Appendix - IAR DST Domains Quick reference guide - Version 2

Domain 1 - Symptom Severity and Distress

Children (5 - 11 years)

Assessment of a child on this domain should consider:

• Current and past symptoms and duration.
• Level of distress associated with the mental health issues.
• Previous experience of a mental health condition.
• Are symptoms improving/worsening, is distress improving/worsening, and are new symptoms emerging?

Scoring

0 = No problem in this domain

1 = Mild Symptoms are likely to be sub-diagnostic and have been experienced for less than three months (but this may vary)

a. Mild anxiety-related symptoms (e.g., occasional fears, worry, difficulty concentrating, occasional unexplained somatic symptoms like headache and stomach pain) without significant avoidant behaviour.

b. Mild mood-related symptoms (e.g., sadness, fatigue, apathy, some reluctance to participate in previously enjoyed activities, irritability, occasional disrupted sleep).

c. Mild behavioural symptoms (e.g., distractibility, overactivity, occasional difficulty following instructions or completing tasks, occasional concerning or aggressive behaviours, minor interpersonal difficulties).

d. Currently experiencing a mental health condition associated with mild distress or mild reduction in quality of life.

2 = Moderate Symptoms are at a level that would likely meet diagnostic criteria and have been experienced for more than three months (but this may vary)

a. Moderate anxiety-related symptoms (e.g., excessive worry, agitation, panic, difficulty concentrating, significant self-consciousness or significant concerns about body image, appearance or weight, frequent unexplained somatic complaints) with significant avoidance of anxiety provoking situations.

b. Moderate mood-related symptoms (e.g., excessive sadness, apathy, exhaustion, frequent irritability, loss of interest and pleasure and/or frequent reluctance to participate in previously enjoyed activities, frequent sleep disturbance).

c. Moderate behavioural symptoms (e.g., frequent impulsivity, hyperactivity, non-adherence to age-appropriate rules or social norms, frequent concerning or aggressive behaviours, significant interpersonal difficulties).

d. Currently experiencing a mental health condition associated with moderate levels of distress and/or moderate reduction in quality of life.

e. History of a diagnosed mental health condition earlier in childhood that has not responded to treatment, with continuing symptoms but only associated with mild to moderate levels of distress.

3 = Severe

a. Severe anxiety-related symptoms are present most of the time, the child has difficulty controlling or managing the symptoms and seeks to avoid anxiety provoking situations and/or experiences severe distress if asked to engage in anxiety provoking situations such that there is severe distress and/or significant disruption to the child’s (and/or parent/family’s) life.

b. Severe mood-related symptoms are present most of the time, the child has difficulty controlling or managing the symptoms and the symptoms are associated with severe distress and/or significant disruption to the child’s (and/or parent/family’s) life.

c. Severe behavioural symptoms are present most of the time, the child has difficulty controlling or managing the symptoms and the symptoms are associated with severe disruption and/or distress for the child, and/or their parent/family and interpersonal relationships.

d. Currently experiencing other severe mental health symptoms or severe psychological distress (e.g., complex trauma responses, obsessions, compulsions, severely disordered eating). Symptoms may be ongoing or of more recent or sudden onset.

e. Symptoms suggestive of an early form of a severe mental health condition (e.g., odd thinking/ behaviour/speech, abnormal perceptions, short periods of unusually elevated mood, a substantial decrease in the need for sleep) or symptoms suggestive of an eating disorder.

f. Has been treated by a specialist community mental health service or admitted to hospital for a mental health condition in the previous 12 months.

4 = Very severe

a. Very severe and pervasive anxiety symptoms are present virtually all the time, the child can rarely control or manage the symptoms and the child refuses to engage in anxiety provoking situations or activities. The symptoms are associated with severe distress, significantly reduced quality of life and/or severe disruption to nearly all aspects of the child’s (and/or parent/family’s) life.

b. Very severe and pervasive mood-related symptoms are present virtually all the time, and the child can rarely control or manage the symptoms. The symptoms are associated with severe distress, significantly reduced quality of life and/or severe disruption to nearly all aspects of the child’s (and/or parent/family’s) life.

c. Very severe or extreme behavioural symptoms are present virtually all the time and the child can rarely control or manage the symptoms. The symptoms are associated with severe distress, significantly reduced quality of life and/or severe disruption to nearly all aspects of the child’s (and/or parent/family’s) life.

d. Currently experiencing very severe symptoms (e.g., disordered thinking, extreme mood variation, obsessions, compulsions, extreme avoidant behaviour, extreme interpersonal difficulties, extremely disordered eating). Symptoms may be ongoing or of more recent or sudden onset.

e. Highly unusual and bizarre symptoms/behaviours indicating a severe mental illness (e.g., hallucinations, delusions). Symptoms may be ongoing or of more recent or sudden onset.

Adolescent (12 - 17 years)

Assessment of an adolescent on this domain should consider:

• Current and past symptoms and duration.
• Level of distress associated with the mental health issues.
• Previous experience of a mental health condition.
• Are symptoms improving/worsening, is distress improving/worsening, and are new symptoms emerging?

Scoring

0 = No problem in this domain

1 = Mild Symptoms are likely to be sub-diagnostic and have been experienced for less than three months (but this may vary)

a. Mild anxiety-related symptoms (e.g., occasional fears, worry, difficulty concentrating, body image issues, occasional unexplained somatic symptoms like headache and stomach pain) without significant avoidant behaviour.

b. Mild mood-related symptoms (e.g., sadness, fatigue, apathy, some reluctance to participate in previously enjoyed activities, irritability, occasional disrupted sleep).

c. Mild behavioural symptoms (e.g., distractibility, overactivity, occasional difficulty completing tasks, quick to anger, occasional concerning or aggressive behaviours, occasionally appearing oppositional, minor interpersonal difficulties).

d. Currently experiencing a mental health condition associated with mild distress or mild reduction in quality of life.

2 = Moderate Symptoms are at a level that would likely meet diagnostic criteria and have been experienced for more than three months (but this may vary)

a. Moderate anxiety-related symptoms (e.g., excessive worry, agitation, panic, difficulty concentrating, significant self-consciousness or significant concerns about body image, appearance or weight, frequent unexplained somatic complaints) with significant avoidance of anxiety provoking situations.

b. Moderate mood-related symptoms (e.g., excessive sadness, apathy, exhaustion, frequent irritability, loss of interest and pleasure and/or frequent reluctance to participate in previously enjoyed activities, frequent sleep disturbance).

c. Moderate behavioural symptoms (e.g., frequent impulsivity, hyperactivity, non-adherence to age-appropriate rules or social norms, frequent concerning or aggressive behaviours, significant interpersonal difficulties).

d. Currently experiencing a mental health condition associated with moderate levels of distress and/or moderate reduction in quality of life.

e. History of a diagnosed mental health condition earlier in childhood that has not responded to treatment, with continuing symptoms but only associated with mild to moderate levels of distress.

3 = Severe

a. Severe anxiety-related symptoms are present most of the time, the adolescent has difficulty controlling or managing the symptoms and seeks to avoid anxiety provoking situations and/or experiences severe distress if asked to engage in anxiety provoking situations such that there is severe distress and/or significant disruption to the adolescent’s (and/or parent/family’s) life.

b. Severe mood-related symptoms are present most of the time, the adolescent has difficulty controlling or managing the symptoms and the symptoms are associated with severe distress and/or significant disruption to the adolescent’s (and/or parent/family’s) life.

c. Significant behavioural symptoms are present most of the time the adolescent has difficulty controlling or managing the symptoms and the symptoms are associated with severe disruption and/or distress for the adolescent, and/or their parent/family and interpersonal relationships.

d. Currently experiencing other severe mental health symptoms or severe psychological distress (e.g., complex trauma responses, obsessions, compulsions, severely disordered eating). Symptoms may be ongoing or of more recent or sudden onset.

e. Symptoms suggestive of an early form of a severe mental health condition (e.g., odd thinking/ behaviour/speech, abnormal perceptions, suspicious thinking, rapid mood swings, a substantial decrease in the need for sleep) or symptoms suggestive of an eating disorder.

f. Has been treated by a specialist community mental health service or admitted to hospital for a mental health condition in the previous 12-months.

4 = Very severe

a. Very severe and pervasive anxiety symptoms are present virtually all the time, the adolescent can rarely control or manage the symptoms and the adolescent refuses to engage in anxiety provoking situations or activities. The symptoms are associated with severe distress, significantly reduced quality of life and/or severe disruption to nearly all aspects of the adolescent’s (and/or parent/family’s) life.

b. Very severe and pervasive mood-related symptoms are present virtually all the time, and the adolescent can rarely control or manage the symptoms. The symptoms are associated with severe distress, significantly reduced quality of life and/or severe disruption to nearly all aspects of the adolescent’s (and/or parent/family’s) life.

c. Extreme behavioural symptoms are present virtually all the time, and the adolescent can rarely control or manage the symptoms. The symptoms are associated with severe distress, significantly reduced quality of life and/or severe disruption to nearly all aspects of the adolescent’s (and/or parent/family’s) life.

d. Currently experiencing very severe symptoms (e.g., disordered thinking, extreme mood variation, obsessions, extreme avoidant behaviour, extreme interpersonal difficulties, extremely disordered eating). Symptoms may be ongoing or of more recent or sudden onset.

e. Highly unusual and bizarre symptoms/behaviours indicating a severe mental illness (e.g., hallucinations, delusions). Symptoms may be ongoing or of more recent or sudden onset.

