All supervised living, residential treatment programs, and/or Crisis Stabilization Units must have policies

All supervised living, residential treatment programs, and/or Crisis Stabilization Units must have policies and procedures that can be implemented in the event of an emergency that ensure medication, prescription and nonprescription, based on the needs of the individuals in the program and guidance of appropriate medical staff is available for up to seventy-two (72) hours post-event. Each program must have policies and procedures that state they will not only have seventy-two (72) hour supply of all prescription and non-prescription medication for each resident, but they must also have appropriate staff available to administer those medications. DMH Disaster Preparedness and Response Plan Development guidance ATTACHMENT A – Hazard Vulnerability Analysis (HVA) • An HVA is conducted to determine the risks associated with probable or possible disasters or events. • An HVA identifies the events most likely to affect your organization and the probable impact if they do occur • Depending on the evaluated level of preparedness, the facility must take necessary steps to ensure they are prepared to meet the challenges presented by the hazards There are Four Areas of Concern: Natural, Technological, Human, and Hazmat Events These should be broken out into each individual type of event (i.e. tornado, fire, etc.) Items to address for each event type: • Probability  What is the known risk this will happen - Low – Rare - Moderate – Unusual - High – High Potential or Have Experienced  Use of historical data about previous events can help predict the likelihood • Response  How long would it take to have an on-scene response  How big will that response be  Historical evaluation of response success • Human Impact  Potential for staff death or injury  Potential for patient death or injury • Property Impact  Cost and time to replace/repair  Cost to set up temporary replacement  Time to recover • Business Impact  Business interruption  Employees and/or patients unable to report to work  Interruption of critical supplies  Financial impact/burden • Preparedness  Status of current plans (how ready are you for each type of event)  Frequency of drills  Availability of alternate sources for critical supplies/services • Internal Resources  Types and amount of supplies on hand and will they meet the need  Staff availability • External Resources  Types of agreements with community agencies  Coordination with local and state agencies  Coordination with nearby health care facilities  Coordination with treatment specific facilities  Community resources DMH Disaster Preparedness and Response Plan Development guidance ATTACHEMENT B – Disaster, Fire, and COOP Drill Guidance Disaster, Fire, and COOP Drills for all Programs Purpose Each provider certified by the DMH must maintain an emergency/disaster response plan for each service location/site for responding to natural disasters and manmade disasters (fires, bomb threats, utility failures and other threatening situation such as workplace violence). Providers must maintain a Continuity of Operations Plan (COOP) describing how operations will continue in the event of a natural or manmade disaster. Each location/site must document proof of implementation of these written plans as evidenced by written reports of scheduled and conducted fire, disaster, and COOP drills. Timeline • Disaster drills must be conducted and documented at least quarterly. ▪ Disaster drills must rotate the nature of the event for the drill based on each facility and program’s emergency/disaster plan. • Fire drills must be conducted and documented at least monthly for all supervised living and/or residential programs and quarterly for all day programs. ▪ Fire drills for residential programs must be conducted on a rotating schedule across all three shift schedules. • COOP drills must be conducted and documented at least annually. General Information Each provider is responsible for developing report formats that will document all aspects of each type of drill in order to ensure the safety of all persons involved in the drill. Elements to be recorded in each drill report include but are not limited to: • Name and location of the program • Type/nature of the drill • Date of the drill • Time the drill began • Time the drill ended • Nature of the event (tornado, bomb, hurricane, other) for a disaster drill • Number of participants • Names of staff participating • Assessment of the drill that addresses elements of the emergency/disaster or COOP plan as well as the behavior of those participating in the drill • Signature and title of the staff person completing the report Providers are welcome to contact the Office of Incident Management at 601-359-6652 for technical assistance in the development of drill reports. DMH Clean 2016 Fire and Disaster Drills for all Programs guidance Disaster, Fire, and COOP Drills for all Programs Purpose Each provider certified by the DMH must maintain an emergency/disaster response plan for each service location/site for responding to natural disasters and manmade disasters (fires, bomb threats, utility failures and other threatening situations such as workplace violence). Providers must maintain a Continuity of Operations Plan (COOP) describing how operations will continue in the event of a natural or manmade disaster. Each location/site must document proof of implementation of these written plans as evidenced by written reports of scheduled and conducted fire, disaster, and COOP drills. Timeline • Disaster drills must be conducted and documented at least quarterly. ▪ Disaster drills must rotate the nature of the event for the drill based on each facility and program’s emergency/disaster plan. • Fire drills must be conducted and documented at least monthly for all supervised living and/or residential programs and quarterly for all day programs. ▪ Fire drills for supervised living residential treatment service must be conducted on a rotating schedule across all three shift schedules. • COOP drills must be conducted and documented at least annually. General Information Each provider is responsible for developing a report that will document all aspects of each type of drill in order to ensure the safety of all persons involved in the drill. Elements to be recorded in each drill report include but are not limited to: • Name and location of the program • Type/nature of the drill • Date of the drill • Time the drill began • Time the drill ended • Nature of the event (tornado, bomb, hurricane, other) for a disaster drill – must rotate quarterly based on potential hazards • Number of participants • Names of staff participating • Assessment of the drill that addresses elements of the emergency/disaster or COOP plan as well as the behavior of those participating in the drill • Signature and title of the staff person completing the report Providers are welcome to contact the Division of Disaster Preparedness and Response at 601- 359-1288 for technical assistance in the development of drill reports. DMH Clean 2016 Fire and Disater Drills for all Programs form Fire and Disaster Drill Report Form Program Name_______________________ Date of Drill__________________________ Time of Drill (am/pm)_____________________ Type of Drill : Fire (quarterly for day programs, monthly for residential programs) Disaster (quarterly for all programs) Type of Disaster: COOP (annual for all programs) (Disaster type must rotate each quarter through all applicable disasters) Exact Start Time of Drill: Exact End Time of Drill: Amount of Time to Complete Drill : Number of Participants (not staff) : Staff Participating in Drill : Written assessment of general performance on the drill : (please be specific about actions that took place during the drill) Signature of Staff Member Preparing Report : Clean 2016 DMH Required Plan of Complaince guidance Required Plan of Compliance Purpose All DMH Certified Providers must submit a Plan of Compliance in response to findings included in a DMH Written Report of Findings. This template must be utilized by providers. Timeline The plan must be completed within the timeframe stated in the DMH Written Report of Findings. Finding Reference the DMH Operational Standard included in the DMH Written Report of Findings. Program/Service Reference the program or service (if there is not a specific physical location for the program) included in the DMH Written Report of Findings. Corrective Action Steps Outline the action steps the provider will put in place to correct the findings. Do not include justification. A request for a waiver of a DMH Operational Standard is not considered a corrective action step. Time Line Include the implementation date and estimated date of completion for each corrective action. Deficiencies related to Chapters 13, 32 and/or 34 of the DMH Operational Standards must be corrected within 30 days of the date of this letter. Plan for Continued Compliance Outline the plan for how the agency will continue to comply with DMH Operational Standards and the identified correction action plan(s). Clean 2016 DMH Required Plan of Complaince Template Required Plan of Compliance Plan of Compliance Please complete all requested information and mail completed form and supporting documentation to: Division of Certification MS Department of Mental Health 239 North Lamar Street, Suite 1101 Jackson, MS 39201 In lieu of mailing the form, you may e-mail the completed electronic form and supporting documentation to the Division of Certification. For contact information call #601-359-1288. Provider Name: Phone: Provider Contact Person for follow-up: Fax: Email: Finding (DMH Standard Number) Program/Service/ Record Corrective Action(s) Time Line Plan for Continued Compliance Implementation Date: Projected Completion Date: Implementation Date: Projected Completion Date: Implementation Date: Projected Completion Date: Implementation Date: Projected Completion Date: DMH Staff