrifyinghappentoyou?

49.Haveyoueverbeenbadlyhurt,orbeenindangerofgettingbadlyhurtorkilled?

51.Haveyouhadalotofbadthoughtsordreamsaboutabadorscaryeventthathappenedtoyou?

52.Haveyoueverseensomeoneseverelyinjuredorkilled(inperson–notinmoviesoronTV)?



APPENDIX C: 10TH JUDICIAL DISTRICT AGENCIES IMPLEMENTING

MAYSI‐2

Agency Contact# AddressWhenMAYSI‐

2isadministered

10thJudicialDistrictJuvenileProbation

AmandaMcGowan,Supervisor

[email protected]

719‐258‐5658

1120CourtStreet,Pueblo,CO81003

Intake

PuebloYouthCenter

AnnetteDietrich,Director

[email protected]

719‐546‐4902

1406W.17thStreet,Pueblo,CO81003

Intake



APPENDIX D: PUBLIC MENTAL HEALTH SERVICES & COMMUNITY

SERVICES RELEVANT TO MAYSI‐2 IN THE 10TH JUDICIAL DISTRICT

DRUG/ALCOHOLTREATMENTPROVIDERS/**DUITREATMENTPROVIDERS

AllagencieslistedareColoradoState/Courtapprovedproviders:

**Adult/YouthCounselingRoyMcClendonSvcs.CentralPuebloCenter803W.4thSt.SuiteFPueblo,CO81003(719)583‐8222

**AmericanCounselingInstitute635WCoronaSuite203Pueblo,CO81003(719)542‐7467

AssociatesforPsychotherapy924IndianaAve.Pueblo,CO81004(719)564‐9039or1(800)330‐3878

**AwarenessInstituteJJRaigoza1245PalmerAve.Pueblo,CO81004(719)546‐0904

**BridgeToAwareness310West“C”St.Pueblo,CO81003(719)296‐1366

**CrestoneRecoveryProgram(SPMHC)3691ParkerSuite200Pueblo,CO81008(719)545‐2746

CrossroadsTurningPoint‐Inc.509E13thSt.Pueblo,CO81001(719)546‐6666

**CrossroadsTurningPointsInc.BradBertrand1615BonforteBlvd.Pueblo,CO81001(719)404‐1992

**DepartmentofVeteranAffairsClinic4112OutlookBlvd.Pueblo,CO81008(719)553‐1000

**Nextep2415LakeAve.Pueblo,CO81004(719)583‐8428

**OasisCounseling200W.29thSt.Pueblo,CO81003(719)544‐[email protected]

**OasisCounseling431QuincyStPuebloCO81005(719)545‐1093

**OasisWest279S.JoeMartinezBlvdPueblo,CO81007(719)647‐1787

**SouthernColoradoComprehensiveCourtSvc200W.“B”St.Suite226Pueblo,CO81003(719)595‐1634



INPATIENTTREATMENTPROGRAMS

Women’sSTAR‐TCCrossroadsATurningPoint3470BaltimorePueblo,CO81008(719)561‐9850

PuebloSTIRRT‐FemaleCrossroadsTurningPoints3500BaltimoreAve.Pueblo,CO81008(719)545‐1181

PuebloSTIRRT‐MaleCrossroadsTurningPoints1711E.EvensPueblo,CO81004(719)566‐0234

Men’sTherapeuticCommunityCorrections509E13thSt.Pueblo,Co81001(719)546‐6666

ParkviewChemicalDependencyUnit58ClubManorDr.Pueblo,CO81008(719)584‐4890or(719)584‐4343

OasisCounseling431QuincyPueblo,CO81004(719)544‐3497(719)250‐7003

Resada11000CountyRd.GG.5POBox162LasAnimas,CO81054(719)456‐2600

IN‐HOMEDETENTION

SouthernColoradoComprehensiveCourt200W.“B”St.Suite226Pueblo,CO81003(719)595‐1634

CCSI(CommunityCorrectionsServices,Inc.)1901NHudsonAve.Pueblo,CO81001(719)544‐6674