Adult (18 - 64 years)

Assessment of an individual on this domain should consider:

• Current and past symptoms and duration.
• Level of distress associated with the mental health issues.
• Previous experience of a mental health condition.
• Are symptoms improving/worsening, is distress improving/worsening, and are new symptoms emerging?

Scoring

0 = No problem in this domain

1 = Mild Symptoms are likely to be sub-diagnostic and have been experienced for less than 6 months (but this may vary)

a. Mild anxiety-related symptoms (e.g., occasional fears, worry, difficulty concentrating, occasional unexplained somatic symptoms) without significant avoidant behaviour.

b. Mild mood-related symptoms (e.g., sadness, fatigue, apathy, some reluctance to participate in previously enjoyed activities, irritability, occasional disrupted sleep).

c. Mild behavioural symptoms (e.g., distractibility, overactivity, occasional difficulty completing tasks, quick to anger, occasional concerning or aggressive behaviours, minor interpersonal difficulties).

d. Currently experiencing a mental health condition associated with mild distress or mild reduction in quality of life.

2 = Moderate Symptoms are at a level that would likely meet diagnostic criteria and have been experienced for more than 6 months (but this may vary)

a. Moderate anxiety-related symptoms (e.g., excessive worry, agitation, panic, difficulty concentrating, frequent unexplained somatic complaints) with significant avoidance of anxiety provoking situations.

b. Moderate mood-related symptoms (e.g., excessive sadness, apathy, exhaustion, frequent irritability, loss of interest and pleasure, and/or frequent reluctance to participate in previously enjoyed activities, guilt or worthlessness, frequent sleep disturbance).

c. Moderate behavioural symptoms (e.g., frequent impulsivity, hyperactivity, frequent disinhibited behaviour, non-adherence to social norms, frequent concerning or aggressive behaviours, significant interpersonal difficulties).

d. Currently experiencing a mental health condition associated with moderate levels of distress and/or moderate reduction in quality of life.

e. History of a diagnosed mental health condition that has not responded to treatment, with continuing symptoms but only associated with mild to moderate levels of distress.

3 = Severe

a. Severe anxiety-related symptoms are present most of the time, the person has difficulty controlling or managing the symptoms and seeks to avoid anxiety provoking situations and/or experiences severe distress if asked to engage in anxiety provoking situations such that there is severe distress and/or significant disruption to the person’s life.

b. Severe mood-related symptoms are present most of the time, the person has difficulty controlling or managing the symptoms, and the symptoms are associated with severe distress and/or significant disruption to the person’s life.

c. Significant behavioural symptoms are present most of the time, the person has difficulty controlling or managing the symptoms, and the symptoms are associated with severe distress and/or significant disruption to the person’s life.

d. Currently experiencing other severe mental health symptoms (e.g., complex trauma responses, obsessions, compulsions, severely disordered eating). Symptoms may be ongoing or of more recent or sudden onset.

e. Symptoms suggestive of an early form of a severe mental health condition (e.g., odd thinking/ behaviour/speech, abnormal perceptions, suspicious thinking, rapid mood swings, a substantial decrease in the need for sleep).

f. Has been treated by a specialist community mental health service or admitted to a hospital for a mental health condition in the previous 12 months.

4 = Very severe

a. Very severe and pervasive anxiety symptoms are present virtually all the time, the person can rarely control or manage the symptoms and the person refuses to engage in anxiety provoking situations or activities. The symptoms are associated with severe distress, significantly reduced quality of life and/or severe disruption to nearly all aspects of the person’s life.

b. Very severe and pervasive mood-related symptoms are present virtually all the time, and the person can rarely control or manage the symptoms. The symptoms are associated with severe distress, significantly reduced quality of life and/or severe disruption to nearly all aspects of the person’s life.

c. Extreme behavioural symptoms are present virtually all the time, and the person can rarely control or manage the symptoms. The symptoms are associated with severe distress, significantly reduced quality of life and/or severe disruption to nearly all aspects of the person’s life.

d. Currently experiencing very severe symptoms (e.g., disordered thinking, extreme mood variation, obsessions, compulsions, extreme avoidant behaviour, extreme interpersonal difficulties, extremely disordered eating). Symptoms may be ongoing or of more recent or sudden onset.

e. Highly unusual and bizarre symptoms/behaviours indicating a severe mental illness (e.g., hallucinations, delusions). Symptoms may be ongoing or of more recent or sudden onset.

Older Adult (65 years and older)

Assessment of an older adult on this domain should consider:

• Current and past symptoms and duration.
• Level of distress associated with the mental health issues.
• Previous experience of a mental health condition.
• Are symptoms improving/worsening, is distress improving/worsening, and are new symptoms emerging?

Scoring

0 = No problem in this domain

1 = Mild Symptoms are likely to be sub-diagnostic and have been experienced for less than six months (but this may vary)

a. Mild anxiety-related symptoms (e.g., occasional fears, worry, difficulty concentrating, occasional unexplained somatic symptoms) without significant avoidant behaviour.

b. Mild mood-related symptoms (e.g., sadness, fatigue, apathy, some reluctance to participate in previously enjoyed activities, irritability, occasional disrupted sleep).

c. Mild behavioural symptoms (e.g., distractibility, overactivity, occasional difficulty completing tasks, quick to anger, occasional concerning or aggressive behaviours, minor interpersonal difficulties).

d. Currently experiencing a mental health condition associated with mild distress or mild reduction in quality of life.

2 = Moderate Symptoms are at a level that would likely meet diagnostic criteria and have been experienced for more than six months (but this may vary)

a. Moderate anxiety-related symptoms (e.g., excessive worry, agitation, panic, difficulty concentrating, frequent unexplained somatic complaints) with significant avoidance of anxiety provoking situations.

b. Moderate mood-related symptoms (e.g., excessive sadness, apathy, exhaustion, frequent irritability, loss of interest and pleasure and/or frequent reluctance to participate in previously enjoyed activities, guilt or worthlessness, frequent sleep disturbance).

c. Moderate behavioural symptoms (e.g., frequent impulsivity, hyperactivity, frequent disinhibited behaviour, non-adherence to social norms, frequent concerning or aggressive behaviours, significant interpersonal difficulties).

d. Currently experiencing a mental health condition associated with moderate levels of distress and/or moderate reduction in quality of life.

e. History of a diagnosed mental health condition that has not responded to treatment, with continuing symptoms but only associated with mild to moderate levels of distress.

3 = Severe

a. Severe anxiety-related symptoms are present most of the time, the person has difficulty controlling or managing the symptoms and seeks to avoid anxiety provoking situations and/or experiences severe distress if asked to engage in anxiety provoking situations such that there is severe distress and/or significant disruption to the person’s life.

b. Severe mood-related symptoms are present most of the time, the person has difficulty controlling or managing the symptoms, and the symptoms are associated with severe distress and/or significant disruption to the person’s life.

c. Significant behavioural symptoms are present most of the time, the person has difficulty controlling or managing the symptoms, and the symptoms are associated with severe distress and/or significant disruption to the person’s life.

d. Currently experiencing other severe mental health symptoms (e.g., complex trauma responses, obsessions, compulsions, severely disordered eating). Symptoms may be ongoing or of more recent or sudden onset.

e. Symptoms suggestive of an early form of a severe mental health condition (e.g., odd thinking/ behaviour/speech, abnormal perceptions, suspicious thinking, rapid mood swings, a substantial decrease in the need for sleep).

f. Has been treated by a specialist community mental health service or admitted to a hospital for a mental health condition in the previous 12 months.

4 = Very severe

a. Very severe and pervasive anxiety symptoms are present virtually all the time, the person can rarely control or manage the symptoms and the person refuses to engage in anxiety provoking situations or activities. The symptoms are associated with severe distress, significantly reduced quality of life and/or severe disruption to nearly all aspects of the person’s life.

b. Very severe and pervasive mood-related symptoms are present virtually all the time, and the person can rarely control or manage the symptoms. The symptoms are associated with severe distress, significantly reduced quality of life and/or severe disruption to nearly all aspects of the person’s life.

c. Extreme behavioural symptoms are present virtually all the time, and the person can rarely control or manage the symptoms. The symptoms are associated with severe distress, significantly reduced quality of life and/or severe disruption to nearly all aspects of the person’s life.

d. Currently experiencing very severe symptoms (e.g., disordered thinking, extreme mood variation, obsessions, compulsions, extreme avoidant behaviour, extreme interpersonal difficulties, extremely disordered eating). Symptoms may be ongoing or of more recent or sudden onset.

e. Highly unusual and bizarre symptoms/behaviours indicating a severe mental illness (e.g., hallucinations, delusions). Symptoms may be ongoing or of more recent or sudden onset.

Domain 2 - Harm

Children (5 - 11 years)

This domain is focused on:

• Suicidality – current and past suicidal ideation, intent, planning, and attempts.

• Intentional, non-suicidal self-harm – current and past.

• Impulsive, dangerous, or risky behaviours with the potential for psychological or physical harm to self or others (consider and include risks associated with the use of alcohol and other drugs).

• The psychological or physical harm caused by abuse, exploitation, or neglect by others.

• Unintentional harm to self, arising from symptoms or self-neglect.

The IAR for children includes the harm from others in domain 2 because there are direct implications for the intensity of a mental health response for children at risk of, or experiencing, harm from others is likely to require. Placing harm from others in another domain (e.g., domain 6) does not carry the same weight within the logic that underpins the recommendations about a level of care. Note that the presence of external stressors (e.g., family violence) is rated at domain 6, but the degree of harm arising from those stressors is rated separately at domain 2.