Verification of Training on Abuse or Neglect Reporting guidance Staff Verification of Training on Suspected Abuse or Neglect Reporting Requirements Purpose All provider staff must be informed of and trained on the procedures for reporting suspicions of abuse or neglect in accordance with state reporting laws to include but not limited to the Vulnerable Persons Act and Child Abuse or Neglect Reporting requirements. Time Line All provider staff must be informed of and trained on the procedures for reporting suspicions of abuse or neglect of individuals receiving services in accordance with state reporting laws. Individuals acknowledge receipt of the information and training during General Orientation before service delivery. A copy of the verification must be maintained in the staff personnel record. Verification form is updated if training is repeated or new training is provided. Clean 2016 Staff Verification of Training on Abuse or Neglect Reporting Requirements form Staff Verification of Training on Suspected Abuse or Neglect Reporting Requirements I acknowledge that I have been informed of and trained on the procedures for reporting suspicions of abuse or neglect in accordance with state reporting laws to include but not limited to the Vulnerable Persons Act and Child Abuse or Neglect Reporting requirements. I understand that I have a personal responsibility to report suspicions of abuse or neglect in accordance with state reporting laws. Staff Signature/ Position or Credentials Witness/ Position or Credentials Date Department of Mental Health Record Guide For Mental Health, Intellectual and Developmental Disabilities, and Substance Use Disorders Community Providers 2016 Revision Mississippi Department of Mental Health Diana S. Mikula, Executive Director 239 North Lamar Suite 1101 Jackson, MS 39201 DMH Record Guide Contents i TABLE OF CONTENTS Section A – General Information Page 1 Section B – All Records Page 5 Face Sheet Consent for Receive Services Rights of Individuals Receiving Services Acknowledgment of Grievance Consent to Release/Obtain Information Medication/Emergency Contact Information Section C – Required for All Mental Health and Substance Use Page 21 Records Initial Assessment Trauma History Individual Service Plan Individual Crisis Support Plan Recovery Support Plan Progress Note Weekly Progress Note Periodic Staffing/Review of the Individual Service Plan Readmission Assessment Update Substance Use Disorder Specific Assessment Section D – As Needed for All Records Page 57 Initial Assessment and Crisis Contact Summary Serious Incident Report Medical Examination Documentation of Healthcare Provider Visit Self-Administration Medication Log Telephone/ Visitation Agreement Search & Seizure Report Physical Escort Log Time Out Log Seclusion Behavior Management Log Service Termination/Change Summary Provider Discharge Summary Section E – Day Service Programs Page 87 Acute Partial Hospitalization Services Summary Note Individual Recovery Action Plan Section F – Mental Health Services Page 93 DMH Record Guide Contents ii Adult Making A Plan (AMAP) Case Summary Adult Making A Plan (AMAP) Monthly Report Crisis Stabilization Services Daily Note Adult Pre-Evaluation Screening Youth Pre-Evaluation Screening Violence Risk Assessment for Certified Holding Facility Suicide Risk Assessment for Certified Holding Facility Section G – Alzheimer’s and Other Dementia Services Page 118 Life Story Narrative Section H – Children and Youth Services Page 126 Therapeutic Foster Care Contact Log MAP Team Report MAP Team Case Summary Wraparound Facilitation Individual Support Plan Section I – Intellectual/Developmental Disabilities Services Page 144 IDD Plan of Services and Supports IDD Activity Support Plan IDD Service Note IDD Weekly Service Note ID/DD Waiver / IDD CSP Service Authorization ID/DD Waiver Home and Community Supports Service Agreement ID/DD Waiver In-Home Respite Service Agreement ID/DD Waiver In-Home Nursing Respite Service Agreement ID/DD Waiver In-Home Nursing Respite Service Note IDD Employment Profile ID/DD Waiver Job Discovery Profile ID/DD Request for Behavior Support and/or Crisis Support Services ID/DD Waiver Medical Verification for BS/ CI Services ID/DD Waiver Functional Behavior Assessment ID/DD Waiver Behavior Support Plan ID/DD Justification for Behavior Support Services ID/DD Waiver Behavior Support Quarterly Review Report ID/DD Waiver Request for Additional Behavior Support Services ID/DD Waiver Request for Additional Crisis Support Services ID/DD Waiver Request for Crisis Intervention Services ID/DD Waiver Crisis Intervention Plan ID/DD Waiver Crisis Intervention Daily Service Note ID/DD Waiver Crisis Intervention Log- Episodic ID/DD Waiver Request for Additional Crisis Intervention Services Section J – Substance Use Disorder Services Page 240 Risk Assessment Interview and Educational Activities for TB/HIV/STD DMH Record Guide Contents iii Substance Abuse Monthly Capacity Management & Waiting List Reports Section K – Administrative Information Page 249 Disaster Preparedness and Response Guidance Disaster, Fire, and COOP Drills for All Programs DMH Plan of Compliance Template Staff Verification of Training on Suspected Abuse or Neglect Reporting Section A General Information DMH Strikethrough 2016 Record Guide Purpose & Guidance 2016 DMH Operational Standards Record Guide Purpose Documentation required in the Mississippi Department of Mental Health (DMH) Record Guide serves as one of the methods for planning and evaluating services and supports provided by agencies and providers certified by the DMH. The intent of the record system outlined in this guide is to help ensure compliance with the DMH Operational Standards. The emphasis of this Record Guide is on guidance needed to satisfy any and all documentation requirements referenced in the DMH Operational Standards or otherwise needed to ensure documentation of all services provided by agencies certified by DMH. Because of the DMH mandatory data collection and reporting requirements, along with the increasing use of electronic record keeping that many providers are implementing, the need to maintain paper forms is declining. This guide seeks to describe the type and amount of documentation that is necessary and provide a sample of a format with all information needed to satisfy the DMH record keeping requirements. Additional information may be added and the appearance of the form may be changed by the local provider. However, if required data or information is deleted in the process of modifying the form, it will no longer satisfy DMH Operational Standards for record keeping. General Information A single case record must be maintained for all individuals served by the agency/provider and must contain specific mandatory data and information. Additional data or information may be included to ensure that sufficient information is maintained to protect the privacy of all individuals receiving services. Two years of documentation must be maintained in the active record. All completed documentation should be present in the individual’s record no later than the 10th day of the following month to the service was delivered unless more stringent timelines are required by DMH. The Record Guide is divided into sections that allow the user to identify those forms or data tools required for all individual records, those that are used when the circumstances of the individual receiving services dictates their use, those that are specific to an area of service, and those that are administrative documentation that is not maintained in an individual’s record. Each form has specific guidance that states the purpose of the form/data tool. Also included in the guidance are references to the DMH Operational Standards and specific information regarding the nature and purpose of all forms/data tools. References to “days” in the Record Guide mean calendar days. Any section or area of a form that is not applicable must contain a strikethrough line that clearly indicates the item was not overlooked or omitted and that it does not apply to the individual receiving services. DMH Strikethrough 2016 Record Guide Purpose & Guidance Signatory Authority Signatures are necessary to verify that information has been correctly and thoroughly shared with individuals receiving services. Signatures are also necessary to create a legally binding document. Forms in the Record Guide require signatures necessary for proper authorization of a particular form. Each signature line provided is clearly marked as to who is expected to sign. All signature lines on all forms must either be signed or marked as “not applicable” if that is the correct response. For example, all of the signature lines provided may not be necessary to document the individuals who participated in development of the Individual Service Plan or the Periodic Staffing/Review of the Individual Service Plan. Electronic signatures are allowed on any form in the Record Guide. Signature of the Individual Receiving Services The individual receiving services must sign for himself or herself unless one of the following conditions applies or is present: 1. The individual is under 18 years of age. 2. A legal representative has been appointed for the person by a court of competent jurisdiction. 