Attachment B - Mental Health Assessment Form Instructional Letter for Mental Health Providers

Dear Colleague,

Under your care is an unaccompanied child who is in the custody of the Office of Refugee Resettlement (ORR) in the Department of Health and Human Services (DHHS). As such, ORR must collect specific information on healthcare services received by the child. While in ORR custody, children are placed in government-funded care provider programs that are responsible for providing day-to-day care. The ultimate goals of ORR are to ensure the health and safety of the child while in custody and to unify the child with their sponsor, as soon as possible.

The entire Mental Health Assessment Form (MHAF) must be completed by the evaluating healthcare provider during every visit with a psychiatrist, psychiatric nurse practitioner or physician’s assistant, licensed psychologist or any other community based licensed mental health provider (e.g., social worker), and returned to the care provider program staff member at the conclusion of the evaluation.

The MHAF is comprised of 4 sections - General Information, History and Assessment, Review of Systems (ROS) and Mental Status Exam (MSE) and Diagnosis and Plan. Please note the following section-specific guidance:

• Mental Status Exam section: Provide specific details for all abnormal findings

• Diagnosis and Plan section –

• Medications: If a medication is given/prescribed, a corresponding diagnosis must be indicated.

• Special healthcare needs that require accommodation while admitted in ORR care -

• Onsite care provider clinician evaluation: Indicate if you feel the child would benefit from receiving additional care with program-based licensed mental health therapists or therapists who are working toward licensure (Note, all children routinely meet with program-based therapists on a weekly basis).

• Placement at a residential treatment center (RTC): If you feel an RTC admission is indicated, you must clearly state that it is due to a child being of harm to themselves or others. This statement is necessary as ORR operates under the principal of maintaining a child in the least restrictive environment and is constrained by policy that prohibits placing a child at an RTC unless they represent a harm to self or others (Note, RTC recommendations can only be made by licensed psychologists or psychiatrists).

• Health concerns that require follow-up services – Mental health specialist evaluation: Provide details on the specific type of services recommended (e.g., ongoing evidence-based therapy, intensive outpatient treatment, partial hospitalization, acute inpatient care)

• Clearance to travel: As stated, ORR’s primary objective is the safe and timely unification of children with their sponsors. For children identified with potential acute health conditions, ORR relies on healthcare provider recommendations to determine whether indicated follow-up services must occur prior to a child’s travel to unify with their sponsor or if they may be addressed after unification. Given this, please clearly identify on the form if a child is cleared to travel with or without restrictions by the conclusion of their evaluation with you.

Please ensure that copies of all health records, including clinical notes, lab results and imaging reports are forwarded to care provider program staff as soon as they are available. Also, please verify that all information entered on the form is legible and complete as this information will be transcribed and uploaded into a secure electronic data system owned by ORR.

If you have any questions or concerns regarding the information collected on this form or require additional direction, please contact the ORR’s Division of Health for Unaccompanied Children (DHUC) at DCSMedical@acf.hhs.gov.

Thank you,

Director, Division of Health for Unaccompanied Children (DHUC)

Unaccompanied Children Programs

Office of Refugee Resettlement

Administration for Children and Families

U.S. Department of Health and Human Services