Scoring

0 = No concerns about harm

1 = Previous but no current concerns about harm

a. No current suicidal ideation, but the child has experienced suicidal ideation in the past (with no previous intent, plans, or attempts). Demonstrates future-oriented thinking and has strong protective factors.

b. Occasional non-suicidal self-injurious acts in the recent past and not requiring any medical treatment.

c. May have engaged in past behaviours that posed a risk to self or others, but no current or recent instances.

d. Currently at low risk of harm from abuse, exploitation, or neglect by others.

2 = Some current concerns about harm

a. Previous suicide attempt (more than 12 months ago) but no current ideation, intent, or plan. The child demonstrates future-orientated thinking and has strong protective factors.

b. Frequent non-suicidal self-injurious acts in the recent past but that did not require any medical treatment.

c. Current or recent behaviours that pose a non-life-threatening risk to self or others.

d. Currently at some risk of harm from abuse, exploitation, or neglect by others.

e. Intermittent lapses in self-care that may lead to harm.

3 = Significant current concerns about harm

a. Current suicidal ideation but no current intent and no history of suicide attempts. No plan or strong reluctance to carry out the plan, strong protective factors, and a commitment to engage in a safety plan, including involvement of family, significant others, and services.

b. Recent suicide attempt (within past 12 months) but no current ideation, intent, or plan.

c. Frequent non-suicidal self-injurious acts in the recent past, one or more of which required medical treatment.

d. Recent or current impulsive, dangerous, or risky behaviours that pose a risk of harm to self or others, or that have had or are likely to have a serious negative impact.

e. Serious medical risks and/or complications associated with a mental illness.

f. Significant risk of, or recent experience of, abuse, exploitation, or neglect by others.

g. Clearly compromised self-care ability that is ongoing to the extent that indirect or unintentional harm to self is likely.

4 = Very significant current concerns about harm

a. Current suicidal ideation with intent, typically with a plan and means to carry out the plan, or history of previous suicide attempt. Few or no protective factors. Limited or no future-orientated thinking.

b. History of life-threatening self-injurious acts that are prominent in the current presentation.

c. There is evidence of current severe symptoms (e.g., hallucinations, avoidant behaviour, paranoia, disordered thinking, delusions, impulsivity) with behaviour that is likely to present an imminent or unpredictable danger to self or others.

d. Extremely compromised self-care ability to the extent that there is a real and present danger of the child experiencing harm related to these deficits.

e. Life-threatening medical risks and/or complications associated with a mental illness.

f. Other signs or indicators of imminent risk of serious harm to themselves or others.

Adolescent (12 - 17 years)

This domain is focused on:

• Suicidality – current and past suicidal ideation, intent, planning, and attempts.
• Intentional, non-suicidal self-harm – current and past.
• Impulsive, dangerous, or risky behaviours with the potential for psychological or physical harm to self or others (consider and include risks associated with the use of alcohol and other drugs).
• The psychological or physical harm caused by abuse, exploitation, or neglect by others.
• Unintentional harm to self, arising from symptoms or self-neglect.

The IAR for adolescents includes the harm from others in Domain 2 because there are direct implications for the intensity of mental health response an adolescent at risk of or experiencing harm from others is likely to require. Placing harm from others in another domain (e.g., Domain 6) does not carry the same weight within the logic that underpins the recommendations about a level of care. Note that the presence of external stressors (e.g., family violence) is rated at Domain 6, but the degree of harm arising from those stressors is rated separately at Domain 2.

Scoring

0 = No concerns about harm

1 = Previous but no current concerns about harm

a. No current suicidal ideation, but the adolescent has experienced suicidal ideation, plans, or intent in the past. Demonstrates future-oriented thinking and has strong protective factors.

b. Occasional non-suicidal self-injurious acts in the recent past and not requiring any medical treatment.

c. May have engaged in past behaviours that posed a risk to self or others, but no current or recent instances.

d. Currently at low risk of harm from abuse, exploitation, or neglect by others.

2 = Some current concerns about harm

a. Current suicidal ideation, without plan or intent but may have had plans, intent, or suicide attempts in the past. Demonstrates future-orientated thinking and has strong protective factors or previous suicide attempt (longer than 12 months ago) but no current ideation, intent, or plan.

b. Frequent non-suicidal self-injurious acts in the recent past that did not require any medical treatment.

c. Current or recent behaviours that pose a non-life-threatening risk to self or others.

d. Currently at some risk of harm from abuse, exploitation, or neglect by others.

e. Intermittent lapses in self-care that may lead to harm.

3 = Significant current concerns about harm

a. Current suicidal ideation with a plan, but no current intent or a strong reluctance to carry out a plan. May have a history of suicide attempts. Strong protective factors and a commitment to engage in a safety plan, including the involvement of family, significant others, or services.

b. Recent suicide attempt (within past 12 months) but no current ideation, intent, or plan.

c. Frequent non-suicidal self-injurious acts in the recent past and requiring medical treatment.

d. Recent or current impulsive, dangerous, or risky behaviours that pose a risk of harm to self or others, or that have had or are likely to have a serious negative impact.

e. Serious medical risks and/or complications associated with a mental illness.

f. Significant risk of, or recent experience of, abuse, exploitation, or neglect by others.

g. Clearly compromised self-care ability that is ongoing to the extent that indirect or unintentional harm to self is likely.

4 = Very significant current concerns about harm

a. Current suicidal ideation with intent, typically with a plan and means to carry out the plan or history of previous suicide attempt. Few or no protective factors. Limited or no future-orientated thinking.

b. History of life-threatening self-injurious acts that are prominent in the current presentation.

c. There is evidence of current severe symptoms (e.g., hallucinations, avoidant behaviour, paranoia, disordered thinking, delusions, impulsivity) with behaviour that is likely to present an imminent or unpredictable danger to self or others.

d. Extremely compromised self-care ability to the extent that there is a real and present danger of the adolescent experiencing harm related to these deficits.

e. Life-threatening medical risks and/or complications associated with a mental illness.

f. Other signs or indicators of imminent risk of serious harm to themselves or others.

Adult (18 - 64 years)

This domain is focused on:

• Suicidality – current and past suicidal ideation, intent, planning, and attempts.
• Intentional, non-suicidal self-harm – current and past.
• Impulsive, dangerous, or risky behaviours with the potential for psychological or physical harm to self or others (consider and include risks associated with the use of alcohol and other drugs).
• The psychological or physical harm caused by abuse, exploitation, or neglect by others.
• Unintentional harm to self, arising from symptoms or self-neglect.

The IAR for adults includes the harm from others in domain 2 because there are direct implications for the intensity of a mental health response a person at risk of or experiencing harm from others is likely to require. Placing harm from others in another domain (e.g., domain 6) does not carry the same weight within the logic that underpins the recommendations about a level of care. Note that the presence of external stressors (e.g., family violence) is rated at domain 6, but the degree of harm arising from those stressors is rated separately at domain 2.

Scoring

0 = No concerns about harm

1 = Previous but no current concerns about harm

a. No recent or current suicidal ideation but has experienced suicidal ideation, plans, or intent in the past. No recent history of suicide attempts but may have made attempts in the past. Demonstrates future-oriented thinking and has strong protective factors.

b. Occasional non-suicidal self-injurious acts in the recent past and not requiring any medical treatment.

c. May have engaged in past behaviours that posed a risk to self or others, but no current or recent instances.

d. Currently at low risk of harm from abuse, exploitation, or neglect by others.

2 = Some current concerns about harm

a. Current suicidal ideation, without plan or intent, but may have had plans, intent, or suicide attempts in the past. Demonstrates future-orientated thinking and has strong protective factors.

b. Frequent non-suicidal self-injurious acts in the recent past that did not require any medical treatment.

c. Current or recent behaviours that pose a non-life-threatening risk to self or others.

d. Currently at some risk of harm from abuse, exploitation, or neglect by others.

e. Frequent lapses in self-care that may lead to harm.

3 = Significant current concerns about harm

a. Current suicidal ideation with a plan but no current intent or a strong reluctance to carry out a plan. May have a history of suicide attempts. Strong protective factors and a commitment to engage in a safety plan, including the involvement of family, significant others, or services.

b. Recent suicide attempt (within the past 12 months) but no current ideation, intent, or plan.

c. Frequent non-suicidal self-injurious acts in the recent past and requiring medical treatment.

d. Recent or current impulsive, dangerous, or risky behaviours that pose a risk of harm to self or others, or that have had or are likely to have a serious negative impact.

e. Serious medical risks and/or complications associated with a mental illness.

f. Significant risk of, or recent experience of, abuse, exploitation, or neglect by others.

g. Clearly compromised self-care ability that is ongoing to the extent that indirect or unintentional harm to self is likely.

4 = Very significant current concerns about harm

a. Recent suicide attempt (within the past 12 months) or current suicidal ideation, with intent, typically with a plan and means to carry out the plan. Few or no protective factors. Limited or no future-orientated thinking.

b. History of life-threatening self-injurious acts that are prominent in the current presentation.

c. There is evidence of current severe symptoms (e.g., hallucinations, avoidant behaviour, paranoia, disordered thinking, delusions, impulsivity, disinhibition) with behaviour that is likely to present an imminent or unpredictable danger to self or others.

d. Extremely compromised self-care ability to the extent that there is a real and present danger of the person experiencing harm related to these deficits.

e. Life-threatening medical risks and/or complications associated with a mental illness.

f. Other signs or indicators of imminent risk of serious harm to themselves or others.