3. If a person cannot physically sign or is not mentally/cognitively able to understand the form, a parent or next of kin can sign if they indicate they are signing as such. Physical, mental or cognitive ability to sign and understand the form must be determined by a medical doctor or psychologist. Documentation must be maintained in the record. Signature of Individual Authorized to Give Consent or Sign in Lieu of the Individual Receiving Services If one of the conditions stated above applies and the person is unable to sign for himself or herself, the person who is authorized to give consent or sign in lieu of the individual must sign the form(s). If the individual is under 18 years of age, this authorized representative is the parent unless a court ordered (legal) guardian or a conservator has been appointed for the child/youth. If the individual receiving services, regardless of his/her age, has a court ordered (legal) guardian or a conservator, the guardian/conservator must sign all forms on behalf of the individual receiving services. In the case of a court ordered (legal) guardian/conservator, a copy of guardianship/conservatorship papers must be maintained in the record. The legal guardian or conservator of an individual receiving service(s) must review and sign the paperwork required in order for an individual to receive services. Should the individual’s legal guardian or conservator choose to delegate his/her responsibility and signatory authority to another individual for the completion of daily paperwork (including delegating signature authority to the individual being served), DMH will accept the signature of that individual. The legal guardian or conservator must provide written documentation of such delegation and to whom the signatory authority is being delegated. This must be maintained in the individual’s record. Daily signature DMH Strikethrough 2016 Record Guide Purpose & Guidance authority cannot be delegated to the service provider. However, the legal guardian or conservator must continue to sign annual paperwork, such as the Consent for Services and Individual Service Plan. Signature of Witness/Credential In the case of some DMH documentation, a witness must sign in order to verify that the signature(s) are valid, particularly if a person is signing in lieu of the individual receiving services. Forms requiring the signature of a witness will have a signature line provided for the witness. This requirement will be reflected in the guidance for that particular form. If an individual signs with a mark or an “X,” the signature of a witness is required. If the form does not include a line for a witness, the witness will sign next to the mark or “X.” If the witness is an employee of the facility or program, he/she must include his/her credentials or position. Billing All questions concerning billing should reference the funding source. Questions concerning Medicaid billing should reference the Medicaid Guidelines issued by the Division of Medicaid, Office of the Governor. Section B Required For All Records Face Sheet Consent to Receive Services Rights of Individuals Receiving Services Acknowledgment of Grievance Procedure Consent to Release/Obtain Information Initial Assessment Trauma History Medication/Emergency Contact Information Individual Service Plan Individual Crisis Support Plan Recovery Support Plan Periodic Staffing/ Review of the Individual Service Plan Progress Note Weekly Progress Note DMH Face Sheet guidance Face Sheet Purpose The Face Sheet contains relevant data and/or personal information necessary to readily identify the individual receiving services. Information on the Face Sheet is used for routine service provision activities such as scheduling, billing, and reference. Timeline The Initial Face Sheet must be prepared at admission as part of the intake process. The Face Sheet must be updated whenever information or data changes and/or at least annually. When changes in information or data are made, or at the annual update, a new/corrected Face Sheet must be dated and placed in the individual record. Face Sheet Information Each DMH certified provider must maintain current and accurate data for submission of all reports and data as required by DMH. The Face Sheet can be generated as a report by the agency’s database system once all the data has been entered into the agency’s system. Depending on the specific data collection and reporting system that the agency uses, additional personal information may have to be added to complete the Face Sheet. The Face Sheet must contain all 44 data elements required in the DMH Manual of Uniform Data Standards. The required elements of the Face Sheet are provided on the following page. Providers should reference the DMH Manual of Uniform Data Standards for applicable codes and should consult with the agency employee responsible for data submission. Providers can also contact DMH Division of Information Services for additional guidance, 601-359-1288. DMH Face Sheet Required Elements Required Data Elements for Face Sheet 1. Record transaction type (add, change, delete) 2. Organization code 3. Unique client ID within organization 4. Client status 5. Admission date (most recent) to organization 6. Admission type (primary, collateral, unregister) 7. Admission referral category 8. Admission referral organization code (referrals to/from a DMH operated program only) 9. Legal status of client at admission 10. Client last name 11. Client first name 12. Client maiden name (if applicable) 13. Social Security Number (unique client identifier) 14. Birth date 15. Age of client (calculated from birth date) 16. Sex 17. Race 18. Hispanic origin 19. Education level: last grade completed 20. Marital status 21. County of residence prior to admission 22. Living arrangement 23. Type of residence 24. Employment status - Include place of employment if applicable. 25. Primary source of household income 26. Household annual income amount 27. No. of persons in household dependent on income 28. Is the individual pregnant? 29. Eligibility for SSI/SSDI 30. Eligibility for Medicaid 31. Expected principle source of payment 32. Veterans status 33. Physical impairment (1 of 2) 34. Physical impairment (2 of 2) 35. Presenting problem (1 of 2) 36. Presenting problem (2 of 2) 37. Treatment category (MH, MR, SA, dual) 38. Primary treatment category (if dual) 39. Is client seriously mentally ill (Y/N) DMH Face Sheet Required Elements 40. Is client seriously emotionally disturbed child? 41. Medicaid number 42. State ID (generated by CDR upon 1st submission) 43. Client receives integrated treatment 44. Indicates whether client receives ACT/PACT Assertive Community Treatment DMH Strikethrough 2016 Consent to Receive Services Guidance Consent To Receive Services Purpose In addition to all rights of individuals receiving services, each individual must provide his/her consent to receive services from the agency. Time Line Individuals receiving services must be informed of and consent to services at the time of the intake admission and before services are provided. Individuals must provide their consent for services at least annually, on or before the anniversary date of the current consent, as long as the individual continues to receive services. For ID/DD Waiver Support Coordination Services, individuals must provide their consent for services at least annually, before the end of the person's certification period For IDD providers, individuals must provide their consent at the time the Activity Support Plan is developed and annually thereafter. Consent to Receive Services This section can be read by, or if necessary, read to the individual receiving services and/or a person who is legally authorized to act on his/her behalf. In either case, the Consent To Receive Services and the limits of confidentiality must be clearly explained to the individual receiving services and/or a person authorized to act on his/her behalf. Signatures If the individual receiving services is unable to sign and the form is being signed by a court ordered (legal) guardian/conservator, a copy of guardianship/conservatorship papers must be maintained in the record. The Consent to Receive Services, Rights of Individuals Receiving Services and Acknowledgment of Grievance forms can be combined into one document as long as space is included in the document for signature or initials of the individual receiving services or legal guardian to acknowledge each separate action. Strikethrough 2016 Consent to Receive Services form Consent To Receive Services Name ID Number Service(s) The information which I have provided as a condition of receiving services is true and complete to the best of my knowledge. I consent to receive services as may be recommended by the professional staff. I understand the professional staff may discuss the services being provided to me, and that I may request the names of those involved. I further understand that my failure to comply with therapeutic recommendations of the professional staff may result in my being discharged. I understand that I have the freedom of choice to receive services in a setting that is integrated in and supports full access to the greater community; and is a setting that facilitates individual choice regarding services and supports, and who provides them. I understand that State and federal laws and regulations prohibit any entity receiving confidential information from redistributing the information to any other entity without the specific written consent of the person to whom it pertains or as otherwise permitted by law and regulations. I understand that confidential information may be released without my consent when necessary for continued treatment services; when release is necessary for the determination of eligibility for benefits, compliance with statutory reporting requirements, or other lawful purpose; if you communicate to the treating physician, psychologist, master social worker or licensed professional counselor an actual threat of physical violence against a clearly identified or reasonably identifiable potential victim or victims; in compliance with reporting requirements under state law of incidents of suspected child abuse or neglect, or by court order. Individual/Legal Representative Signature Date Staff Signature/Credentials Date DMH Strikethrough 2016 Rights of Individuals Receiving Services guidance Rights of Individuals Receiving Services Purpose Each individual who receives services from a DMH certified agency or provider has legal, ethical, and privacy rights that must be protected. DMH certified agencies must maintain documentation showing each individual who receives services has been informed of these rights. This document also