MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION NEWBORN CRISIS ASSESSMENT TOOL (NCAT)
CASE DATA
Referral Number	County	Drug Involved Non-Drug Involved
Case Name	Children’s Service Worker
Child’s Information
Infant’s Name	DOB
Birth Weight	Gestational Age	Discharge Date
Parent’s Information
Mother’s Name	Father’s Name
Is Father on Birth Certificate? Yes No	If no, was an affidavit signed by the alleged father? Yes No
Additional Comments:
PRIOR HISTORY
No history Prior Newborn Crisis Assessment on sibling(s) Parents/caregivers have a history of abuse/neglect or previous CD case with protective services History of children out of the home with relatives, friends, or foster care Protective services case is currently open CD investigation/assessment currently pending Siblings currently placed out of the home Siblings currently under court jurisdiction Siblings have been Termination of Parental Rights History of domestic violence Prior history of safe sleep related incident, death of another child in the home or serious injury to another child in the home.
Summary/Comments:
MEDICAL DOCUMENTATION
HOSPITAL	PHYSICIAN	PHONE
HOSPITAL CONTACT PERSON	PHONE
PRENATAL CARE
Regular prenatal care	Prenatal Care Provider:
Inconsistent, late, or no prenatal care Prenatal drug use Unwanted pregnancy
Comments:
Pregnancy Complications; Yes No
Describe:
TOXICOLOGY AT BIRTH
Mom Urine Drug Screen	Infant Urine Drug Screen	Infant Meconium Drug Screen	Cord Drug Screen
Pending Positive	Not done Negative	Pending Positive	Not done Negative	Pending Positive	Not done Negative	Pending Positive	Not done Negative
Substances	Substances	Substances	Substances
Substances	Substances	Substances	Substances
Substances	Substances	Substances	Substances
Has the infant been identified as affected by substance abuse, withdrawal symptoms resulting from prenatal drug exposure, or “a Fetal Alcohol Spectrum Disorder”? Yes No
Withdrawal Symptoms: None Seizures/abnormal neurological findings Uncontrolled crying, increased irritability, trembling Abnormal GI, persistent feeding problems, watery stools Mild sensory deficit, increased or decreased activity Requires medication for withdrawal
Comments:
*Note: When determining if an infant has been “affected” by substance use or withdrawal symptoms resulting from prenatal drug exposure, or a Fetal Alcohol Spectrum Disorder, Children’s Division staff shall assess if the child’s physical, mental, or general well-being is affected by the use of substances by the parent/caretaker and a Plan of Safe Care is needed.
HEALTH CARE NEEDS OF INFANT
Special Health Care Needs of the Infant: None Infant on monitor, apnea Low birth weight (below 2400 grams or 5 lbs) Frequent medical follow-up needed Special feedings needed Special home care/treatment for infant
General Health Care Needs of the Infant:
Child has an identified pediatrician/primary care physician (PCP)
Name of Pediatrician/PCP or NA if none identified at this time
Child has medical coverage, i.e. Medicaid/insurance,
Type of coverage or NA if no coverage at this time
Comments:
BEHAVIOR ASSOCIATED WITH DRUG AND ALCOHOL USE OF PARENT(S)
No observed or known behaviors associated with drug and alcohol use Parent/caregiver admits to alcohol and/or drug use and is participating in a treatment program Evidence of drug/alcohol use and is not participating in a treatment program Prior treatment for drug/alcohol use Sibling(s) exposed to drugs or alcohol in utero Chemical use poses risk to family’s financial resources and affects ability to meet basic need of family Friends or family members appear under the influence of drugs or alcohol Drugs sold, used or made in the home
What substance use worries exist?
What is or has been successful in regard to treating your substance use?
What support do you need to help you with your substance use?
Scaling: On a scale of 0 to 10 where 10 is your substance use does not affect your ability to parent your infant and 0 you do not have the ability to parent your infant based on your substance use.
What supports could be provided for you to increase your number?