Older Adult (65 years and older)

This domain is focused on:

• Suicidality – current and past suicidal ideation, intent, planning, and attempts.
• Intentional, non-suicidal self-harm – current and past.
• Impulsive, dangerous, or risky behaviours with the potential for psychological or physical harm to self or others (consider and include risks associated with the use of alcohol and other drugs).
• The psychological or physical harm caused by abuse, exploitation, or neglect by others.
• Unintentional harm to self, arising from symptoms or self-neglect.

The IAR for older adults includes the harm from others in domain 2 because there are direct implications for the intensity of mental health response an older adult at risk of or experiencing harm from others is likely to require. Placing harm from others in another domain (e.g., domain 6) does not carry the same weight within the logic that underpins the recommendations about a level of care. Note that the presence of external stressors (e.g., family violence) is rated at domain 6, but the degree of harm arising from those stressors is rated separately at domain 2.

Scoring

0 = No concerns about harm

1 = Previous but no current concerns about harm

a. No recent or current suicidal ideation, but has experienced ideation, plans, or intent in the past. No recent history of suicide attempts but may have made attempts in the past. Demonstrates future-oriented thinking and has strong protective factors.

b. Occasional non-suicidal self-injurious acts in the recent past and not requiring any medical treatment.

c. May have engaged in past behaviours that posed a risk to self or others, but no current or recent instances.

d. Currently at low risk of harm from abuse, exploitation, or neglect by others.

2 = Some current concerns about harm

a. Current suicidal ideation, without plan or intent but may have had plans, intent, or suicide attempts in the past. Demonstrates future-orientated thinking and has strong protective factors.

b. Frequent non-suicidal self-injurious acts in the recent past and not requiring any medical treatment.

c. Current or recent behaviours that pose a non-life-threatening risk to self or others.

d. Currently at some risk of harm from abuse, exploitation, or neglect by others.

e. Frequent lapses in self-care that may lead to harm.

3 = Significant current concerns about harm

a. Current suicidal ideation with a plan, but no current intent or a strong reluctance to carry out a plan. May have a history of suicide attempts. Strong protective factors and a commitment to engage in a safety plan, including the involvement of family, significant others, or services.

b. Recent suicide attempt (within past 12 months) but no current ideation, intent, or plan.

c. Frequent non-suicidal self-injurious acts in the recent past and requiring medical treatment.

d. Recent or current impulsive, dangerous, or risky behaviours that pose a risk of harm to self or others, or that have had or are likely to have a serious negative impact.

e. Serious medical risks and/or complications associated with a mental illness.

f. Significant risk of, or recent experience of, abuse, exploitation, or neglect by others.

g. Clearly compromised self-care ability that is ongoing to the extent that indirect or unintentional harm to self is likely.

4 = Very significant current concerns about harm

a. Recent suicide attempt (within past 12 months) or current suicidal ideation, with intent, typically with a plan and means to carry out. Few or no protective factors. Limited or no future-orientated thinking.

b. History of life-threatening self-injurious acts that are prominent in the current presentation.

c. There is evidence of current severe symptoms (e.g., hallucinations, avoidant behaviour, paranoia, disordered thinking, delusions, impulsivity, disinhibition) with behaviour that is likely to present an imminent or unpredictable danger to self or others.

d. Extremely compromised self-care ability to the extent that there is a real and present danger of the person experiencing harm related to these deficits.

e. Life-threatening medical risks and/or complications associated with a mental illness.

f. Other signs or indicators of imminent risk of serious harm to themselves or others.

Domain 3 - Functioning

Children (5 - 11 years)

Assessment of a child on this domain should consider the impact of the mental health issues on:

• The child’s ability to fulfil usual roles/responsibilities appropriate to their age, developmental level, capability, and cultural background.

• The child’s functioning within the family or home environment, in educational settings, with friends and peers, at play and in the community.

• The child’s ability to undertake basic activities of daily living appropriate to their age, capability, and developmental level (e.g., self-care, mobility, toileting, nutrition, and personal hygiene).

Scoring

0 = No problem in this domain

1 = Mild impact

a. Mildly diminished ability to function in one or more of their usual roles (e.g., at home, in educational settings, with friends and peers, at play and in the community), but without significant or adverse consequences.

b. Mental health issues contribute to brief and transient disruptions in one or more areas of functioning.

2 = Moderate impact

a. Moderate functional impairment in more than one of their usual roles (e.g., at home, in educational settings, with friends and peers, at play and in the community) to the extent that they are frequently unable to meet the requirements of those roles, but without significant adverse consequences.

b. Mental health issues contribute to occasional difficulties with basic activities of daily living (e.g., eating, mobility, bathing, getting dressed, and toileting) or instrumental activities of daily living (e.g., preparing food, tidying up, completing tasks) but without threat to health.

3 = Severe impact

a. Significant difficulties with functioning, resulting in disruption to many areas of the child’s life most of the time (e.g., limited participation in educational or recreational activities, deterioration in or some withdrawal from relationships with friends and peers), but the child can function independently with adequate treatment, appropriate accommodations and supports e.g., in educational settings and family, and community support.

b. Mental health issues frequently contribute to difficulties with basic activities of daily living (e.g., eating, mobility, bathing, getting dressed, and toileting) or instrumental activities of daily living (e.g., preparing food, tidying up, completing tasks) on a consistent basis but without threat to health.

4 = Very severe to extreme impact

a. Profound difficulties with functioning, resulting in significant disruption to virtually all areas of the child’s life (e.g., unable to participate in educational activities, complete withdrawal from friends and peers).

b. Mental health issues contribute to severe and persistent self-neglect that poses a threat to health.

Adolescent (12 - 17 years)

Assessment of an adolescent on this domain should consider the impact of the mental health issues on:

• The adolescents’ ability to fulfil usual roles/responsibilities appropriate to their age, developmental level, and cultural background.
• The adolescent’s functioning within the family or home environment, in educational or vocational settings, with friends and peers, and in the community.
• The adolescent’s ability to undertake basic activities of daily living appropriate to their age and developmental level (e.g., self-care, mobility, toileting, feeding, and personal hygiene).

Scoring

0 = No problem in this domain

1 = Mild impact

a. Mildly diminished ability to function in one or more of their usual roles (e.g., at home, in educational settings, with friends and peers, at play and in the community), but without significant or adverse consequences.

b. Mental health issues contribute to brief and transient disruptions in one or more areas of functioning.

2 = Moderate impact

a. Moderate functional impairment in more than one of their usual roles (e.g., at home, in educational settings, with friends and peers, at play and in the community) to the extent that they are frequently unable to meet the requirements of those roles, but without significant adverse consequences.

b. Mental health issues contribute to occasional difficulties with basic activities of daily living (e.g., eating, mobility, bathing, getting dressed, and toileting) or instrumental activities of daily living (e.g., preparing food, tidying up, completing tasks) but without threat to health.

3 = Severe impact

a. Significant difficulties with functioning, resulting in disruption to many areas of the adolescent’s life most of the time (e.g., limited participation in educational or vocational activities, deterioration in or some withdrawal from the community or relationships with friends and peers), but the adolescent can function independently with adequate treatment, family, and community support.

b. Mental health issues frequently contribute to difficulties with basic activities of daily living (e.g., eating, mobility, bathing, getting dressed, and toileting) or instrumental activities of daily living (e.g., preparing food, tidying up, completing tasks) on a consistent basis but without threat to health.

4 = Very severe to extreme impact

a. Profound difficulties with functioning, resulting in significant disruption to virtually all areas of the adolescent’s life (e.g., unable to participate in educational, social, or vocational activities, complete withdrawal from community, friends, and peers).

b. Mental health issues contribute to severe and persistent self-neglect that poses a threat to health.

Adult (18 - 64 years)

Assessment of an individual on this domain should consider the impact of mental health issues on:

• Their ability to fulfil usual roles/responsibilities appropriate to their age, capability, and cultural background.
• Their functioning within the family or home environment, vocational or social settings, caregiving roles, and in the community.
• Their ability to undertake basic activities of daily living appropriate to their age and capability (e.g., self-care, mobility, toileting, nutrition, and personal hygiene).

Scoring

0 = No problem in this domain

1 = Mild impact

a. Mildly diminished ability to function in one or more of their usual roles (e.g., at home, vocational or social settings, caregiving roles or in the community), but without significant or adverse consequences.

b. Mental health issues contribute to brief and transient disruptions in one or more areas of functioning.

2 = Moderate impact

a. Moderate functional impairment in more than one of their usual roles (e.g., at home, vocational or social settings, caregiving roles or in the community) to the extent that they are reasonably frequently unable to meet the requirements of those roles but without significant or adverse consequences.

b. Mental health issues contribute to occasional difficulties with basic activities of daily living (e.g., eating, mobility, bathing, getting dressed toileting) or instrumental activities of daily living (e.g., preparing food, cleaning, transportation, managing money) but without threat to health.

3 = Severe impact

a. Significant difficulties with functioning, resulting in disruption to many areas of the person's life (e.g., limited participation in vocational or social activities, deterioration in or some withdrawal from community or relationships), but the person can function independently with adequate treatment, family, and community support.

b. Mental health issues contribute to frequent difficulties with basic activities of daily living (e.g., eating, mobility, bathing, getting dressed, toileting) or instrumental activities of daily living (e.g., preparing food, cleaning, transportation, managing money) on a consistent basis but without threat to health. The person requires treatment, family, and community support to maintain independent functioning.

4 = Very severe to extreme impact

a. Profound difficulties with functioning, resulting in significant disruption to virtually all areas of the person's life (e.g., unable to participate in vocational or social activities, complete withdrawal from the community).

b. Mental health issues contribute to severe and persistent self-neglect that poses a threat to health.