informs the individual receiving services of legal circumstances in which the provider will be required to release information concerning his/her treatment/services. After the individual receiving services has been informed of his/her rights, the individual is then offered the opportunity to consent to receive services treatment. Time Line Individuals receiving services must be informed of his/her rights during the intake admission process and before services are provided. Individuals must be informed of his/her rights at least annually, on or before the anniversary date of the current form, as long as the individual continues to receive services. For ID/DD Waiver Support Coordination Services, individuals must be informed of their rights at least annually, before the end of the person's certification period For IDD providers, individuals must be informed of their rights at the time the Activity Support Plan is developed and annually thereafter. Intake/Admission Date The intake/admission date is the original date of intake/admission to the service. This date remains the same from year to year as long as the person is continuously enrolled in the service. Rights The rights can be read by, or if necessary, read to the individual receiving services and/or to a person who is legally authorized to act on his/her behalf. The rights must be clearly explained to the individual receiving services and/or a person authorized to act on his/her behalf. The individual must be offered a copy of the form to take with them. Signed documentation of receipt must be maintained in the record. Providers may omit #18-22 if those service types are not provided by the agency. The Consent to Receive Services, Rights of Individuals Receiving Services and Acknowledgment of Grievance forms can be combined into one document as long as space is included in the document for signature or initials of the individual receiving services or legal guardian to acknowledge each separate action. Strikethrough 2016 Rights of Individuals Receiving Services form Rights of Individuals Receiving Services Name ID Number I, began receiving services provided by Name Name of Provider on and have been informed of the following: Intake/Admission Date 1. My options within the program and of other services available 2. The program’s rules and regulations 3. The responsibility of the program to refer me to another agency if this program becomes unable to serve me or meet my needs 4. My right to refuse treatment and withdraw from this program at any time 5. My right not to be subjected to corporal punishment or unethical treatment which includes my right to be free from any forms of abuse, neglect, exploitation or harassment and my right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff 6. My right to voice my opinions, recommendations and to file a written grievance which will result in program review and response without retribution 7. My right to be informed of and provided a copy of the local procedure for filing a grievance at the local level or with the DMH Office of Consumer Support 8. My right to privacy and confidentiality in respect to facility visitors in day programs, residential treatment programs, and community living programs as much as physically possible 9. My right regarding the program’s nondiscrimination policies related to HIV infection and AIDS 10. My right to be treated with consideration, respect, and full recognition of my dignity and individual worth 11. My right to have reasonable access to the clergy and advocates and have access to legal counsel at all times 12. My right to review my records, except when restricted by law 13. My right to fully participate in and receive a copy of my Individual Service Plan/Plan of Care Services and Supports or Activity Plan. This includes: 1) having the right to make decisions regarding my care, being involved in my care planning and treatment and being able to request or refuse treatment; 2) having access to information in my case records within a reasonable time frame (5 days) or having the reason for not having access communicated to me; and, 3) having the right to be informed about any hazardous side effects of medication prescribed by staff medical personnel 14. My right to retain all Constitutional rights, except when restricted by due process and resulting court order 15. My right to have a family member or representative of my choice notified should I be admitted to a hospital 16. My right to receive care in a safe setting 17. My right to confidentiality regarding my personal information involving receiving services as well as the compilation, storage, and dissemination of my individual case records in accordance with standards outlined by the Department of Mental Health and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), if applicable Additionally, rights for individuals in supervised and residential treatment arrangements: 18. My right to be provided a means of communicating with persons outside the program 19. My right to have visitation by close relatives and/or significant others during reasonable hours unless clinically contraindicated and documented in my case record 20. My right to be provided with safe storage, accessibility, and accountability of my funds 21. My right to be permitted to send/receive mail without hindrance unless clinically contraindicated and documented in my case record 22. My right to be permitted to conduct private telephone conversations with family and friends, unless clinically contraindicated and documented in my case record I have been informed of, understand, and have received a written copy of the above information. Individual Receiving Services Date Legal Representative Date Staff/Credentials Date DMH Strikethrough 2016 Acknowledgment of Grievance guidance Acknowledgment of Grievance Procedures Purpose The provider’s grievance procedures must be provided to the individual and/or legal representative during the intake admission process. The information can be read by, or if necessary, read to the individual receiving services and/or a person who is legally authorized to act on his/her behalf. Time Line Individuals receiving services must be informed of and provided a copy of the provider’s Grievance Procedures at the time of the initial intake admission and before services are provided. Each individual receiving services must be presented with the provider’s Grievance Procedures when they are being asked to give his/her consent to receive services. Individuals acknowledge receipt of the Grievance Procedures at least annually, on or before the anniversary date of the current acknowledgment, as long as the individual continues to receive services. A copy of the Grievance Procedures given to the individual receiving services should be attached and kept with the signed form. For ID/DD Waiver Support Coordination Services, individuals must sign the acknowledgment at least annually, before the end of the person's certification period For IDD providers, individuals must sign the acknowledgment at the time the Activity Support Plan is developed and annually thereafter. The Consent to Receive Services, Rights of Individuals Receiving Services and Acknowledgment of Grievance forms can be combined into one document as long as space is included in the document for signature or initials of the individual receiving services or legal guardian to acknowledge each separate action. DMH Strikethrough 2016 Acknowledgment of Grievance form Acknowledgment of Grievance Procedures Name ID Number I have been informed of the policies and procedures for reporting a grievance concerning any treatment or service that I receive. Individual/Legal Representative Signature Date Staff Signature/Credentials Date DMH Strikethrough 2016 Consent to Release-Obtain Information guidance Consent to Release/Obtain Information Purpose Providers must have prior written authorization before information regarding an individual receiving service can be released. A fully executed Consent to Release/Obtain Information must be in place in order to legally exchange, release, or obtain information between individuals, agencies and/or providers. The original Consent to Release/Obtain Information form must always be maintained in the individual’s case record. Release/Obtain Information Enter the name and address of the agency from which the action is required. Complete the Release Information To when requesting a provider to send confidential information about an individual to another entity. Complete the Obtain Information From section when confidential information regarding an individual receiving/requesting to receive services needs to be obtained from another entity. The specific purpose for which the information is needed must be indicated. Staff must specify the exact reason for obtaining/releasing the information. Extent/Nature of Information The specific extent and/or nature of the information to be disclosed must be checked. If ‘Other’ is checked, the specific extent/nature of the disclosure must be described in detail. A generic authorization for the non-specific release of medical or other personal information is not sufficient for this purpose. Date/Event/Condition In order to clearly show the point in time when the Consent will expire, the following information must be provided: 1) the month, day, and year, or 2) an event, or; 3) a condition that will deem the Consent form expired; meaning no further action can be taken once the specific date/event/condition is satisfied. An example of an event or condition may be, “30 days after discharge or termination of services”. For children and youth receiving services in a school setting, a date period that covers a specific school year must be used. The actions, conditions and limits of the consent must be clearly explained to the individual receiving services and/or to a person who is legally authorized to act on his/her behalf. The provider must clearly explain the conditions under which confidential information may