HomeDetentionSystems319S.Union,SuiteDPueblo,CO81003(719)583‐7866

Nextep2415LakeAvenuePueblo,CO81005(719)583‐8428

Intervention801W4thSt.Suite101Pueblo,CO81003(719)543‐1000



APPENDIX D CONTINUED: PUBLIC MENTAL HEALTH SERVICES &

COMMUNITY SERVICES RELEVANT TO MAYSI‐2 IN THE 10TH

JUDICIAL DISTRICT

DOMESTICVIOLENCETREATMENTPROVIDERS*ThefollowingisalistofproviderstowhichtheProbationDepartmentiscurrentlyrefers.TheDVOMBapprovedtreatmentproviderlistcanbelocatedonthewebat;

dcj.state.co.us/odvsom/

SeeDV&SOList

IforderedtocompletetheYWCA’s“EffectsofDVonChildren”Call545‐8195(1class)

ANGERMANAGEMENTCLASSES

ColoradoCourts&CouplesCounselingSvcs.544E.AbriendoAve.Pueblo,CO81004(719)334‐9657

NewBeginningsM.H.Svc1301W.17thStreetPueblo,CO81003(719)545‐5211

ParkviewFamilyCounseling400W.16thSt.Pueblo,CO81003(719)584‐4700

FiresfortheNation114ErisSt.Pueblo,CO81001(719)543‐6429(719)543‐8008

WilliamBeaver,M.A.,Inc.710HunterAve.Pueblo,CO81001(719)542‐3355(office)(719)542‐1699(fax)

Adult/YouthCounselingCentralPuebloCenter803W.4thSt.SuiteFPueblo,CO81003(719)583‐8222

SouthernColoradoComprehensiveCourt200W.“B”St.,Suite226Pueblo,CO81003(719)595‐1634

PARENTINGCLASSES

SpanishPeaksMentalHealth1304ChinookLn.Pueblo,CO81001(719)545‐2746

St.MaryCorwinRMC1008MinnequaAve.Pueblo,CO81005(719)560‐4817

ParkviewMedicalCenter400W.16thSt.2EastConferenceRoomPueblo,CO81003(719)584‐4457



THEFTSEMINAR

Adult/YouthCounselCentralPuebloCenter803W.4thSt.SuiteFPueblo,CO81003(719)583‐8222

SouthernColoradoComprehensiveCourt200W.“B”St.Suite226Pueblo,CO81003(719)595‐1634

MENTALHEALTHTREATMENTPROVIDERS

SpanishPeaksMentalHealth1304ChinookLn.Pueblo,CO81001(719)545‐2746

AssociatesforPsychotherapy924IndianaAve.Pueblo,CO81004(719)564‐9039or1(800)330‐3878

ParkviewMedicalCenter400W.16thSt.Pueblo,CO81003(719)584‐4767or(719)584‐4700

SouthernColoradoComprehensiveCourtSvc.200W.“B”St.Suite226Pueblo,CO81003(719)595‐1634

CatholicCharitiesofDioceseofPueblo,Inc.429W.10thSt.,Suite101Pueblo,CO81003(719)544‐4215Updated8/17/2011



APPENDIX E: 10TH JUDICIAL DISTRICT RELEASE OF INFORMATION

CaseNumber:____________________

AuthorizationforReleaseofInformationRelatedtoaMinorinaJuvenileDelinquencyCase I, ________________________________________, hereby consent to communication between Name of Client/Juvenile _______________________________________________ and the following: Name of Education/Treatment Program Judge

10th Judicial District Probation Department

Defense Attorney Parent/Guardian/ Legal Custodian

Prosecuting Attorney Guardian Ad Litem

Social Services

Useful Public Service

Mental health provider

School/Education Programs

SB94

Service Management Team (SMT) (may include a substance abuse treatment provider, a mental health treatment provider, HB1451 representative, and D-60 representative)

Other (Person who has a duty to monitor treatment in connection with the disposition of this case or a need to know) __________________________________________________________________ The purpose of and need for the disclosure is to inform the person(s) and/or organizations listed

above of my attendance and progress in treatment, or Other Reason for disclosure_______________________________________________________