Older Adult (65 years and older)

Assessment of an older adult on this domain should consider the impact of the mental health issues on:

• Their ability to fulfil usual roles/responsibilities appropriate to their age, capability, and cultural background.
• Their functioning within the family or home environment, vocational or social settings, caregiving roles, and in the community.
• Their ability to undertake basic activities of daily living appropriate to their age and capability (e.g., self-care, mobility, toileting, nutrition, and personal hygiene).

Scoring

0 = No problem in this domain

1 = Mild impact

a. Mildly diminished ability to function in one or more of their usual roles (e.g., at home, vocational or social settings, caregiving roles or in the community), but without significant or adverse consequences.

b. Mental health issues contribute to brief and transient disruptions in one or more areas of functioning.

2 = Moderate impact

a. Moderate functional impairment in more than one of their usual roles (e.g., at home, vocational or social settings, caregiving roles or in the community) to the extent that they are reasonably frequently unable to meet the requirements of those roles but without significant or adverse consequences.

b. Mental health issues contribute to occasional difficulties with basic activities of daily living (e.g., eating, mobility, bathing, getting dressed, toileting) or instrumental activities of daily living (e.g., preparing food, cleaning, transportation, managing money) but without threat to health.

3 = Severe impact

a. Significant difficulties with functioning, resulting in disruption to many areas of the person's life (e.g., limited participation in vocational or social activities, deterioration in or some withdrawal from community or relationships). The person requires treatment, family, and community support to maintain independent functioning.

b. Mental health issues contribute to frequent difficulties with basic activities of daily living (e.g., eating, mobility, bathing, getting dressed, toileting) or instrumental activities of daily living (e.g., preparing food, cleaning, transportation, managing money) on a consistent basis but without threat to health.

4 = Very severe impact

a. Profound difficulties with functioning, resulting in significant disruption to virtually all areas of the person's life (e.g., unable to participate in vocational or social activities, complete withdrawal from the community).

b. Mental health issues contribute to severe and persistent self-neglect that poses a threat to health.

Domain 4 - Impact of co-existing conditions

Children (5 - 11 years)

Assessment of a child on this domain should consider the presence, and impact of, three possible coexisting conditions:

• Physical health conditions.
• Cognitive impairment, intellectual disability, developmental delay, neurological conditions, or learning and communication disorders.
• Substance use.

Where the child has more than one of the coexisting conditions, consider the condition which has the most impact.

Scoring

0 = No problem in this domain

1 = Minor impact

a. Physical health condition(s) present but are stable and have no or a minimal impact on the child's mental health.
b. Cognitive impairment, intellectual disability, developmental delay, neurological condition, or learning and communication disorder present but has no or minimal impact on the child’s mental health. c. Past experimentation or experience with substances, but no recent episodes and no impact on the child's mental health.

2 = Moderate impact

a. Physical health condition(s) present and moderately impacts the child's mental health. b. Cognitive impairment, intellectual disability, developmental delay, neurological condition, or learning and communication disorder and moderately impacts, or has the potential to moderately impact the mental health of the child. c. Occasional substance use impacts on, or has the potential to impact on, the child’s mental health. d. Non prescribed use of prescription medications impacts on, or has the potential to impact on, the child’s mental health.

3 = Severe impact

a. Physical health condition(s) present, which requires intensive medical monitoring, and severely impacts the child's mental health (e.g., worsened symptoms, heightened distress).

b. Cognitive impairment, intellectual disability, developmental delay, neurological condition, or learning and communication disorder present and severely impacts the child’s mental health.

c. Frequent substance use threatens health and wellbeing or represents a barrier to mental health-related recovery.

d. Non prescribed use of prescription medications significantly impacts the child’s mental health or presents a barrier to mental health-related recovery.

e. Occasional use of high or extreme risk substances. (e.g., substances with a high risk of adverse outcomes such as injury, loss of life, criminal charges and/or use of injection drugs which have a high risk of infection of blood-borne diseases).

4 = Very severe impact

a. One or more significant physical health conditions exist that are poorly managed or life-threatening and in the context of a concurrent mental health condition.

b. Cognitive impairment, intellectual disability, developmental delay, neurological condition, or learning and communication disorder present and very severely impacts the child’s mental health.

c. Regular and uncontrolled substance use.

d. Frequent non-prescribed use of prescribed medications that has the potential to threaten health and well-being.

e. Frequent use of high or extreme-risk substances (e.g., substances with a high risk of adverse outcomes such as injury, loss of life, criminal charges and/or use of injection drugs which have a high risk of infection of blood-borne diseases).

Adolescent (12 - 17 years)

Assessment of an adolescent on this domain should consider the presence, and impact of, three possible coexisting conditions:

• Physical health conditions.
• Cognitive impairment, intellectual disability, developmental delay, neurological conditions, or learning and communication disorders.
• Substance use.

Where the adolescent has more than one of the coexisting conditions, consider the condition which has the most impact.

Scoring

0 = No problem in this domain

1 = Minor impact

a. Physical health condition(s) present but are stable and have no or a minimal impact on the adolescent's mental health.

b. Cognitive impairment, intellectual disability, developmental delay, neurological condition, or learning and communication disorder present but has no or minimal impact on the adolescent's mental health.

c. Recent episodes of substance use are limited, are not currently causing any concerns, and do not impact the adolescent’s mental health.

2 = Moderate impact

a. Physical health condition(s) present and moderately impacts the adolescent's mental health.

b. Cognitive impairment, intellectual disability, developmental delay, neurological condition, or learning and communication disorder and moderately impacts, or has the potential to moderately impact the mental health of the adolescent.

c. Occasional substance use impacts on, or has the potential to impact on, the adolescent's mental health.

d. Non prescribed use of prescription medications impacts on, or has the potential to impact on, the adolescent’s mental health.

3 = Severe impact

a. Physical health condition(s) present, which requires intensive medical monitoring and severely impacts the adolescent's mental health (e.g., worsened symptoms, heightened distress).

b. Cognitive impairment, intellectual disability, developmental delay, neurological condition, or learning and communication disorder present and severely impacts the adolescent’s mental health.

c. Frequent substance use threatens health and wellbeing or represents a barrier to mental health-related recovery.

d. Non prescribed use of prescription medications significantly impacts the adolescent’s mental health or presents a barrier to mental health-related recovery.

e. Occasional use of high or extreme risk substances. (e.g., substances with a high risk of adverse outcomes such as injury, loss of life, criminal charges and/or use of injection drugs which have a high risk of infection of blood-borne diseases).

4 = Very severe impact

a. One or more significant physical health conditions exist that are poorly managed or life-threatening and in the context of a concurrent mental health condition.

b. Cognitive impairment, intellectual disability, developmental delay, neurological condition, or learning and communication disorder present and very severely impacts the adolescent's mental health.

c. Regular and uncontrolled substance use.

d. Regular and uncontrolled non-prescribed use of prescribed medications that has the potential to threaten health and well-being.

e. Frequent use of high or extreme risk substances (i.e., substances with a high risk of adverse outcomes such as injury, loss of life, criminal charges and/or use of injection drugs which have a high risk of infection of blood-borne diseases).

Adult (18 - 64 years)

Assessment on this domain should consider the presence and impact of the following co-existing conditions:

• Physical health conditions (consider all physical health issues).
• Cognitive impairment, intellectual disability, neurological conditions, or learning and communication disorders.
• Substance use.

Where the person has more than one of the coexisting conditions, consider the condition which has the most impact.

Scoring

0 = No problem in this domain

1 = Minor impact

a. Physical health condition(s) present but are stable and have no or minimal impact on the person's mental health.

b. Cognitive impairment, intellectual disability, neurological condition, or learning and communication disorder present but has no or minimal impact on the person's mental health.

c. Recent episodes of substance use are limited, are not currently causing any concerns, and do not impact the person's mental health.

2 = Moderate impact

a. Physical health condition(s) present and moderately impacts the person's mental health.

b. Cognitive impairment, intellectual disability, neurological condition, or learning and communication disorder present and moderately impacts on the person's mental health.

c. Occasional substance use that significantly impacts on, or has the potential to significantly impact, the person's mental health.

d. Non prescribed use of prescription medications that significantly impacts on, or has the potential to significantly impact, the person's mental health.

3 = Severe impact

a. Physical health condition(s) present, which requires intensive medical monitoring and severely impacts the person's mental health (e.g., worsened symptoms, heightened distress).

b. Cognitive impairment, intellectual disability, neurological condition, or learning and communication disorder present and severely impacts the person's mental health.

c. Frequent substance use threatens health and well-being or represents a barrier to mental health-related recovery.

d. Non prescribed use of prescription medications severely impacts the person's mental health or presents a barrier to mental health-related recovery.

4 = Very severe impact

a. One or more significant physical health conditions exist which are poorly managed or life-threatening and in the context of a concurrent mental health condition.

b. Cognitive impairment, intellectual disability, neurological condition, or learning and communication disorder present and very severely impacts the person's mental health.

c. Regular and uncontrolled substance use severely threatens health and well-being.

d. Regular and uncontrolled non-prescribed use of prescribed medications severely threatens health and well-being.

Older Adult (65 years and older)

Assessment on this domain should consider the presence, and impact of three possible co-existing conditions:

• Physical health conditions (consider all physical health issues).
• Cognitive impairment, intellectual disability, neurological conditions, or learning and communication disorders.
• Substance use.

Where the older adult has more than one co-existing condition, the rating selected should be based on the condition which has the most impact.