be released without consent. Confidential information may be released without consent when necessary for continued services treatment; when release is necessary for the determination of eligibility for benefits, compliance with statutory reporting requirements, or other lawful purpose; if you communicate to the treating physician, psychologist, master social worker or licensed professional counselor an actual threat of physical violence against a clearly identified or reasonably identifiable potential victim or victims; in compliance with reporting requirements under state law of incidents of suspected child abuse or neglect or by court order. DMH Strikethrough 2016 Consent to Release-Obtain Information guidance Witness The Consent to Release/Obtain Information requires the signature of a witness. If the witness is an employee of the program, he/she must include his/her credentials (if applicable). If the individual receiving services can only make their mark (for example “X”), place the mark in quotations and write out beside it, John Doe’s Mark substituting individual’s name. A second witness to the individual’s signature is required in this case. DMH Strikethrough 2016 Consent to Release-Obtain Information form Consent to Release/Obtain Information Name ID Number Date I hereby give my consent/permission for (Agency Name and Address)  To release information to: (Agency/Person Name/Title and Address)  To obtain information from: (Agency/Person Name/Title and Address) For the specific purpose of:   Treatment Coordination of Services  Other The extent and nature of the information to be disclosed/obtained must be indicated (check all that apply):  Evaluations  Diagnosis/Prognosis/Recommendations  Progress Notes  Psychiatric Records  Substance Abuse Records  Admission/ Discharge Summary  Contact Summaries  Activity Support Plan  Identifying Information  Individual Service Plan/ Plan of Services & Supports  Other I understand that I may revoke this consent at any time except to the extent that action has been taken. I further understand that this consent will expire upon (Specific Date/Event/Condition) and cannot be renewed without my consent. I understand that to revoke this authorization, Individual or Legal Representative must provide a written request and the revocation will not apply to action or information that has already been released/obtained in response to this authorization. Any information obtained as a result of this release is confidential. State and federal laws and regulations prohibit any entity receiving confidential information from redistributing the information to any other entity without the specific written consent of the person to whom it pertains or as otherwise permitted by law and regulations. I understand the information I authorize for release may include information related to history/diagnosis and/or treatment of HIV, AIDS, communicable or sexually transmitted diseases and alcohol/drug abuse or dependency. I understand that confidential information may be released without my consent when necessary for continued treatment services; when release is necessary for the determination of eligibility for benefits, compliance with statutory reporting requirements, or other lawful purpose; if you communicate to the treating physician, psychologist, master social worker or licensed professional counselor an actual threat of physical violence against a clearly identified or reasonably identifiable potential victim or victims; in compliance with reporting requirements under state law of incidents of suspected child abuse or neglect or by court order. By signing below, I acknowledge receipt of a copy of the signed authorization Individual Receiving Services Date Legal Representative Date Witness/Credentials Date DMH Strikethrough 2016 Medication-Emergency Contact Information guidance Medication/Emergency Contact Information Purpose Documentation of medications must be maintained while the individual is receiving services from a DMH certified agency or provider. The Medication/Emergency Contact Information is not to be used for the regular dispensing of medication. An important component is the documentation of all the individual’s known allergic and/or adverse reactions. Emergency contact information must be completed to ensure immediate and appropriate response in the event of an emergency. Timeline The medications the individual is taking and the emergency contact information are recorded during the intake admission process. The information must be updated when medications are discontinued or added and at least annually. Updates The person entering updated information (new medications/changes to existing medications/discontinuation of a medication) must write the date the changes were made and sign the form in the designated space. The same form can be used until all spaces for medications are filled. At that time, a new form must be completed to ensure clarity. Any time the emergency contact information changes, a new form must be completed and placed in the individual’s record. Staff Signature/Date Initiated Each medication entry must be signed by the person completing the form. If known, enter the date the individual began taking the medication. If this information is unavailable, signify such by entering “NK” in the “Date Initiated” column. Current Medication All sections must be addressed. ALL known and/or reported medications the individual is currently taking must be listed, regardless of type or purpose, including over-the-counter (OTC) medications the individual may be taking. The name of the medical professional prescribing each medication must be listed. All known or reported prescribed medications must be documented. Medication information regarding dosage and frequency must be listed exactly as prescribed. If there are no prescribed or OTC medications, the person completing the form must write “no prescription or OTC meds” and his/her initials. Previous Medications/ Dietary Needs Previously prescribed or taken medications listed; including any adverse reactions as reported by the individual; any special dietary needs. Date Terminated/Changed/Staff Signature If a medication dosage or frequency is changed, enter the date in the column. This space is also to be used if a medication is discontinued. The staff person entering the information must sign the form. Allergies/ Adverse Reactions Each of the individual’s known allergies and his/her reactions to them must be documented. Include unusual reactions if applicable. Allergies may include, but not be limited to, medications, insect bites, plants, foods, fragrances/aromas, or anything else that produces an allergic or adverse reaction. DMH Strikethrough 2016 Medication-Emergency Contact Information form Medication/Emergency Contact Information Name ID Number Name/Credentials of Staff Initially Completing the form: Date Initially Completed: CURRENT MEDICATIONS List ALL known and/or reported medications the individual is currently taking regardless of type or purpose to include over-the-counter (OTC) medications (use additional pages, if needed): Staff Signature/ Credential Date Initiated Name of Medication Prescribed by Dosage/ Frequency Date Terminated/ Changed Staff Signature/ Credential Known Allergies/Reactions: PREVIOUS MEDICATIONS Medication Directions Comments (to include adverse reactions if applicable) DMH Strikethrough 2016 Medication-Emergency Contact Information form Special Dietary Needs (if applicable): Emergency Information: In case of emergency (when parent/legal representative cannot be reached) contact: Name: Phone Number: (primary) (secondary) Address: Primary Doctor: Doctor’s Phone: Doctor’s Address: Hospital Preference: Insurance Carrier(s): Policy Number(s): Section C Required For All Mental Health and Substance Use Records Initial Assessment Trauma History Individual Service Plan Individual Crisis Support Plan Recovery Support Plan Periodic Staffing/ Review of the Individual Service Plan Progress Note Weekly Progress Note Readmission Assessment Update Substance Use Disorder Specific Assessment Strikethrough 2016 Initial Assessment guidance Initial Assessment Purpose The Initial Assessment is used to document pertinent information that will be used as part of the process for determining what service or combination of services might best meet an individual’s stated/presenting need(s). The information gathered is both historical as well as what is currently happening in an individual’s life. *Note- An Initial Assessment is not required for ID/DD Waiver or 1915(i) Services. The ID/DD Evaluation performed by the Diagnostic and Evaluation team to determine eligibility for the ID/DD Waiver or the 1915(i) Community Support Program takes the place of the Initial Assessment. Responses of “No” or “Not Present”, are acceptable. If an entire section does not apply to someone, the recorder can enter “Not Applicable.” However, if the answer is “Yes” or “Present”, then additional narrative and explanation is required. Timeline The Initial Assessment is part of the intake process and must be completed within the service specific timeline requirements. Admission Date Enter the date the individual was admitted to service(s). Assessment Date Enter the date the Initial Assessment was started. Informant If assessment information is provided by someone other than the individual receiving services, enter the person’s relationship to the individual requesting services. A Consent to Release/ Obtain Information must be completed if applicable. Guardianship Information If individual has a legal guardian record name and contact information. Confidentiality Mark yes if limits of confidentiality are discussed with individual/guardian. If not, mark no with an explanation. Description of Need Record the reason(s) the individual gives as to why he/she is seeking services, current needs, goals etc. If substance use disorder is indicated in this section, a Substance Use Specific Assessment must be completed. Strikethrough 