Children's Functional Assessment Rating Scale (CFARS) - Florida

1. Client's Last Name: 2. Client's First Name: 3. Social Security Number: 4. Date of Birth: 5. Contractor ID: 6. Provider ID: 7. Site ID: 8. Evaluation Date: 9. County of Service: 10. Title 21 Coverage: 11. Staff Id: 12. SAMH Contract Number: 13. Form Type: 14. DCF Evaluation Purpose:
1=Admission/Initiation into episode of care 2=Six(6) months interval after admission 3=Discharge for agency 4=Administrative discharge

51-0448002 59-0192430 10

05 N

GHME1 C
(C=CFARs, F=FARS (1 through 5) 5=None of the above

(Only if DCF evaluation purpose is none of the abov

15. Program Evaluation Purpose:

1=Admission to Program 2=Six(6) months after admission to program 3=Annually after admission to porgram or service 4=Planned discharge/transfer to program service within agency 5=Administrative discharge 6=None of the above

16. Substance Abuse History:

Ratings Scale: 1=No problem 2=Less than slight problem 3=Slight problem 4=Slight to moderate problem 5=Moderate problem 6=Moderate to severe problem 7=Severe problem 8=Severe to extreme problem 9=Extreme problem

Please respond to the following functional domains based on the above scale 17. Depression: 18. Hyperactivity: 19. Cognitive Performance: 20. Traumatic Stress: 21. Interpersonal Relationships: 22. ADL Functioning 23. Work or School 24. Danger To Others: 25. Anxiety: 26. Thought Process: 27. Medical / Physical: 28. Substance Use: 29. Behavior in "Home" Setting: 30. Socio-Legal: 31. Danger to Self:

32. Security / Management Needs: Total: Signature

Children's Home Society of Florida Confidential

Date:
Revised 07/01/2006

e is none of the above.)

e discharge bove

sed 07/01/2006