The extent of information to be disclosed is: Name Diagnosis Information

Referral Information Attendance Data

Clinical Progress Data

Treatment history

Education/Termination Data

Drug Testing Results

Medical History/Exam Data

Any and all case file information

Evaluation data

Other: (Specify)_________________________________



I agree that the Probation Departmentmay send information listed above, including the PresentenceInvestigationReporttotheagenciesandindividualslistedabovethroughthee‐mailsystem._____(Initial)

IunderstandthatImayrevokethisconsentatanytimeinwriting.However, if thecourthasmadeitatermandconditionofprobationthatIsignanauthorizationforreleaseofinformationandIrevokemyconsent, Imaybe inviolationofmyprobation. Iamawarethat if I revokemyconsent, inwriting, thewithdrawalwillnotbeeffectiveastousesand/ordisclosuresofmyhealthinformationthattheperson(s)andororganization(s)listedabovehavealreadymadeinreferencetothisauthorization.

I understand that this consent expires and cannot be used past the following date: __________ (not toexceedoneyear).IfthecourthasmadeitatermandconditionofprobationthatIsignanauthorizationforreleaseofinformationIwillberequiredtosignanotherauthorizationeveryyearuntilsuchtimeasmyprobationisterminated.

Iunderstandthatcopiesofthisformmaybeusedplaceoftheoriginal.

Iunderstandthatmyalcoholand/ordrugtreatmentrecordsareprotectedbyfederallawandregulationsgoverningConfidentialityofAlcoholandDrugAbusePatientRecords,42C.F.R.Part2andmayalsobeprotectedbytheHealthInsurancePortabilityandAccountabilityActof1996(“HIPAA”),45C.F.R.Pts.160and 164, and cannot be disclosed without my written consent unless otherwise provided for in theregulations. Ialsounderstand thatrecipientsof this informationmayre‐disclose itonly inconnectionwiththeirofficialduties.

Iunderstandthatgenerally__________________________________________(NameofTreatmentProvider)maynotconditionmytreatmentonwhetherIsignaconsentform,butincertainlimitedcircumstancesImaybedeniedtreatmentifIdonotsignaconsentform.

Client/JuvenileSignature:____________________________________________________

Date:_____________________________________________

Witness:________________________________________________________

Date:_________________________________________________

Parent/GuardianSignature:____________________________________________________

Date:_____________________________________________

RelationshiptoDefendant:________________________________________________________

PROHIBITIONONREDISCLOSURE

Thisnoticeaccompaniesadisclosureofinformationconcerningaclientinalcohol/drugtreatment,madetoyouwith theauthorizationof suchclient. This informationhasbeendisclosed toyou fromrecordsprotectedbyfederalconfidentialityrules(42C.F.R.Part2).Thefederalrulesprohibityoufrommakinganyfurtherdisclosureofthisinformationunlessfurtherdisclosureisexpresslypermittedbythewrittenconsent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A generalauthorization for the release ofmedical or other information is NOT sufficient for this purpose. Thefederalrulesrestrictanyuseoftheinformationtocriminallyinvestigateorprosecuteanyalcoholordrugabusepatient.



APPENDIX F: DEPARTMENTAL POLICY 112

ProbationDepartment

PoliciesandProcedures

JudicialDistrict

PolicyNo.:112

Chapter:Administration Effective:September2007Topic:ReleaseofOffenderInformation

Reviewdate:September2009Reviewdate:October2012

Applicability:allstaffDirectivesandReference:ChiefJusticeDirective05‐01,FederalLaw42CFRpart2;C.R.S.24‐72‐305.5;ColoradoChildren’sCode19‐1‐303and19‐1‐304;Standardsforprobation2.1and2.2

I. DEFINITIONS:

Release of information – A form signed by the probationer that gives the Probation Departmentpermissiontoreleaseinformationfromthedepartment’sfileontheprobationer.

OfficialAction–Thoseactionstakenbyacriminal justiceagencyrelatedtoacase. Arrest information,summonsandcomplaint,decisionstograntprobation,andmodifyorrevokeprobationareallexamplesofanofficialaction.OfficialactioninformationisPublicrecordinformation.

