Fillable 04.15.16 NRF Intake Assessment Form

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04.15.16 NRF Intake Assessment Form

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1
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Neurorelational Framework (NRF)
Intake Assessment for Child/Family/Adult
Client: ________________________ DOB: _____________ DOS: ____________ ID: _____________
This NRF Intake Assessment, which holds the conceptualization of the Three Steps is meant to be used as a background guide. For
some experienced clinicians who are used to offering semi-structured interviews while still building rapport, it may be brought into
sessions as a way to jot down notes, but never to be read from as a script. For those of you used to offering more organic intakes, this
assessment helps you to hold in mind certain concepts and a flow of the three steps (although they may unfold out of order).
STEP 1: STRESS RECOVERY & RESPONSE
1. Please describe the parent/child’s bedtime routine (what do you do in the hour before you or s/he
goes to bed):
Parent:____________________________________________________________________________________
Child:______________________________________________________________________________________
2. Are there techniques or rituals to help the parent/child relax at bedtime? Such as taking a warm bath,
listening to relaxing music, deep breathing, or imagery.
Parent: YES NO _________________________________________________________________________
Child: YES NO _________________________________________________________________________
3. Is the sleeping environment comfortable for the parent/child? Comfortable bed, comfortable bedroom
temperature, a clean, quiet and darkened bedroom.
Parent: YES NO _________________________________________________________________________
Child: YES NO _________________________________________________________________________
4. Does the parent/child nap?
Parent: YES NO _________________________________________________________________________
Child: YES NO _________________________________________________________________________
5. On average, how long does it usually take the parent/child to fall asleep?
Parent: ___________________________________ Child: ____________________________________
6. On average, how many hours of sleep; does the parent/child usually get in a night?
Parent: ___________________________________ Child: ____________________________________
7. On average, how many times does the parent/child wake at night?
Parent: ___________________________________ Child: ____________________________________
8. Does the parent/child snore? Parent: YES NO Child: YES NO
9. In general, how would you describe the parent/child when s/he wakes up:
Parent: Refreshed Not Refreshed __________________________________________________________
Child: Refreshed Not Refreshed __________________________________________________________
10. Does the parent/child take any non-medical or medical sleep aides?
Parent: YES NO If so, what? _______________________________________________________________
Child: YES NO If so, what? ________________________________________________________________
11. Others in the home have trouble with falling asleep, staying asleep or feeling refreshed when
waking?
______________________________________________________________________________________
2
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Extra Notes:
3
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth & Connie Lillas
Parent 1
Child
Parent 2
4
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Extra Notes:
5
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Green Zone Description: feel calm, present, regulated, and able to both learn and to connect.
What does it look like when you/your child is in the green zone? (describe eye contact, face, voice, body gestures, body tone)
In a 24-hour day, how many hours are you/your child in the green zone? _____
Is there a particular time of day or week are you/your child more likely to be in a green zone?
Morning ______ Afternoon ______ Night ______ Weekday_____ (more structure?) Weekend_____ (less structure?)
EYES
Bright, shiny eyes
Looks directly at people, objects
Looks away for breaks, then returns to eye
contact
Seems alert, takes in information
FACE
Smiles, shows joy
Neutral
Can express all emotions
VOICE
Laughing
Tone changes
BODY
Relaxed with good muscle tone
Stable, balanced and coordinated
movements
Moves arms and legs toward center of the body
Molds body into a caring adult when held
Moves faster or slower depending on environment
RHYTHM/RATE OF MOVEMENT
Changes smoothly to respond to the environment
Movements not too fast or too slow
Red Zone Description: the neuro system is firing quickly and there is a lot of activity that is either positive or negative
(excitement, anger) with a fast pace. “Pedal to the Medal”
What does it look like when you/your child is in the red zone? (describe eye contact, face, voice, body gestures, body tone)
In a 24-hour day, how many hours are you/your child in the red zone? _____
Is there a particular time of day or week are you/your child more likely to be in a red zone?
Morning _____ Afternoon _____ Night _____ Weekday______ (more structure?) Weekend_____ (less structure?)