Scoring

0 = No problem in this domain

1 = Minor impact

a. Physical health condition/s present but are stable and have no or a minimal impact on the person's mental health.

b. Cognitive impairment, intellectual disability, neurological condition, or learning and communication disorder present but has no or minimal impact on the person's mental health.

c. Recent episodes of substance use are limited, are not currently causing any concerns, and do not impact the person's mental health.

2 = Moderate impact

a. Physical health condition/s present and moderately impacts the person's mental health.

b. Cognitive impairment, intellectual disability, neurological condition, or learning and communication disorder present and moderately impacts on the person's mental health.

c. Occasional substance use that significantly impacts on, or has the potential to significantly impact on, the person's mental health.

d. Non prescribed use of prescription medications that significantly impacts on, or has the potential to significantly impact, the person's mental health.

3 = Severe impact

a. Physical health condition/s present, which requires intensive medical monitoring and severely impacts the person's mental health (e.g., worsened symptoms, heightened distress).

b. Cognitive impairment, intellectual disability, neurological condition, or learning and communication disorder present and severely impacts the person's mental health.

c. Frequent substance use threatens health and well-being or represents a barrier to mental health-related recovery.

d. Non prescribed use of prescription medications severely impacts the person's mental health or presents a barrier to mental health-related recovery.

4 = Very severe impact

a. One or more significant physical health conditions exist which are poorly managed or life-threatening and in the context of a concurrent mental health condition.

b. Cognitive impairment, intellectual disability, neurological condition, or learning and communication disorder present and very severely impacts the person's mental health.

c. Regular and uncontrolled substance use severely threatens health and well-being.

d. Regular and uncontrolled non-prescribed use of prescribed medications severely threatens health and well-being

Domain 5 - Service use and response history

Children (5 - 11 years)

This domain considers the child and their family’s previous use of services and support focussed on mental health-related assistance for the child. The initial assessment on this domain should consider:

• Whether the child/family has previously sought help from or required mental health services and related supports (including specialist or mental health inpatient services).
• Their progress or benefit from past services and support.

Definition of the term services and support – Relevant services and support refer to safe, developmentally, and culturally appropriate evidence-informed mental health, health or community services focussed on or relevant to the child’s mental health (such as a psychological service delivered by a GP or mental health professional, or other behavioural services) rather than the personal supports provided by friends, family, or social networks. Consider both the child and their family’s use of previous services and support but do not include those services and support relevant to, but not focused on, the child's mental health.

Scoring

0 = No previous service use

a. Has not previously sought help or required a referral for mental health issues.

1 = Excellent progress from previous service use

a. Previously accessed services for a mental health issue and experienced a significant benefit resulting in no need for additional services at that time.

2 = Moderate progress from previous service use

a. Previously accessed services and experienced a moderate benefit and required some additional services (either ongoing or periodically) to maintain the benefit.

3 = Minor progress from previous service use

a. Previously accessed services with only minor benefits resulting in a need for additional services or longer duration of services.

4 = Negligible or no progress from previous service use

a. Previously accessed services with little or no benefit.

Adolescent (12 - 17 years)

This domain considers the adolescent and their family’s previous use of services and support focussed on mental health-related assistance. The initial assessment on this domain should consider:

• Whether the adolescent or their family has previously sought help from or required mental health services and related supports (including specialist or mental health inpatient services).
• Their progress or benefit from past services and support.

Definition of the term services and support - Relevant services and support refer to safe, developmentally, and culturally appropriate evidence-informed mental health, health or community services focussed on or relevant to the adolescent's mental health (such as a psychological service delivered by a GP or mental health professional or other behavioural services) rather than the personal supports provided by friends, family, or social networks.

Consider both the adolescent and their family’s use of previous services and support but do not include those services and support relevant to, but not focused on, the adolescent's mental health.

Scoring

0 = No previous service use

a. Has not previously sought help or required a referral for mental health issues.

1 = Excellent progress from previous service use

a. Previously accessed services for a mental health issue and experienced a significant benefit resulting in no need for additional services at that time.

2 = Moderate progress from previous service use

a. Previously accessed services and experienced a moderate benefit and required some additional services (either ongoing or periodically) to maintain the benefit.

3 = Minor progress from previous service use

a. Previously accessed services with only minor benefits resulting in a need for additional services or longer duration of services.

4 = Negligible or no progress from previous service use

a. Previously accessed services with little or no benefit.

Adult (18 - 64 years)

This domain considers the person's previous use of services and support focussed on mental health-related assistance. The initial assessment on this domain should consider:

• Whether the person has previously sought help from or required mental health services and related supports (including specialist or mental health inpatient services).
• Their progress or benefit from past or current services and support.

Definition of the term services and support - Relevant services and support refer to safe developmentally and culturally appropriate evidence-informed mental health, health or community services focussed on or relevant to the person's mental health (such as a psychological service delivered by a GP or mental health professional, other behavioural services) rather than the personal supports provided by friends, family, or social networks.

Scoring

0 = No previous service use

a. Has not previously sought help or required a referral for mental health issues.

1 = Excellent progress from previous service use

a. Previously accessed services for a mental health issue and experienced a significant benefit resulting in no need for additional services at that time.

2 = Moderate progress from previous service use

a. Previously accessed services and experienced a moderate benefit and required some additional services (either ongoing or periodically) to maintain the benefit.

3 = Minor progress from previous service use

a. Previously accessed services with only minor benefits resulting in a need for additional services or longer duration of services.

4 = Negligible progress from previous service use

a. Previously accessed services with little or no benefit.

Older Adult (65 years and older)

This domain considers the older adult's previous use of services and support focussed on mental health-related assistance. The initial assessment on this domain should consider:

• Whether the person has previously sought help from or required mental health services and related supports (including specialist or mental health inpatient services).
• Their progress or benefit from past services and support.

Definition of the term services and support - Relevant services and support refer to safe, culturally appropriate, evidence-informed mental health, health or community services focussed on or relevant to the person's mental health (such as a psychological service delivered by a GP or mental health professional, other behavioural services) rather than the personal supports provided by friends, family, or social networks.

Scoring

0 = No previous service use

a. Has not previously sought help or required a referral for mental health issues.

1 = Excellent progress from previous service use

a. Previously accessed services for a mental health issue and experienced a significant benefit resulting in no need for additional services at that time.

2 = Moderate progress from previous service use

a. Previously accessed services and experienced a moderate benefit and required some additional services (either ongoing or periodically) to maintain the benefit.

3 = Minor progress from previous service use

a. Previously accessed services with only minor benefits resulting in a need for additional services or longer duration of services.

4 = Negligible progress from previous service use

a. Previously accessed services with little or no benefit.

Domain 6 - Social and environmental stressors

Children (5 - 11 years)

Assessment on this domain should consider the degree to which any or all of the following factors are relevant to the child’s current circumstances and the referral decision:

• Significant losses (e.g., loss of friends or social connections, death of a loved one).
• Significant transitions (e.g., disruption to educational activities, parental separation/divorce, death of a loved one, transitions relating to gender identity or sexual orientation).
• Peer group stress (e.g., bullying, conflict with or isolation from the peer group, loss of friendships).
• Trauma (e.g., emotional, physical, psychological, or sexual abuse, exploitation, witnessing or being a victim of violence, family and domestic violence, natural disaster, exposure to suicide in family/community/school or peer group, loss, conflict).
• Victimisation (e.g., human rights abuses, discrimination, racial abuse, victim of crime, refugee, or asylum-seeking experiences).
• Family or household stress (e.g., household drug or alcohol abuse, the parent or family member with an illness or disability, carer stress or stress associated with a caregiver role).
• Performance-related pressure (e.g., unrealistic role expectations or responsibilities, schooling demands, caregiving responsibilities) and stressors related to high-performance demands in school, dance, sport, and other relevant extra-curricular activities.
• Socioeconomic disadvantage (e.g., poverty, parental unemployment, unstable or insecure housing).
• Legal issues (e.g., the juvenile justice system or family court involvement, enforced separation from family).

Evidence points to the contribution made by historical childhood adverse events to longer-term mental health development. Assessment on this domain should consider the child’s history but only record higher ratings where earlier experiences impact the current situation and require additional specific resources and services.

Scoring

0 = No problem in this domain

1 = Mildly stressful environment

a. The child is experiencing (or has experienced) one or more stressors that have or are likely to have only a minor impact on the child's mental health.

2 = Moderately stressful environment

a. The child is experiencing (or has experienced) one or more stressors that have, or are likely to have, a moderate impact on the child's mental health.

3 = Highly stressful environment

a. The child is experiencing (or has experienced) one or more stressors that have or are likely to have a significant impact on the child's mental health.

4 = Extremely stressful environment

a. The child is experiencing (or has experienced) one or more stressors that are extreme, enduring or recurring and are having, or are likely to have, a severe impact on the child's mental health.

Adolescent (12 - 17 years)

Assessment on this domain should consider the degree to which any or all of the following factors are relevant to the adolescent’s current circumstances and the referral decision:

• Significant losses (e.g., loss of friends or social connections, death of a loved one).
• Significant transitions (e.g., disruption to educational activities, parental separation/divorce, death of a loved one, transitions relating to gender identity or sexual orientation).
• Peer group stress (e.g., bullying, conflict with or isolation from the peer group, loss of friendships).
• Trauma (e.g., emotional, physical, psychological, or sexual abuse, exploitation, witnessing or being a victim of violence, family and domestic violence, natural disaster, exposure to suicide in family/community/school or peer group, loss, conflict).
• Victimisation (e.g., human rights abuses, discrimination, racial abuse, victim of crime, refugee, or asylum-seeking experiences).
• Family or household stress (e.g., household drug or alcohol abuse, the parent or family member with an illness or disability, carer stress or stress associated with a caregiver role).
• Performance-related pressure (e.g., unrealistic role expectations or responsibilities, schooling demands, caregiving responsibilities) and stressors related to high-performance demands in school, dance, sport, and other relevant extra-curricular activities.
• Socioeconomic disadvantage (e.g., poverty, parental unemployment, unstable or insecure housing).
• Legal issues (e.g., the juvenile justice system or family court involvement, enforced separation from family).