LSI–LevelofSupervisionInventory

ASUS–AdultSubstanceUseSurvey

SSI–SimpleScreeningInstrument

ASUDS–AdultSubstanceUseDrivingSurvey

II. POLICY:

For thepurposesof anoffender’s right to confidentiality, disclosureof theoffender’s case informationthat isnotdefinedaspublicrecord isnotpermittedunless there isaduty towarnsituation, thecourtordersrelease,orthereisareleaseofinformationsignedbytheoffender.

JuvenileDelinquencyrecordsshallnotbereleasedunlessorderedbytheCourt,orareleaseissignedbyallparties,orpartiesarecoveredunder19‐1‐304(1)(c).SeeAttachmentA.

Presentence investigation reports, alcohol evaluation reports, treatment records, medical informationandmental health records shall not be released unless ordered by the court, or there is a release ofinformationsignedbytheoffender.

Offender information may be shared with other criminal justice agencies for purposes of direct casesupervision or if the information being shared is directly related to the investigation of a crime orprotectionofthecommunity.Informationrelatedtotreatment,medicalconditionsormentalhealthshallnotbereleasedabsentareleaseofinformationsignedbytheoffender.

Copyrightedinformationshallnotbereleasedwithoutasubpoena.TheseshallbeforwardedtotheChiefProbationOfficer.TheLSI,ASUSandSSImaybereleasedtoothercriminaljusticeagenciesandagenciesapproved by ADAD. The ASUDS shall never be released. The summary profile scoring guide on theASUDSmaybereleasedtoothercriminaljusticeagenciesandagenciesapprovedbyADAD.Theattorney



ofrecordinaprobationcasemayviewthecopyrightedinstrumentswiththeexceptionofacompletedASUDS,butmaynotobtainacopyoftheinstrumentunlessthecourtordersrelease.

III. PROCEDURE:

1. PublicRecord(OfficialActions)Information(AppliestoAdultCasesOnly)

a. Whenrequestaremadebythevictimoramemberofthepublicforpublicrecord(OfficialActions) information, the staff person shall check to make sure that the informationrequested is Public Record information. If so, the informationmay be provided to therequestingparty.

b. Iftheinformationisnotpublicrecordorthestaffpersonisindoubt,theyshallreferthepersonrequestingtheinformationtotheChiefProbationOfficer.

2. JuvenileDelinquencyrecords:

a. Juvenile records shall not be released unless ordered by the court. Section 19‐1‐304(1)(c), C.R.S., allows for certain parties access to juvenile records. This does notinclude treatment and mental health information. Please see attachment A (§19‐1‐304(1)(c),C.R.S.)

b. Afterinformationisreleased,theprobationstaffmemberwilldocumentinE‐clipsewhatwasreleased,andtowhomtheinformationwasreleased.Iftheinformationwasreleasedtoapersonthatiscoveredunder19‐1‐304(1)(c)thestaffmemberwill indicatethattheinformationwasreleasedtoapersoncoveredbystatute.

3. ConsentforReleaseofInformation

a. ProbationOfficers requesting information from another agency on a limited basis shallusetheConsentforReleaseofInformationform.

b. ProbationOfficers requesting information on an ongoing basis from a service providershallcompletetheoffenderConsentforReleaseofInformationthatspecificallydetailsthesharingofinformationbetweenagencies.

c. Informationrequestedthatpertainstodrugandalcoholtreatment,mayonlybereleasedwithasignedauthorizationforreleasethatiscompliantwithfederallaw42CFR2.

d. Copies of all Consent Forms shall be maintained in the offender’s file along withdocumentationofwhatinformationwasreleased.

e. Probation Officers shall have release forms updated and signed by the offender on ayearlybasis.

