Coordinated Services Team Initiative (Cst) Page 7
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7B.
Functional Impairment in two of the following capacities (compared with
expected developmental level):
____
Functioning in self care – Impairment in self care is manifested by a person’s consistent inability
to take care of personal grooming, hygiene, clothes, and meeting of nutritional needs.
____
Functioning in community – Impairment in community function is manifested by a consistent
lack of age appropriate behavioral controls, decision-making, judgment and value systems
which results in potential involvement or involvement in the juvenile justice system.
____
Functioning in social relationships – Impairment of social relationships is manifested by the
consistent inability to develop and maintain satisfactory relationships with peers and adults.
____
Functioning in the family – Impairment in family function is manifested by a pattern of
significantly disruptive behavior exemplified by repeated and/or unprovoked violence to siblings
and/or parents, disregard for safety and welfare of self or others (e.g. fire setting, serious and
chronic destructiveness, inability to conform to reasonable limitations and expectations which
may result in removal from the family or its equivalent).
____ Functioning at school/work – impairment in any one of the following:
____ Impairment in functioning at school is manifested by the inability to pursue educational
goals in a normal time frame – e.g. consistently failing grades, repeated truancy,
expulsion, property damage or violence toward others; or
Identified as having an Emotional/Behavioral Disability (EBD) under ch. PI 11 and
115.76 WI Statutes; or
____ Impairment at work is the inability to conform to work schedule, poor performance,
poor relationships with supervisor and other workers, hostile behavior on the job.
4. The child/adolescent is receiving services from two or more of the following service systems: Please complete
“Service Provider Information” on page 2 for each service selected.
____ Mental Health
____ Social Services
____ Child Protection Services
____ Juvenile Justice
____ Special Education
____ Alcohol & Other Drug Abuse Services
Eligibility Criteria Waived Under Certain Circumstances for Day Treatment of Intensive In-Home
Psychotherapy under HealthCheck:
This individual would otherwise meet the definition of SED but has not yet received services from more than
one system, but, in judgment of the medical consultant, would be likely to do so were the intensity of treatment
requested could not be provided. Please explain:
This individual would otherwise meet the definition of SED but functional impairment has not persisted for six
months but, in the judgment of the medical consultant, the nature of the acute episode is such that such
impairment in functioning (as defined in the definition of SED above) is likely to be evident without the intensity
of treatment requested. Please explain:
Module 2
Page 24
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