Evidence points to the contribution made by historical childhood adverse events to longer-term mental health development. Assessment on this domain should consider the adolescent’s history but only record higher ratings where earlier experiences impact the current situation and require additional specific resources and services.

Scoring

0 = No problem in this domain

1 = Mildly stressful environment

a. The adolescent is experiencing (or has experienced) one or more stressors that are currently having or are likely to have a minor impact on the adolescent’s mental health.

2 = Moderately stressful environment

a. The adolescent is experiencing (or has experienced) one or more stressors that are currently having or are likely to have a moderate impact on the adolescent’s mental health.

3 = Highly stressful environment

a. The adolescent is experiencing (or has experienced) one or more stressors that are currently having or are likely to have a significant impact on the adolescent’s mental health.

4 = Extremely stressful environment

a. The adolescent is experiencing (or has experienced) one or more stressors that are extreme, enduring, or recurring and are currently having, or are likely to have, a severe impact on the adolescent’s mental health.

Adult (18 - 64 years)

Assessment on this domain should consider the degree to which any or all of the following factors are relevant to the person's current circumstances and the referral decision:

• Significant losses (e.g., job loss, relationship breakdown, loss of friends or social connections, death of a loved one).
• Significant change and transitions (e.g., a change in living environment, relationship breakdown/divorce, death of loved one, a romantic breakup, transitions relating to gender or sexual identity).
• Trauma (e.g., emotional, physical, psychological, or sexual abuse, exploitation, witnessing or being a victim of violence, family and domestic violence, intimate partner violence, natural disaster, exposure to suicide in family/community, loss, conflict).
• Victimisation (e.g., human rights abuses, discrimination, racial abuse, financial abuse, victim of crime, refugee, or asylum-seeking experiences).
• Family or household stress (e.g., household drug or alcohol abuse, a family member with an illness or disability, carer stress or stress associated with a caregiver role, access to children/grandchildren).
• Performance-related pressure (e.g., unrealistic role expectations and caregiving responsibilities).
• Socioeconomic disadvantage (e.g., poverty, unemployment, unstable or insecure housing).
• Legal issues (e.g., involvement in the criminal justice system or family court, enforced separation from family).
• Loneliness or isolation.
• Self-care (e.g., difficulties with mobility, toileting, nutrition, or personal hygiene).

Scoring

0 = No problem in this domain

1 = Mildly stressful environment

a. The person is experiencing (or has experienced) one or more stressors that are currently having or are likely to have a minor impact on their mental health.

2 = Moderately stressful environment

a. The person is experiencing (or has experienced) one or more stressors that are currently having or are likely to have a moderate impact on their mental health.

3 = Highly stressful environment

a. The person is experiencing (or has experienced) one or more stressors that are currently having or are likely to have a significant impact on their mental health.

4 = Extremely stressful environment

a. The person is experiencing (or has experienced) one or more stressors that are extreme, enduring, or recurring and are currently having, or are likely to have, a severe impact on their mental health.

Older Adult (65 years and older)

Assessment on this domain should consider the degree to which any or all of the following factors are relevant to the person's current circumstances and the referral decision:

• Significant losses (e.g., job loss, relationship breakdown, loss of friends or social connections, death of a loved one).
• Significant change and transitions (e.g., the transition from gainful employment to retirement, unexpected retirement, a change in living environment, transition to residential aged care, uncertainty about future care arrangements, changes in independence, managing an illness).
• Trauma (e.g., emotional, physical, psychological, or sexual abuse, exploitation, witnessing or being a victim of violence, family and domestic violence, intimate partner violence, elder abuse, natural disaster, exposure to suicide in family/community, loss, conflict).
• Victimisation (e.g., ageism, elder abuse, human rights abuses, discrimination, racial abuse, financial abuse, victim of crime, refugee, or asylum-seeking experiences).
• Family or household stress (e.g., household drug or alcohol abuse, a parent or family member with an illness or disability, carer stress or stress associated with a caregiver role, access to children/grandchildren).
• Performance-related pressure (e.g., unrealistic role expectations and caregiving responsibilities).
• Socioeconomic disadvantage (e.g., poverty, unemployment, unstable or insecure housing).
• Legal issues (e.g., involvement in the criminal justice system or family court, enforced separation from family).
• Loneliness or isolation.
• Self-care (e.g., difficulties with mobility, toileting, nutrition, or personal hygiene).

Scoring

0 = No problem in this domain

1 = Mildly stressful environment

a. The person is experiencing (or has experienced) one or more stressors that are currently having or are likely to have a minor impact on their mental health.

2 = Moderately stressful environment

a. The person is experiencing (or has experienced) one or more stressors that are currently having or are likely to have a moderate impact on their mental health.

3 = Highly stressful environment

a. The person is experiencing (or has experienced) one or more stressors that are currently having or are likely to have a significant impact on their mental health.

4 = Extremely stressful environment

a. The person is experiencing (or has experienced) one or more stressors that are extreme, enduring, or recurring and are currently having, or are likely to have, a severe impact on their mental health.

Domain 7 - Family and other supports

Children (5 - 11 years)

This domain considers whether personal supports, including emotionally nurturing relationships, practical support, and social support are present in the child’s environment and their potential to contribute to improved mental health.

This domain does not include or consider professional support. Personal supports include:

• Family/primary caregivers.
• Friends and peers.
• Supports within the school environment.
• Supports within the community (e.g., cultural connections, elders, spiritual leaders, sporting groups, neighbours etc.).

Personal supports may be present, but unable to provide the needed support at the time. There are a range of factors that may impact on whether personal supports are able to be provided, such as competing caring responsibilities, a lack of access to respite or other supports, financial or practical constraints, additional skill development requirements, or illness or distress in family or primary caregivers. It is important to avoid blame or judgement of personal supports when exploring this domain.

Where appropriate, a mental health assessment and intervention for the support person (or family as a whole) should be considered.

Scoring

0 = Highly supported

a. There are family/primary caregivers and other personal supports available that are highly supportive, willing, and capable to meet the child’s developmental, emotional, practical, and social needs.

1 = Well supported

a. There are a few family/primary caregivers and other personal supports available that are supportive, willing, and capable of meeting the child’s developmental, emotional, practical, and social needs.

2 = Limited supports

a. There are a few family/primary caregivers available to provide support, but their willingness to provide support is variable or difficult to access, or the sources of support have insufficient resources or capabilities to meet the child’s developmental, emotional, practical, and social needs whenever it is needed, or the child is reluctant to utilise the available supports.

b. Other personal supports are available for the child but only partially compensate for needs not met within the family.

3 = Minimal supports

a. Very few actual or potential useful sources of support are available, willing, and capable of meeting the child’s developmental, emotional, practical, and social needs.

b. There are serious limitations in the capacity or availability of supports outside the family, so that developmental, emotional, practical, or social needs are mostly unmet.

4 = No supports

a. No useful sources of support are available, and developmental, emotional, practical, and/or social needs are mostly unmet.

b. The child has no access to other supports that could compensate for needs not met within the family.

Adolescent (12 - 17 years)

This domain considers whether personal supports, including emotionally nurturing relationships, practical support, and social support are present in the child’s environment and their potential to contribute to improved mental health.

This domain does not include or consider professional support. Personal supports include:

• Family/primary caregivers.
• Friends and peers.
• Supports within the school environment.
• Supports within the community (e.g., cultural connections, elders, spiritual leaders, sporting groups, neighbours etc.).

Personal supports may be present, but unable to provide the needed support at the time. There are a range of factors that may impact on whether personal supports are able to be provided, such as competing caring responsibilities, a lack of access to respite or other supports, financial or practical constraints, additional skill development requirements, or illness or distress in family or primary caregivers. It is important to avoid blame or judgement of personal supports when exploring this domain.

Where appropriate, a mental health assessment and intervention for the support person (or family as a whole) should be considered.

Scoring

0 = Highly supported

a. There are family/primary caregivers and other personal supports available that are highly supportive, willing, and capable to meet the child’s developmental, emotional, practical, and social needs.

1 = Well supported

a. There are a few family/primary caregivers and other personal supports available that are supportive, willing, and capable of meeting the child’s developmental, emotional, practical, and social needs.

2 = Limited supports

a. There are a few family/primary caregivers available to provide support, but their willingness to provide support is variable or difficult to access, or the sources of support have insufficient resources or capabilities to meet the child’s developmental, emotional, practical, and social needs whenever it is needed, or the child is reluctant to utilise the available supports.

b. Other personal supports are available for the child but only partially compensate for needs not met within the family.

3 = Minimal supports

a. Very few actual or potential useful sources of support are available, willing, and capable of meeting the adolescent’s developmental, emotional, practical, and social needs.

b. There are serious limitations in the capacity or availability of supports outside the family, so that developmental, emotional, practical, or social needs are mostly unmet.

4 = No supports

a. No useful sources of support are available, and developmental, emotional, practical, and/or social needs are mostly unmet.

b. The adolescent has no access to other supports that could compensate for needs not met within the family.