RED ZONE
Too Fast/Gas Pedal
EYES
Open, squinted or closed eyes
May have direct, intense eye contact
May avoid eye contact
Eyes roll upward
Eyes look quickly around the room
FACE
Wide, open mouth
Anger, disgust
Frown
Fake/forced smile
Clenched jaw or teeth
VOICE
High-pitched crying, yelling or screaming
Loud
Hostile or grumpy
Sarcastic
Out of control laughing
BODY
Fingers spread out
Arched back; tense body position
Constant motion
Demands space by pushing, shoving, and getting into
others’ space
Biting, hitting, kicking, jumping, throwing
Bumps into things, falls
Threatening gestures (shakes finger or fist)
RHYTHM/RATE OF MOVEMENT
Fast movements
Impulsive movements
6
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Blue Zone Description: the neuro system is running slow and there is flat affect, withdrawn, detached, zoning out, & in own
world with a slow pace. “Brakes”
What does it look like when you/your child is in the blue zone? (describe eye contact, face, voice, body gestures, body tone
In a 24-hour day, how many hours are you/your child in the blue zone? _____
Is there a particular time of day or week are you/your child more likely to be in a blue zone?
Morning ______ Afternoon ______ Night ______ Weekday_____ (more structure?) Weekend_____ (less structure?)
BLUE ZONE
Too Sl
ow/Brakes
EYES
Glazed eyes (looks through rather than at things)
Looks away for a long time, looks down
Seems drowsy/tired
Does not look around the room for interesting items
Looks at things more than people
FACE
Flat/blank
Mouth turned down, sad
No smiles or hints of smiles
Few emotions shown
VOICE
Flat
Makes few to no sounds
Sounds cold, soft, sad, too quiet
BODY
Slumped/slouching
Low muscle tone
Little or no exploring play or curiosity
Wanders
Frozen or slow-moving
RHYTHM/RATE OF MOVEMENT
Slow movements
Slow to start moving
Combo Zone Description: here, in the neuro system, both the gas pedal and brake are on, and client can present w/
anxiety, clinging, whining behavior or appear to be calm but wound up & feels fear on the inside, with a jerky pace. “The New Driver”
What does it look like when you/your child is in the combo zone? (describe eye contact, face, voice, body gestures, body tone)
In a 24-hour day, how many hours are you/your child in the combo zone? _____
Is there a particular time of day or week are you/your child more likely to be in a combo zone?
Morning ______ Afternoon ______ Night ______ Weekday_____ (more structure?) Weekend_____ (less structure?)
COMBO ZONE
Fast & Jerky/Gas & Brake
EYES
Wide open eyes
Looks around as if worried or scared
Stares at things
Rolling of the eyes
FACE
Raised eyebrows
Furrowed brow
Trembling lips or mouth
Seems in pain
Mouth wide open
Startled expression
VOICE
High-pitched, nasal, sing-song voice
Moans or groans in pain
Whimpers
Wobbly/quivering voice or fast changes
BODY
Tense or rigid posture
Cowers or hides
Fast, repetitive movements (wrings hands, shakes foot)
Trembling hands
Clings, grabs
Flails around
RHYTHM/RATE OF MOVEMENT
Fast movements
Jerky movements
7
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Extra Notes:
8
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Is there a mismatch of personalities in the home that cause conflict in the family? YES NO
Co-escalating Pattern? YES NO Polarizing Pattern? YES NO Chaotic Pattern? YES NO
Toxic Stress Patterns:
1. Is stress occurring too frequently or does the stress response happen very suddenly?
Parent: YES NO Child: YES NO
2. Is there an inability to adjust to initial challenges that, over time, should no longer be stressful?
Parent: YES NO Child: YES NO
3. Has the stress response occurred over a long period of time?
Parent: YES NO Child: YES NO
4. Is the parent/child unable to return to a stable green zone from the stress response?
Parent: YES NO Child: YES NO
5. Is the sleep cycle disorganized? Parent: YES NO Child: YES NO
Heart, Hand, Head (HHH) Personality Preferences
Step 1 Summary Evaluation
PARALLEL PROCESS: How does this child/parent impact my physiology? In what
context(s) have I lost my regulation with this child/family?
Under Coordination
Under Stress
Zone Characteristics
Rank Order Priority
(first, second, third)
Parent Child
Heart
Responsive, engaging
Gives too much, over
accommodates
Hyper vigilance, fear, anxiety,
hyper/frenzied
Hand
Directives, delegates,
doers, leads
Demanding, dominates
& controls
Crying, anger, rage, mania
hyperactivity
Head
Reflective, thinkers,
problem-solvers
Detaches, dismisses &
ignores
Shut down, glazed, tuned out,
depressed, dissociated.