MENTAL HEALTH OF PARENT(S)
No known mental health needs Currently receiving mental health services Postpartum Depression Currently receiving physician assisted medication management for mental health needs History of suicide attempts Currently making suicidal gestures Chronic emotional, problems which impair ability to provide minimal care or supervision to infant Currently threatening to harm or actually harming the child Inability to function independently Not oriented to person, place, time Evasive, verbally hostile or physically assaultive/threatening to service provider Low cognitive functioning that would affect parent’s ability to take care of infant
What mental health worries exist?
What is or has been successful in regard to treating your mental health needs?
What supports do you need to assist you with your mental health needs?
Scaling: On a scale from 0 to 10, where 10 is your mental health needs do not affect your ability to parent and 0 you do not have the ability to parent your children based on your mental health needs.
What supports do you need to increase your number?
Domestic Violence reported in the household: Yes No Comments:
ATTACHMENT AND BONDING
What are you worried about in regard to parenting your infant?
What are you excited about in regard to parenting your infant?
What support do you need to help you parent your infant?
Observations of parent/child interaction and bonding:
Scaling: On a scale of 0 to 10, where 10 is you have all the supports you need and feel prepared to parent your infant and 0 you do not have any supports and do not feel prepared to parent our infant.
What supports could be provided to increase your number?
ASSESSMENT OF OTHER CHILDREN IN THE HOME
No other children residing in the home Parent(s) meeting mental health needs of other children in the home Parent(s) meeting educational needs of other children in the home Parent(s) meeting medical needs of other children in the home Parent(s) meeting physical needs of other children in the home, i.e., food, clothing, safe shelter, appropriate sleeping arrangements
Summary of observations of other children in the home:
OBSERVATIONS OF INFANT’S HOME ENVIRONMENT
Observed supply of baby formula Mother is breastfeeding. Observed crib or bassinet for infant Observed car seat for the infant Observed baby supplies for infant, i.e. diapers, bottles, wipes, clothing Observed food for others living in the home Observed operable plumbing and electricity/heating in the home Home free of physical or environmental hazards that might be dangerous for the infant Home free of infestations of insects or rodents
Describe infant’s sleeping environment:
Parent(s) has been given the Safe Sleep Flyer (CD 278) and worker explained the importance of a safe sleeping environment for the infant.
Parent has acknowledged and signed that they have received and understand the Safe Sleep Flyer (CD278).
Referrals made to Family Support Division, WIC, First Steps, Home Visiting, Parents As Teachers, or other community agency as needed.
Comments:
PLAN OF SAFE CARE
Was a Plan of Safe Care developed with the family? Yes No N/A
Was a referral(s) made for appropriate services for the affected child or family member/caregiver? Yes No N/A
Describe services referred:
A Plan of Safe Care should be inclusive of the following: Parents’ or infant’s treatment needs; Other identified needs that are not determined to be immediate safety concerns; Involvement of systems outside of child welfare A plan that is able to continue beyond the child welfare assessment if a case is not opened for further services.
Plan of Safe Care:
Who was involved with creating the Plan of Safe Care?
Were all involved with creating the Plan of Safe Care in agreement with the plan? Yes No
Comments:
SAFETY NETWORK
List name, relationship, and contact information for anyone the family identifies as being a support. This can include family, friends, and service providers.
WORKER’S SCALING ASSESSMENT OF SUBSTANCE USE AND MENTAL HEALTH
Scaling: On a scale of 0 to 10 where 10 is parents’ substance use does not affect their ability to parent their infant and 0 they do not have the ability to parent their infant based on substance use.
Comments:
Scaling: On a scale from 0 to 10, where 10 is parent’s mental health needs do not affect their ability to parent and 0 they do not have the ability to parent their children based on mental health needs.
Comments:
OTHER OBSERVATIONS, CONCERNS, OR RECOMMENDATIONS
Use this section to comment and summarize any other observations, concerns, or recommendations that have not already been addressed above.
SIGNATURES
CHILDREN’S SERVICE WORKER >	DATE
SUPERVISOR>	DATE