2016 Initial Assessment guidance Social / Cultural Complete social information, current living situation, and family history sections as applicable with information provided by the informant. History Complete the history section as applicable with information provided by informant. The developmental history section should be completed for Children and Youth up to age 21 and all individuals with IDD. The school functioning education section and additional information section should be completed for all Children and Youth up to age 21. The employment section should be completed for adults not employed at the time of the assessment. All items in the history sections must be completed. Responses of “No” or “Not Present”, are acceptable. If an entire section does not apply to someone, the recorder can enter “Not Applicable.” However, if the answer is “Yes” or “Present”, then additional narrative and explanation is required. Medical History Complete the additional medical information as applicable with information provided by informant. All items in the history sections must be completed. Responses of “No” or “Not Present”, are acceptable. If an entire section does not apply to someone, the recorder can enter “Not Applicable.” However, if the answer is “Yes” or “Present”, then additional narrative and explanation is required. Individual Mental Health History Complete the outpatient mental health and psychiatric hospitalization/ residential treatment sections as applicable with information provided by informant. All items in the history sections must be completed. Responses of “No” or “Not Present”, are acceptable. If an entire section does not apply to someone, the recorder can enter “Not Applicable.” However, if the answer is “Yes” or “Present”, then additional narrative and explanation is required. Initial Behavioral Observation Record observations for all areas listed. All areas must be evaluated. Comments must be included to further explain or clarify the specific observed behaviors. Indication of Functional Limitation(s) An assessment must be conducted and the results documented for the major life areas specified for each individual seeking readmission to services. Strikethrough 2016 Initial Assessment guidance The Child and Adolescent Functional Assessment Scale (CAFAS) is required for all children/youth receiving mental health services. The CAFAS must be completed within 630 days for all children/youth receiving mental health services or within timelines as required by service. An approved functional assessment is required for all adults receiving mental health services. An approved functional assessment must be completed within 630 days for all adults receiving mental health services or within timelines as required by service. DMH will review and approve a functional assessment for use with the adult SMI population. An approved functional assessment is required for all individuals receiving substance use disorder services. DMH will review and approve a functional assessment for use with the SUD population. Summary/Recommendations The person conducting the Initial Assessment must summarize the observations and findings to include an analysis of the individual’s strengths and needs, both expressed and observed. Based on the results of the Initial Assessment, services must be recommended and offered to the individual. Referrals to other appropriate providers must also be offered to the individual. Observations, findings and recommendations should support a life of recovery related to the following dimensions: Health- managing one’s disease; making informed, healthy choices that support physical and emotional well-being Home- having a stable and safe place to live Community- having relationships and social networks that provide support, friendship, love and hope Purpose- conducting meaningful daily activities to participate in society Initial Diagnostic Impression Give the written diagnostic impression and appropriate codes. Staff Qualifications The Initial Assessment must be completed by an individual with at least a Master’s degree in mental health or intellectual/developmental disabilities, or a related field and who has either (1) a professional license or (2) a DMH credential as a Mental Health Therapist, Intellectual/Developmental Disabilities Therapist or Substance Abuse Therapist (as appropriate to the population being served). For IDD programs, a QMRP may complete the Initial Assessment. For Alzheimer’s Day Programs only, the program supervisor must complete the Initial Assessment. A copy of the individual’s current history and physical, signed by an MD or Psychologist must be provided to confirm diagnosis. DMH Initial Assessment form Page 1 of 7 Initial Assessment Name:______________________________________________ ID Number:__________________________________________ Admission Date:______________________________________ Assessment Date:____________________________________ Time In: Time Out: Total Time: Informant: □ Individual Receiving Services □ Other: Relationship to Individual______________________ Does the person seeking services have an Outpatient Commitment Order? □ Yes □ No GUARDIANSHIP INFORMATION Name of Guardian / Custodian: Guardianship Documentation Verified: □ Yes □ No Guardian / Custodian Address: Guardian / Custodian Phone Number: Is the family involved with the Department of Human Services? □ Yes □ No If yes, has a consent to release information been obtained? □ Yes □ No If yes, please explain and indicate the name of the assigned case worker: __________________________ CONFIDENTIALITY Were the limits of confidentiality reviewed with Individual and/or Guardian? □ Yes □ No If NO, please explain. DESCRIPTION OF NEED What is your reason for seeking services today? What specific needs do you currently have? (Include a description/perception of difficulties according to the individual seeking services and any applicable family members/legal guardian.) Is the reason for seeking services today related to substance use? □ Yes □ No If yes, the substance use specific assessment must also be completed. What specific needs do you currently have? What previous coping skills have been helpful in the past? DMH Initial Assessment form Page 2 of 7 Thoughts of Suicide: □ Yes (If yes, explain) □ No Attempts of Suicide: □ Yes (If yes, explain) □ No Thoughts of Homicide: □ Yes (If yes, explain) □ No (Indicate the need for “duty to warn”) Acts of Self-Harm: □ Yes (If yes, explain) □ No SOCIAL / CULTURAL Identification of Support Systems: (Address family relationships, interpersonal relationships, and community support systems) Meaningful Activities, Cultural / Ethnic / Spiritual interests, Supports: (Address hobbies, leisure activities, etc.) Cultural / Ethnic / Spiritual interests, Supports: Support Needs (social supports, interpersonal, protective care, support groups, counseling, legal assistance, other): Living Situation What are your views on is your current living arrangements (strengths and concerns)? Who lives with you? What are your views on your current arrangement? Individuals Living in Household Individual Relationship to Client Age Quality of Support According to the person (circle one) Good Fair Poor Good Fair Poor Good Fair Poor Good Fair Poor Good Fair Poor DMH Initial Assessment form Page 3 of 7 Secondary Household (Minors Only) Individual Relationship to Client Age Quality of Support Good Fair Poor Good Fair Poor Good Fair Poor Good Fair Poor Needs Related to Living Situation (money management, benefits, living arrangements, clothing, personal care, child care, rent, other) Developmental History (Complete only for Children & Youth up to age 21 and everyone with ID/DD) During pregnancy, did mother use alcohol or other drugs? □ Yes □ No Describe any problems with the pregnancy or birth: Were developmental milestones met there any developmental issues? □ Yes □ No (If no, explain) Was the child’s first year of life difficult, easy, other? □ Yes (If yes, explain) □ No Describe any childhood accidents or injuries: Education School Functioning (Children & Youth up to age 21) Name of school: Does child/youth receive Special Education Services? □ Yes (If yes, complete release of information to obtain a copy of the current Individualized Education Plan (IEP)) □ No Additional Information (Children & Youth up to age 21) Educational Issues/ Needs ( grades, attendance, suspensions, expulsions)Comments on Educational Classification / Placement (please indicate if client is home schooled, in gifted program, etc.): Grades: Attendance: Previous Grade Retentions: Suspensions / Expulsions: Other Academic / School Concerns: Employment (adults only) (complete only if individual is not employed at the time of assessment) Are you employed?Barriers to Employment: □ Yes □ No If no, do you want to be employed?Employment Related Needs: Employment Barriers/ Related Needs? DMH Initial Assessment form Page 4 of 7 Previous Assessment History Have psychological, educational or functional assessments been completed in the last twelve months? □ Yes (If yes, complete release of information to obtain a copy of the applicable assessment.) If yes, indicate type of assessment__________________________________________________________________ □ No Current Legal Status Has the individual been involved with the legal system within the past twelve months? □ Yes □ No Arrests: □ Yes □ No If yes, indicate type and number of arrest(s): Number of arrests in the past 30 days: Pending Charges: □ Yes □ No If yes, indicate type and number of pending charges: Substance Use Related Legal Issues: Is this person currently on parole and/or probation? □ Yes □ No If applicable, indicate to whom reports should be submitted: ______________________________________ MEDICAL HISTORY Appetite Issues: Sleep Issues: Current or Chronic Diseases □ high blood pressure □ diabetes □ thyroid □ other ____________________ Family History □ high blood pressure □ diabetes □ thyroid □ other ____________________ Other Pertinent Medical