F
amily Member
Green Zone
% / #
Red Zone
% / #
Blue Zone
% / #
Combo Zone
% / #
Frequent Toxic
Pattern #
Stress Response
(HHH)
Dyadic Mismatch Notes
Child:
Parent 1:
Parent 2:
9
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Extra Notes:
10
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
STEP 2: LEVELS OF ENGAGEMENT
1
2
3
4
5
6
Age
appropriate
under all
conditions
including
stress w/
full range of
emotions
Age
appropriate
but vulnerable
to stress &/or
constricted
range of
emotions
Has capacity
but not at
age
appropriate
level
Inconsistent/
needs
sensorimotor
support &
structure to
function at
this capacity
Barely
evidence
capacity
even
w/support
Has not
reached this
level
Functional Capacities
BOTTOM-UP
Level 1: Calm Together: Getting Calm (Green Zone)
Together (by 3 months)
Level 2: Comfort Together: When calm, able to make
visual contact (eye contact/look at faces), or auditory
contact (vocalize or sing together), or movement
contact (rock together), or tactile contact (cuddle
together), and/or olfactory contact (smelling together)
that you both find comforting & connecting (by 3
months)
Level 3: Sharing Joy: When making comforting
contact, able to share joy & fall in love (by 5 months)
Level 4: Serve & Return Communication: When
sharing joy, able to create a continuous back & forth
flow of communication (circles) (by 9 months of age)
Level 5: Reading Non-Verbal Cues: When in the
flow, able to expand & read non-verbal emotional &
gestural cues (by 13-18 months of age)
TOP-DOWN
Level 6: Sharing Emotional Themes: When reading
cues, able to share feelings with others through
pretend play &/or talking (24-36 months)
Level 7: Linking Cause & Effect: When sharing
feelings, able to make sense & solve problems
together (36-48 months of age)
Description Notes of Interaction: _________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Was a KIPS Completed? YES NO Score: __________Interaction Normal Cautionary Failure
PARALLEL PROCESS: How far up the levels of engagement can I get with the parent
and with the child?
11
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Extra Notes:
12
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
STEP 3: BRAIN SYSTEMS
4 Brain System Risk Factors (use worksheet for scores)
Regulation System: I first need to get calm
inside my body
See Step 1 of your Intake Notes
Preferences/Strength (what s/he is able to do
within the capacity)
Parent Child
Triggers/Concerns (what s/he is unable to do
within the capacity)
Parent Child
Capacity for Deep Sleep Cycle:
1. Getting enough sleep?
2. Staying asleep?
3. Waking refreshed?
Capacity for Alert Processing State (Green Zone)
1. Is there enough green zone to support
development?
2. Is there enough green zone to support age
appropriate engagement?
Capacity for an adaptive use of all stress responses
1. Do they show all 3 stress responses?
2. Is the intensity of the stress response
matching the context (mild, mod, to severe
continuum context)?
3. (note) If one is in a toxic stress pattern, note
that usually there is a concern about stability
of the green zone and the flexibility of the
stress responses are compromised
Family Member
Regulation
Sensory
Relevance
Executive
Child:
/19
/10
/20
/3/12
Parent 1:
/22
/10
/18
/14
Parent 2:
/22
/10
/18
/14
13
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Parent Child Parent Child
Capacity for distinct states w/ smooth transitions
between states of arousal (zones)
1. Are the states clear or muddy?
2. Are there smooth changes between states of
arousal (zones) or not?
Capacity for connection to visceral cues
1. Awareness and connection to hunger, thirst,
tired, pain, bowel, bladder cues
2. What are the cues?
3. When do you see them?
4. Can the child send clear messages?
5. Can the parent read them?
Capacity for efficient stress recovery (getting back to
green)
1. Can the child get back to green on his/her
own?
2. Does the child need sensory-motor or
emotional support?
3. How much effort is required by an adult
caregiver to co-regulate the other?
Regulation System Notes:
14
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Extra Notes:
15
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Sensory System: When I’m calm inside my
body, I can begin to take in sensory
information from the outside world
Internal: Balance/vestibular/movement,
Proprioception (use of joints, muscles,
pressure)
External:
Tactile (light and deep touch), Taste,
Smell, Auditory, Vision
Preferences/Strengths (what s/he is able
to do within the capacity)
Parent Child
Triggers/Concerns (what s/he is unable to do
within the capacity)
Parent Child
Sensory Processing: Capacity to orient,
locate, discriminate, follow and track sensory
signals
• Is the infant, child, adult orienting and
registering the sensory information?
• Is the infant, child, adult accurately
identifying the source of the sensory
information?
• Is the infant, child, adult accurately
discriminating the sensory
information?
• Is the infant, child, adult accurately
following and tracking the sensory
information?
16
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Parent Child Parent Child
Sensory Modulation: see Step Two Notes with
the Rating Scale
Capacity to stay green with environmental
(lights, sounds, smells, etc.) and relational
(face, tone of voice, movements, gestures)
sensory input
1. Do you need to match or counter with
high intensity/fast rhythms or low
intensity/slow rhythms of sensory
input to get the child or parent to
green?
