CASII Worksheet

CASII Worksheet
Name*

First NameLast Name
Please check the applicable ratings within each dimension and record the score in the lower right hand corner. Total your score and determine the recommended lvel of care.
Risk of Harm

1. Low Potential for Risk of Harm2. Some Potential for Risk of Harm3. Significant Potential for Risk of Harm4. Serious Potential for Risk of Harm5. Extreme Potential for Risk of Harm
Score - Risk of Harm
Functional Status

1. Minimal Impairment2. Mild Impairment3. Moderate Impairment4. Serious Impairment5. Severe Impairment
Score - Functional Status
Co-Morbidity

1. No Co-Morbidity2. Minor Co-Morbidity3. Significant Co-Morbidity4. Major Co-Morbidity5. Severe Co-Morbidity
Score - Co-Morbidity
Recovery Environment - Level of Stress

1. Minimally Stressful Environment2. Mildly Stressful Environment3. Moderately Stressful Environment4. Highly Stressful Environment5. Extremely Stressful Environment
Score - Recovery Environment - Level of Stress
Recovery Environment - Level of Support

1. Highly Supportive Environment2. Supportive Environment3. Limited Supportive Environment4. Minimal Supportive Environment5. No Supportive Environment
Score - Recovery Environment - Level of Support
Resiliency and Treatment History

1. Full Response to Treatment2. Significantly Response to Treatment3. Moderate Response to Treatment4. Poor Response to Treatment & Recovery Management5. Negligible Response to Treatment
Score - Resiliency and Treatment History
Acceptance and Engagement Child/Adolescent

1. Optimal2. Constructive3. Obstructive4. Destructive5. Inaccessible
Score - Acceptance and Engagement Child/Adolescent
Acceptance and Engagement Parent/Caregiver

1. Optimal2. Constructive3. Obstructive4. Destructive5. Inaccessible
Score - Acceptance and Engagement Parent/Caregiver
Composite Score
Level of Care Recommendation
Level I
Level II
Level III
Level IV
Level V
Level VI
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