Information: Additional Medical History or Health and Safety Issues: Health-Related Needs: INDIVIDUAL MENTAL HEALTH HISTORY Previous Assessment History Have psychological, educational or functional assessments been completed in the last twelve months? □ Yes (If yes, complete release of information to obtain a copy of the applicable assessment.) DMH Initial Assessment form Page 5 of 7 If yes, indicate type of assessment__________________________________________________________________ □ No Previous or Current Diagnoses: Mental Health Needs: Family History of Psychiatric or Substance Use Disorder(s) □ Yes □ No If yes, please describe. Outpatient Behavioral Health Agency □ None Reported Treatment Agency Services Received Dates of Service Has Consent to Release Information Been Requested? □ Yes □ No □ Yes □ No □ Yes □ No Psychiatric Hospitalizations / Residential Treatment □ None Reported Treatments Reason (suicidal, depressed, etc.) Dates of Service Has Consent to Release Information Been Requested? □ Yes □ No □ Yes □ No □ Yes □ No DMH Initial Assessment form Page 6 of 7 Initial Observations General Observations Appearance: □ Appropriate □ Disheveled □ Unclean □ Other __________________________________ Speech: □ Appropriate □ Slow □ Mechanical □ Rapid □ Other _______________________________ Affect: □ Appropriate □ Flat □ Labile □ Other __________________________________________ Delusions: □ N/A □ Description: Hallucinations: □ N/A □ Description: Mood □ Appropriate □ Manic □ Depressed □ Labile □ Irritable □ Other _________________________ Orientation □ Person □ Place □ Time □ Situation □ Other ________________________________________ Indication Of Functional Limitation(s): (Check Major Life Areas Affected) Basic living skills (eating, bathing, dressing, etc.) Instrumental living skills (maintain a household, managing money, getting around the community, taking prescribed medications, etc.) Social functioning (ability to function within the family, vocational or educational function, other social contexts, etc.) SUMMARY / RECOMMENDATIONS Health: Home: Community: Purpose: Other: DMH Initial Assessment form Page 7 of 7 INITIAL DIAGNOSTIC IMPRESSION Codes: Description: SIGNATURES / CREDENTIALS X Date: X Date: X Date: X Date: DMH Trauma History guidance Trauma History Purpose The Trauma History is a screening tool designed to determine whether or not an individual receiving services has experienced trauma in the past. This tool is not a standardized measure and there are no scoring guidelines. This assessment should be administered in an interview format that allows the clinician to explain questions in a developmentally appropriate manner to ensure the client understands what is being asked. The interview process also allows the clinician to observe nonverbal responses to questions that might indicate a trauma response such as anxiety, fear, avoidance, shame, etc. General The timeline for completion of the Trauma History is determined by the type of service or program the individual is entering. All individuals receiving services must complete a trauma history questionnaire. Outpatient Services must complete the trauma history questionnaire within 30 days, Day programs must complete the trauma history questionnaire within 3 days of admission. Primary Residential Services within 5 days of admission to the services. Crisis Stabilization Services must complete the trauma history questionnaire within 48 hours. Results of trauma history questionnaire should be incorporated into ISP and subsequent services. The Trauma History Assessment is not a tool for gathering information or details about the traumatic event. The clinician should maintain a neutral tone when asking each question. If the client indicates he/she has experienced an event, then the therapist only asks at what age the traumatic event(s) started and ended. If the client offers more information, the clinician captures that content but does not attempt to elicit more details than offered, challenge nor process the information shared. If the client reports a positive trauma history, the clinician asks the client to identify the trauma that is most distressing at that time. The identified trauma is then incorporated into the Individual Service Plan and subsequent services and can be referred to when administering formal trauma assessments. DMH Trauma History form Trauma History Name ID Number Date Time In: Time Out: Total: Page of Please indicate if any of the following have happened to you and how it may have affected you. Have you ever served in the military, law enforcement or as a first responder? □ Yes □ No If yes, indicate the capacity in which you served. Have you ever seen or been in a really bad accident? Has someone close to you ever been so badly injured or sick that s/he almost died? Has someone close to you ever died? Have you ever been so sick that you or the doctor thought you might die? Have you ever been unexpectedly separated from someone who you depend on for love or security for more than a few days? Has someone close to you ever tried to kill or hurt him/herself? Has someone ever physically hurt you or threatened to hurt you? DMH Trauma History form Trauma History Name ID Number Page of Have you ever been mugged or seen someone you care about get mugged? Has anyone ever kidnapped you? Have you ever been attacked by a dog or other animal? Have you ever seen or heard people physically fighting or threatening to hurt each other? (In or outside of the family)? Have you ever witnessed a family member who was arrested or in jail? Have you ever had a time in your life when you did not have a place to live or enough food? Has someone ever made you see or do something sexual? Or have you seen or heard someone else being forced to do sex acts? Have you ever watched people using drugs, like smoking drugs or using needles? Staff Signature/Credential Date Individual Service Plan guidance Individual Service Plan Purpose Each individual who receives services must have an Individual Service Plan that is based on the identified strengths and needs of the individual, the goals that will help address his/her needs, the services to be provided, and the activities that will take place toward achieving measurable individual outcomes. The individual seeking/ receiving services must be involved in the development of his/her service plan. For individuals under the age of eighteen (18) or who are unable to effectively participate in the planning process, a parent, legal guardian or conservator must participate in planning on the individual’s behalf. The timeline for completion of the Individual Service Plan is determined by the type of service or program the individual is entering. The Individual Service Plan must be reviewed and revised when goals or objectives are achieved, as needs of the individual change, or according to specific service requirements but at least annually. Individual Strengths List strengths the individual possesses and/or demonstrates that will assist and promote successful achievement of outcomes. Goals The individual receiving services establishes the long term goals. Staff helps the individual set short term goals which will contribute to achievement of the long term goal(s). Identified Barriers List barriers that may prevent the individual from achieving successful outcomes. Barriers must include but are not limited to functional impairments in basic living skills, instrumental living skills or social skills, as indicated by an assessment instrument/ approach approved by DMH. Individualized Areas of Need Refer to the Initial Assessment to identify symptoms, observable behaviors, clinical areas of need and elaborate on duration (how long the symptoms/behaviors have been present or observed), frequency (how often the symptoms/behaviors are present or observed), and how the symptoms/observable behaviors create a functional impairment for the individual. Symptoms, behaviors and clinical areas of need should serve as the focus of treatment, services and supports for individuals. Interventions, Criteria/Outcomes, Initiation and Target Dates In order to effectively work toward achieving the long term and short term goal(s) identified by the individual receiving services, the objectives and interventions must be measurable. Each objective and intervention must have specific criteria or outcomes which clearly indicate an objective has been reached or an intervention has been completed. Each intervention must be Individual Service Plan guidance numbered, assigned to a service area (eg. Peer Support Services, Therapy Services, Community Support Services, etc) and have a specified target date for achievement or completion. Services identified and certified as necessary must be provided to the individual. All services that the individual is receiving must be indicated in relation to an objective/ intervention. Diagnosis Give the written diagnosis and appropriate codes for the individual receiving services. Community Supports Community Support Services must be made available to the following populations: adults with serious mental illness and children/youth with serious emotional disturbance. If the individual refuses Community Support Services, the refusal must be documented in writing. Community Support Services must be offered to these specified individuals during the intake process and at a minimum of every twelve (12) months while they remain in services. Signatory Authority Each individual who participates in the development of the Individual Service Plan must sign the plan as evidence of his/her participation in plan development. If the Individual Service Plan is developed for adults with a serious mental illness (SMI), individuals with intellectual/ developmental disabilities, children and youth with serious emotional disturbance (SED), or individuals with a substance use disorder, a licensed Physician, a licensed Psychologist, a Psychiatric/Mental Health Nurse Practitioner, a Licensed Clinical Social Worker, Licensed Marriage and Family Therapist, Licensed Professional Counselor, Physician Assistant or Alzheimer’s Day Program Supervisor (for Alzheimer’s Day programs only) must sign the Individual Service Plan, certifying the planned services are medically/therapeutically necessary. DMH Individual Service Plan form Individual Service Plan Name:_______________________________________________ ID Number:___________________________________________ Admission Date:_______________________________________ Date of Plan Implementation_____________________________ □ New □ Re-Write □ Addendum INDIVIDUAL’S STRENGTHS LONG TERM GOALS (include hopes/dreams/goals) SHORT TERM GOALS IDENTIFIED BARRIERS (Based on Functional Assessment) DMH Individual Service Plan form INDIVIDUAL’S AREAS OF NEED INDIVIDUALIZED PLAN FOR SERVICES Objective #1: Interventions Service Area Assigned Criteria / Outcomes for Completion Initiation Date: Target Date: 1. 