4. Subpoenas

a. IfaProbationOfficerreceivesasubpoenaorasubpoenaducestecum(withfilematerials)toappearincourtonanofficialactionpertainingtothecasebeingsupervised,theymustappearasordered.Thecasenarrativesandseparatevictimfileinformationisincludedinthe complete probation record and should be printed from E‐clipse and taken to thehearing.Seepolicy201–Victim’sRights



b. Allother subpoenas (i.e. civil actions,divorceactions,dependencyandneglectmatters)foroffenderrecordsshallbeimmediatelysenttotheChiefProbationOfficer.

c. TheChiefProbationOfficer,usingtheConfidentialInformationChecklist(AttachmentB)shall consult with the State Court Administrator’s Office/Attorney General’s office todeterminewhatifanyinformationcanbereleased.

5. Revocationhearing

a. ThedefendantandDefenseattorneyofrecordarenotrequiredtosubpoenathefileonanofficialactionpertainingtothecase.Thedefendantanddefenseattorneyofrecordmustbe allowed to have access to the offender file regardless ofwhether there is a pendingrevocation.

6. RequestforInformationbyDefenseAttorneysofRecord/DistrictAttorney/GuardianAdLitem

a. All information in an offender’s file, with the exception of the NCIC/CCIC reports andcopyrightedinstruments,mustbereleaseduponrequestifsuchinformationpertainstorevocation of probation. The probationer or the defense attorney of record can alsoobtain all information with the above named exceptions, regardless of whether arevocationispending.IftheDistrictAttorneyrequestsaccesstothefilewhenthereisnorevocation pending access must be obtained via a subpoena duces tecum, a searchwarrantorareleaseofinformationsignedbytheoffender.

b. WhenConsentsforReleaseofInformationandsubpoenasdonotspecifytheinformationneeded,theProbationOfficershouldcontacttherequestingparty,andaskthemtospecifywhatinformationisneeded.

c. Whentherequestingparty isunable tospecify the informationneeded, theofficershallprovide them access to the file at a probation location to review the file. Because ofresources limitations,ourpracticeshallbetonotmakecopiesoftheentirefilebutonlythosedocumentsidentifiedasbeingneeded.

d. AstaffpersonoftheDepartmentshallcopytheinformation

e. A copy of the release or subpoena shall be maintained in the file along with a list ofinformationreleased.

7. ReleasetoAllOtherPersonsNotConnectedtotheSupervisionoftheProbationer.

a. Forallpersonswhoarenotdirectlyconnectedtothecaseunderwhichtheprobationerisbeing supervised, records and information, other than public records, can only bereleased with a signed release of information, subpoena or a search warrant (lawenforcementagenciesincludingFBI,ICE,DAinvestigators).



ATTACHMENT A

19-1-304. Juvenile Delinquency records

(1) (c) Probation records - limited access. Except as otherwise authorized by section 19-1-303, a juvenile probation officer's records, whether or not part of the court file, shall not be open to inspection except asprovided in subparagraphs (I) to (XI) of this paragraph (c):

(1)

(II) To law enforcement officers, as defined in section 19-1-103 (72), and to fire investigators, as defined in section 19-1-103 (51). The inspection shall be limited to the followinginformation:

(A) Basic identification information as defined in section 24-72-302 (2), C.R.S.;

(B) Details of the offense and delinquent acts charged;

(C) Restitution information;

(D) Juvenile record;

(E) Probation officer's assessment and recommendations;

(F) Conviction or plea and plea agreement, if any;

(G) Sentencing information; and

(H) Summary of behavior while the juvenile was in detention, if any;

(II.5) To the Colorado bureau of investigation for purposes of conducting a criminal background investigationrelating to authorization of a firearm purchase. The inspection shall be limited to the information identified insub-subparagraphs (A) to (H) of subparagraph (II) of this paragraph (c).

(III) To a court which has jurisdiction over a juvenile or domestic action in which the juvenile is named;

(IV) To any attorney of record in a juvenile or domestic action in which the juvenile is named;

(V) To the state department of human services;

(I) To persons who have the consent of the court;



(VI) To any person conducting an evaluation pursuant to section 14-10-127, C.R.S.;

(VII) To all members of a child protection team;

(VIII) To the juvenile's parent, guardian, or legal custodian;

(IX) To the juvenile's guardian ad litem;

(X) To the principal of a school, or such principal's designee, in which the juvenile is or will be enrolled as a student and, if the student is or will be enrolled in a public school, to the superintendent of the school district inwhich the student is or will be enrolled, or such superintendent's designee; or

(XI) To the department of education when acting pursuant to section 22-2-119, C.R.S., or pursuant to the "Colorado Educator Licensing Act of 1991", article 60.5 of title 22, C.R.S.

