Preschool & Early Childhood Scale Form Scores For Child'S Functioning Template
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1PECFAS SUMMARY SCORING SHEET
PRESCHOOL & EARLY CHILDHOOD FUNCTIONAL ASSESSMENT SCALE
For Child & Family Behavioral Health Treatment Services (65M)
________________
Child’s First Name:
Middle Initial: _____Last Name:_______________________
Child ID:_____________________ Date Assessed:____/____/______ Service Start Date: _____/____/______
Agency Case #:__________MaineCare #_______________
DOB: ___/____/_____ Gender ___M ___F
Child’s County Residence: _________________ Region: ____ I ____II ____ III
Rater Name:________________________ Agency Name:______________________________________
Rater ID#:______________________
Services Program (check the following)
PECFAS Administration:
Child & Family Behavioral Health Treatment Services (65M) ____
_____Entry into Service
Reauthorization ___(1) ___(2) ___(3)
___ Exit ____Other _______________________
Preschool & Early Childhood Scale Scores for Child’s Functioning
DIMENSION
DIMENSION
RATING
Choose one rating option
(30) (20) (10) (0)
Role Performance
School/Preschool
Home
Community
Behavior Toward Others
Moods/Self-harm
Moods/Emotions
Self-Harmful Behavior
Thinking/Communication
TOTAL FOR CHILD
Levels of Overall Dysfunction based on Youth’s Total Score
8-Scale Summary
Description
0-10
Child exhibits no noteworthy impairment
20-30
Child can be treated on an outpatient basis, provided that risk behaviors are not present
40-80
Child may need additional services beyond outpatient services
90-120
Child likely needs care which is more intensive than outpatient and/or which includes multiple
sources of supportive care
130 & higher
Child likely needs the most intensive levels of treatment
Rev 6/1/06 & 10/1/07
FAX OR MAIL COPY TO THE APPROPRIATE DHHS REGIONAL OFFICE
Region I - DHHS, CBHS, 161 Marginal Way, Portland, ME 04101 (Fax: 822-2358);
Region II - DHHS, CBHS, 11 SHS, Greenlaw Bldg, Augusta, ME 04333 (Fax: 287-7557)
Region III – DHHS, CBHS, 176 Hogan Road, Bangor, ME 04401 (Fax: 561-5389)
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