These questions are about how much your reactions to the events of September 11 are causing problems

…{{…{…{…{…{………………………{…{…{{…{…{…{{{…{{{{{{{{{{{{{{{{{{{{{…{…{…{…{…{{{Hurricane Assessment and Referral Tool for Children and Adolescents PROVIDER’S NAME: ___________________________________________________________________ PROVIDER #: ________________ SERVICE LOCATION ADDRESS: ___________________ ZIP: _________________________ Was the parent or caregiver present during the session? NO YES Name of Hurricane(s): ___________________ Child’s Name: ______________________________________________ Child’s School: _________________________________ LOCATION TYPE: (CHECK ONE) (1) TRANSITIONAL HOUSING/SHELTE (2) SCHOOL (3) HOME (4) COMMUNITY CENTER (5) DISASTER RECOVERY CENTER (6) HEALTH PROVIDER (7) PLACE OF WORSHIP (8) MENTAL HEALTH CENTER (9) OTHER _________________________ SERVICE TYPE: DATE ASSESSMENT TOOL ADMINISTERED: SESSION NUMBER: (CHECK ONE) _______ Initial Contact Crisis Counseling Enhanced Services ______ / _______ / ____________ RISK CATEGORIES: (CHOOSE ALL THAT APPLY) (12) Displaced from home; Length of time:____________ (1) Seriously Injured (12a) Number of shelter/displacement centers: _________ (12b) Currently in shelter/displacemer; Length of time: _______ (2) Family member/friend seriously injured or killed; Who? __________________________________________ ...