ATTACHMENT B CONFIDENTIAL/ PROTECTED INFORMATION CHECKLIST WITH

AUTHORITIES 05/17/2010

Drug/Alcohol Treatment Information (including UA testing results if probationer is in treatment): 42 USCS §290dd-2 and 42 CFR § 2.1, §290ee-3, 42 CFR §2.35; § 25-1-312. Records of alcoholics and intoxicated persons; §25-1-1108. Records of drug abusers and persons under the influence of drugs.

o Can provide to district attorney or defense attorney who are involved in case beingsupervisedwithoutreleaseorsubpoena;bestifthereleaseofinformationindicatesupfronttheinformationcanbeprovidedtothem.

o All other uses/requests must have release from client or subpoena, this includes lawenforcementbecause federal lawspecificallyprohibits theuseof treatment informationas the basis for an investigation of other offenses; law enforcement may also obtainthroughasearchwarrant

InformationRelatedToMedicalConditionAndAnySupportingMedicalRecordsThatMayBeContainedInTheFile:HIPAA‐‐45C.F.R.Parts160and164;§24‐72‐204(3)(a)C.R.S.

o same as above regarding release

Information Related to Mental Health Records: HIPAA— 45 C.F.R. Parts 160 and 164; §27-10-120, C.R.S.

Copyrighted Materials

o For Probation some assessment instruments are copyrighted and Judicial pays for alicensetousethese;includedinthecontractisaprovisionthatwewillmakeeffortstonotreleaseordistributethe©instrument,profiles,manualsetc.



o Do not release to ANYONE unless subpoenaed AND court ordered (SCAO should benotifiedifrequestformaterialsrelatesspecificallytocopyrightedmaterialssothatAGcanrepresentandfilemotiontoquashsubpoena)

PSIR

o The PSIR is no longer public information pursuant to CJD 05-01 effective July 1, 2007

Information That is Sealed or Deemed Confidential By Court Order

o In some cases the court will enter an order that certain materials or the entire file are deemed confidential until further notice by the court. No one is allowed access without a court order.

o If a case is sealed pursuant to § 24-72-308, C.R.S. because a case is dismissed or the person is acquitted (for someone on probation this might occur after appeal), the existence of a case shall be denied except upon inquiry by another criminal justice agency.

The Identity of the Victim in a Case Involving Sexual Assault:

o §24-72-304(4), C.R.S. Priortoreleasinganyinformationtoanyoneotherthanacriminaljustice agency, the name of a victim of a sexual assault must be removed from alldocumentsinafile. Thisalsoapplieswhenfilesaresubpoenaedintoacaseotherthantheonethatisbeingsupervised.

TheIdentityofaJuvenileCo‐Defendant

o When an adult case contains information about a juvenile co‐defendant who has beenprosecutedasajuvenile,theidentityofthejuvenileshouldberemovedfromthefilepriorto release to anyone other than parties involved in the case being supervised (DA anddefenseattorney).

Juvenile Records: §19-1-304 C.R.S.

o Juvenile records are not accessible to the public without the consent of the court. See attached for statutory list of persons who can access probation files without the consent of the court.

o School personnel may obtain any information required to perform their legal duties and are required to keep confidential any information they obtain.

o Information on juveniles can be shared with other agencies that perform duties and functions related to delinquency or dependency and neglect with either a signed release from the juvenile and parent or on a need to know basis if the juvenile and parent refuse to sign a release.

CCIC/NCIC—Criminal History Records Information (CHRI). 28 CFR Part 20

o Prohibits the dissemination of reports to anyone other than another criminal justice agency.

ICON/ Eclipse Probation Records and CJD 05-01

o These records are specifically not accessible to the public. See Directive at: http://www.courts.state.co.us/supct/directives/05-01.pdf

maysi‐2 administration & referral protocol manual

Documents