2. How much sensory-motor support do
you have to offer the child/parent or
dyad for Levels of Engagement?
3. Is the infant, child, or adult over or
under-reactive to sensory information?
If so, which sensory modality?
Principle: Experiment with sensations to
find sensory preferences: begin with low
intensity, slow rhythms, and short
durations to be safe
Sensory System Notes:
17
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Extra Notes:
18
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Relevance System: As soon as I take in
sensory information from the outside
world, I begin to organize it inside of me
as something that helps me feel
comfortable/safe or uncomfortable/in
danger
General concept: To what degree and in
what context does the parent/child
experience the outside world - as safe
or dangerous? What becomes relevant
to each person in the family?
Use your notes from the zones in Step 1
to guide these answers below. The
colors of the zones you already know
about are your guide.
Preferences/Strengths (what s/he is able to do
within the capacity)
Parent Child
Triggers/Concerns (what s/he is unable to do
within the capacity)
Parent Child
Capacity to flexibly experience, express &
modulate a full range of emotions
appropriate to context
1. Use your green, red, blue, and
combo zones from Step 1 as a
guide for mapping out
2. Can the child/parent use a full
range of positive to negative
feelings?
3. Can the child/parent show,
experience, and express feelings
within each of these zones?
4. What happens to the intensity
levels? (e.g., can s/he be mad and
stay green?)
5. Can s/he modulate and stay in a
mid-range intensity when the
context calls for it?
19
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Parent Child Parent Child
Capacity to learn from experience by
scanning a full range of positively to
negatively weighted (valenced) memories
appropriate to the context
(note: this capacity builds on the first
capacity in the relevance system of a
range of positive to negative weighted
feelings)
1. Where are the procedural
memories weighted – Towards a
balance of positive/negative?
Too much positive (denial)?
Too much negative (trauma
history)?
2. Does the child/parent show a
capacity to learn from past
experiences (this could be either
be shown procedurally or with
narrative)?
3. Is there an open learning system
where the parent/child can
tolerate disappointment and
having to learn new things that
are frustrating at first?
Capacity to create meanings that
accurately reflect self & others
(note) If there is an imbalance in the
positive/negative valence of feelings and
memories (these first two capacities in
the relevance system), then the appraisal
system of oneself and other(s) will be
imbalanced as well (includes the family’s
cultural values on what is right/wrong;
good/bad behavior)
20
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Parent Child Parent Child
1. Is the child/parent weighted
towards a balance, a more
positive or a more negative
appraisal of oneself? Of others?
Relevance System Notes:
21
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Extra Notes:
22
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Executive System: As I organize
what feels safe or dangerous, I
can respond to the outside
world, addressing the context
Preferences/Strengths (what s/he is able to do
within the capacity)
Parent Child
Triggers/Concerns (what s/he is unable to do
within the capacity)
Parent Child
Capacity to express spontaneous,
automatic & consciously controlled
behaviors in a flexible & purposeful
manner
1. For under 3 years of age, can
they respond with spontaneous
joy to relationships and novelty
and balance that with
participating in regular routines
(e.g., bathing, feeding, changing
clothes, sleeping routines)?
2. For three-year-olds and up, is
there a balance between
spontaneous joy and automatic
routines?
3. For three-year-olds and up, can
s/he appropriately inhibit to stay
on task or shift to another
priority according to the context
(note: this is conscious control)?
Capacity to integrate bottom-up
emotions with top-down control of
thoughts
1. For three years old and up, is
there an ability to identify
feelings, narrate feelings, and
reflect on them?
2. Is there any degree of hindsight,
insight, and foresight occurring?
23
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Parent Child Parent Child
Capacity to asses, integrate & prioritize
one’s own personal needs in relation to
other’s need and the external context
(Theory of Mind)
1. For three years old on up, is the
child/parent more oriented towards
oneself and being more assertive?
2. Towards others and being more
giving?
3. Balanced?
4. Is s/he aware that another person
can have a different feeling,
intention, or perspective different
than his or her own?
5. Can s/he juggle one’s own needs
and other’s needs at the same time?
Executive System Notes:
PARALLEL PROCESS: What brain systems are being used easily when working with this dyad? What brain systems are being
used to exert conscious control when working with this dyad?
24
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
Extra Notes:
25
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
26
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
27
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
28
Original Material from Lillas & Turnbull, 2009; NRF 3 Clinical Steps Manual from Lillas, 2016
Material Organized by Dalene Roth and Connie Lillas
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04.15.16 NRF Intake Assessment Form

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