Adult (18 - 64 years)

This domain considers whether personal supports, including emotionally nurturing relationships, practical support, and social support is present in the person's environment and their potential to contribute to improved mental health.

This domain does not include or consider professional support. Family and other supports include:

• Family members and caregivers.
• Friends and peers.
• Supports within the community (e.g., cultural connections, elders, spiritual leaders, social groups, neighbours etc.).

A lack of support might contribute to the onset or continuation of the mental health issue or impact recovery.

Scoring

0 = Highly supported

a. Personal supports are highly supportive and meet the person’s emotional, practical, and social needs.

1 = Well supported

a. There are a few personal supports available that are seen as valuable by the person and are willing and capable of providing emotional, practical, and social support.

2 = Limited supports

a. Usual sources of useful support may be reluctant to provide support, difficult to access or have insufficient resources to provide emotional, practical, or social support whenever it is needed, or the person is reluctant to access the available supports.

3 = Minimal supports

a. Very few actual or potential useful sources of support are available, willing to and capable of providing emotional, practical, or social support.

b. Despite the person requiring them, a substitute decision-maker has not facilitated access to services and support in the past.

4 = No supports

a. No useful sources of support are available, and emotional, practical, or social needs are mostly unmet.

Older Adult (65 years and older)

This domain considers whether personal supports, including emotionally nurturing relationships, practical support, and social support are present in the person's environment and their potential to contribute to improved mental health. This domain does consider professional services, where the service is focused on providing practical and social support. Family and other supports include:

• Family members and caregivers.
• Friends and peers.
• Supports within the community (e.g., cultural connections, elders, spiritual leaders, social groups, neighbours etc.).
• Practical and social support services (including aged care-related supports).

A lack of support might contribute to the onset or continuation of the mental health issue or impact on recovery.

Scoring

0 = Highly supported

a. Personal supports are highly supportive and meet the person’s emotional, practical, and social needs.

1 = Well supported

a. There are a few personal supports available, that are seen as valuable by the person and are willing and capable of providing emotional, practical, and social support.

2 = Limited supports

a. Usual sources of useful support may be reluctant to provide support, difficult to access or have insufficient resources to provide emotional, practical, or social support whenever it is needed, or the person is reluctant to access the available supports.

3 = Minimal supports

a. Very few actual or potential useful sources of support are available, willing to and capable of providing emotional, practical, or social support.

b. Despite the person requiring them, a substitute decision-maker has not facilitated access to services and support in the past.

4 = No supports

a. No useful sources of support are available, and emotional, practical, and/or social needs are mostly unmet.

Domain 8 - Engagement and motivation

Children (5 - 11 years)

This domain considers the parent/caregiver’s motivation to engage in or accept assistance. Children do not have the agency or resources required to seek services and support independently. Therefore, the parent/caregiver’s engagement and motivation are the focus of this domain for children.

Whilst this domain rates the engagement and motivation of the parent/caregivers, the child should be included in discussions, using language they understand, and supported to express their choices, preferences, fears, and goals about referral next steps. Assessment is unlikely to be valid unless rapport is established with the child and the child participates in the assessment process.

Scoring

0 = Optimal

a. The parent/caregiver is motivated and capable of participating fully in the recommended services and supports.

b. The parent/caregiver is capable of taking an active role in supporting the child to manage the condition.

1 = Positive

a. The parent/caregiver is mostly willing to accept and participate in the recommended services and support.

b. The parent/caregiver can mostly take an active role in supporting the child to manage the condition.

2 = Limited or mixed

a. The parent/caregiver is unsure whether they will accept or participate in the recommended services and supports or has limited capacity to do so.

b. There is significant divergence between the parents/caregivers in the level of engagement, motivation, or ability to participate in the recommended services and supports.

3 = Minimal

a. The parent/caregiver cannot participate in the recommended services and support without considerable practical or emotional assistance.

b. Despite the child requiring them, the parent/caregiver has not facilitated access to services and support in the past due to low engagement or motivation.

4 = Disengaged

a. The parent/caregiver cannot support participation in services and supports or avoids potentially useful and available supports.

Adolescent (12 - 17 years)

This domain considers the adolescent or their parent/caregiver’s awareness of the mental health issue and their motivation to engage in or accept assistance.

Many adolescents do not have the agency or resources required to seek and access services and support independently. Therefore, the engagement and motivation of the parent/caregiver is the primary determinant of access and uptake, and the parent/caregiver sub-scale is used. Whilst the parent/caregiver sub-scale rates the engagement and motivation of the parent/caregivers, the adolescent should be included in discussions, using language they understand, and supported to express their choices, preferences, fears, and goals about referral next steps.

The parent/caregiver sub-scale is used when the adolescent cannot exercise decision-making control of their healthcare decisions. The parent/caregiver sub-scale considers:

• Ability and capacity to support the adolescent to manage the condition.
• The parent/caregiver’s motivation to assist the adolescent to access necessary support (critical if considering self-management options).

Conversely, where the adolescent can exercise decision-making control of their healthcare decisions, the adolescent's engagement and motivation take precedence (adolescent sub-scale). The adolescent sub-scale considers:

• The adolescent’s motivation to participate in the recommended services and support.

Scoring

PARENT/CAREGIVER SUB-SCALE

Use the parent sub-scale where the adolescent cannot exercise decision-making control of their healthcare decisions.

0 = Optimal

a. The parent/caregiver is motivated and capable of participating fully in the recommended services and supports.

b. The parent/caregiver is capable of taking an active role in supporting the adolescent to manage the condition.

1 = Positive

a. The parent/caregiver is mostly willing to accept and participate in the recommended services and support.

b. The parent/caregiver can mostly take an active role in supporting the adolescent to manage the condition.

2 = Limited or mixed

a. The parent/caregiver is unsure whether they will accept or participate in the recommended services and supports or has limited capacity to do so.

b. There is significant divergence between the parents/caregivers in the level of engagement, motivation, or ability to participate in the recommended services and supports.

3 = Minimal

a. The parent/caregiver cannot participate in the recommended services and support without considerable practical or emotional assistance.

b. Despite the adolescent requiring them, the parent/caregiver has not facilitated access to services and supports in the past due to low engagement or motivation.

4 = Disengaged

a. The parent/caregiver cannot support participation in services and supports or avoids potentially useful and available supports.

ADOLESCENT SUB-SCALE

Use the adolescent sub-scale where the adolescent can exercise decision-making control of their healthcare decisions. In most instances, when working with a mature minor (see Informed Consent Practice Point), the use of the adolescent sub-scale will be appropriate.

0 = Optimal

a. The adolescent is motivated to participate in the recommended services and support.

b. The adolescent is capable of taking an active role in managing the condition.

1 = Positive

a. The adolescent is mostly willing to accept and participate in the recommended services and support.

b. The adolescent can mostly take an active role in managing the condition.

2 = Limited

a. The adolescent is hesitant to accept and participate in the recommended services and support.

3 = Minimal

a. The adolescent is very reluctant to accept or participate in services and support.

b. The adolescent has not participated in services and support in the past, despite requiring them, due to low levels of engagement or motivation.

4 = Disengaged

a. The adolescent refuses to accept or participate in the recommended services and support.

Adult (18 - 64 years)

This domain considers the person's capacity and willingness to engage in or accept assistance.

Assessment of an individual on this domain should include the persons:

• Ability and capacity to manage the condition.
• Motivation to access necessary supports (critical if considering self-management options).

Some people may not have the agency or resources required to seek and access services and support independently of a support person, caregiver, or family member. Subsequently, the initial assessment and referral process needs to include support people, caregivers, and family members in discussions and decision-making where appropriate.

Scoring

0 = Optimal

a. The person is motivated to participate in the recommended services and support.

b. The person is capable of taking an active role in managing the condition.

1 = Positive

a. The person is mostly willing to accept and participate in the recommended services and support.

b. The person can mostly take an active role in managing the condition.

2 = Limited

a. The person is hesitant to accept and participate in the recommended services and support.

b. The person has limited ability to take an active role in managing the condition.

3 = Minimal

a. The person is very reluctant to accept or participate in services and support.

b. The person has not participated in services and support in the past, despite requiring them, due to low levels of engagement or motivation.

4 = Disengaged

a. The person refuses to accept or participate in the recommended services and support.

b. The person has minimal ability to take an active role in managing the condition.

Older Adult (65 years and older)

This domain considers the older adult's awareness of the mental health issue and their capacity and willingness to engage in or accept assistance. Assessment of an individual on this domain should include the persons:

• Ability and capacity to manage the condition.
• Motivation to access necessary supports (critical if considering self-management options).

Some older adults may not have the agency or resources required to seek and access services and support independently of a support person, caregiver, or family member. Subsequently, the initial assessment and referral process needs to include support people, caregivers, and family members in discussions and decision-making where appropriate.

Scoring

0 = Optimal

a. The person is motivated to participate in the recommended services and support.

b. The person is capable of taking an active role in managing the condition.

1 = Positive

a. The person is mostly willing to accept and participate in the recommended services and support.

b. The person can mostly take an active role in managing the condition.

2 = Limited

a. The person is hesitant to accept and participate in the recommended services and support.

b. The person has limited ability to take an active role in managing the condition.

3 = Minimal

a. The person is very reluctant to accept or participate in services and support.

b. The person has not participated in services and support in the past, despite requiring them, due to low levels of engagement or motivation.

4 = Disengaged

a. The person refuses to accept or participate in the recommended services and support.

b. The person has minimal ability to take an active role in managing the condition.