2. 3. Objective #2: Interventions Service Area Assigned Criteria / Outcomes for Completion Initiation Date: Target Date: 1. 2. 3. Objective #3: Interventions Service Area Assigned Criteria / Outcomes for Completion Initiation Date: Target Date: 1. 2. 3. DMH Individual Service Plan form DIAGNOSIS Primary Diagnosis(es) Secondary Diagnosis(es) Community Support has been offered to me and I choose: □ YES, I do want to participate (see Recovery Support Plan) ______(initials of individual receiving services) □ NO, I do NOT want to participate ______ (initials of individual receiving services) _____________________________ ___________ _____________________________ ___________ Individual Receiving Services Date Parent / Legal Guardian Date _____________________________ ___________ _____________________________ ___________ Signature / Credentials Date Signature / Credentials Date _____________________________ ___________ _____________________________ ___________ Signature / Credentials Date Signature / Credentials Date _____________________________ ___________ _____________________________ ___________ Signature / Credentials Date Signature / Credentials Date _____________________________ ___________ _____________________________ ___________ Signature / Credentials Date Signature / Credentials Date _____________________________ ___________ _____________________________ ___________ Signature / Credentials Date Signature / Credentials Date __________________________________________________________________________ ___________ Physician / Clinical Psychologist / Nurse Practitioner, LCSW, LMFT, Date LPC, PA, Alzheimer’s Day Program Supervisor Strikethrough 2016 Individual Crisis Support Plan guidance Individual Crisis Support Plan Purpose Providers must develop an Individualized Crisis Support Plan for each individuals receiving services in all populations served, including SMI, SED and Substance Use Disorders the following priority groups: • Individuals discharged from an inpatient psychiatric facility; • Individuals discharged from an institution; • Individuals discharged or transferred from Crisis Stabilization Services; and, • Individuals referred from Crisis Response Services. Identifying Information Record the individual’s name, record number, date the plan was developed and the local toll- free crisis phone number. Treatment Information Record the individual’s diagnosis as indicated on the Individual Service Plan. Explain relevant history and current potential for crisis situation. List all medications the individual is currently prescribed. Explain what may be a potential trigger for the individual to regress into a crisis situation. Action Steps List the action steps the individual, crisis response team and family (if indicated) will take in the event the individual is experiencing a crisis at home or in the community. Include who is responsible for initiating the response with their phone number. Requirements The Crisis Support Plan must be developed within 30 days of admission for all individuals receiving services except those individuals admitted through crisis services. Crisis Support Plans must be developed for individuals admitted through crisis services within 72 hours of admission. The Crisis Support Plan must be developed by the team of individuals who will have responsibilities for implementing the Plan in the event of a crisis. The Plan development team members must have at least a Bachelor’s degree in mental health or a related field and must sign the Crisis Support Plan where indicated. The Crisis Support Plan identifies what could go wrong and how people should respond. Crisis planning includes opportunities for family and team members to practice crisis response by simulating a crisis in a safe, controlled environment. The Crisis Support Plan must include who will notify who and when. The Crisis Support Plan must be portable in the sense that all team members must have a copy to refer to when needed. The Individual receiving services should also maintain a copy of the plan for reference. DMH Strikethrough 2016 Individual Crisis Support Plan form Individual Crisis Support Plan Name ID Number Date Plan Developed Toll-free Crisis Phone Number Diagnosis: Current Medications: Relevant History and Potential Crisis: Known Triggers: Action Steps for Home Person(s) Responsible and Phone Number(s) Action Steps for Community Locations (specify) Person(s) Responsible and Phone Number(s) Signature of Individual Receiving Services Date Signature/Position Date Signature/Position Date Signature/Position Date Recovery Support Plan guidance Recovery Support Plan Purpose The Recovery Support Plan should be completed with the Individual Receiving Services and is used as a tool to assist the individual in making plans to engage in activities and access resources designed to help support him/her in achieving and maintaining recovery/resiliency. The Recovery Support Plan replaces the previous Community Support Plan and the Substance Abuse Recovery Support Plan. This plan is meant to be a flexible document that expounds upon the information provided in the Individual Service Plan (ISP). This documentation is required for individuals receiving Community Supports Services, Recovery Supports Services and Peer Support Services but can be used in conjunction with any individual’s ISP. The Recovery Support Plan must be developed within 30 days of admission for all individuals receiving services. The Recovery Support Plan must be developed by the team of individuals who will have responsibilities for implementing the Plan during service delivery. The Plan development team members must have at least a Bachelor’s degree in mental health or a related field and must sign the Recovery Support Plan where indicated. Needs Statement from Initial Assessment and ISP Record the individual’s Needs Statement from their Initial Assessment and Individual Service Plan. Long Term Goal(s) from the ISP Record the individual’s Long Term Goal(s) from the Individual Service Plan. Objectives: All Recovery Support Plans must have individualized objectives and they must be measurable. Record what the individual hopes to accomplish or achieve while receiving Support Services. Strategies: Describe the strategies or activities that the individual will complete to achieve the desired outcome. Who is responsible? Who is responsible for assisting with the completion of these objectives? This can be the individual themselves, a natural support, or a staff member. Record the person or persons responsible. Target completion date Explain how often activities will be conducted and the expected completion date. Recovery Support Plan guidance Signatures The date, signature, and credentials (if applicable) of all persons responsible for completing objectives should be recorded. DMH Recovery Support Plan form Recovery Support Plan Name:_____________________________________________ ID Number:_________________________________________ Needs Statement(s) from Initial Assessment and ISP: Long Term Goal(s) from ISP: Objectives: Strategies: Who is responsible: Target Completion Date: _____________________________ ___________ _____________________________ ___________ Individual Receiving Services Date Parent / Legal Guardian Date _____________________________ ___________ _____________________________ ___________ Direct Service Provider Date Direct Service Provider Date Strikethrough 2016 Progress Note guidance Progress Note Purpose All programs must document single therapeutic support interventions and activities that take place with/for an individual. The Progress Note can also be used “as needed” to provide supplemental documentation that cannot be adequately captured in the Weekly Progress Note. Location Document the location where services were provided. Time Document the time services began and ended along with the total amount of time services were provided. General Providers must document therapeutic interventions and activities (such as outpatient therapy, community support services, supported and supervised living services) utilizing the SAP format. Summary should address the summary of activities related to the service being provided for each contact/ service event. Assessment should address the progress made, or lack of progress made, toward the goals and objectives on the plan directing the treatment, services and/or supports for the individual (ex. ISP). Plan should address the plan for future activities related to the service. This can include staff or individual activities. Signatures Staff completing the Progress Note must sign and date the form at the end of each note. The signature of a supervisor is not required but can be used to document supervision of provisionally credentialed staff. DMH Strikethrough 2016 Progress Note form Progress Note Name __________________________________ ID Number _____________________________ Service Type ____________________________ Day / Date Location Time Began (am/pm) Time Ended (am/pm) Total Time S: A: P: Provider Signature/Credentials Supervisor Signature (if applicable) Day / Date Location Time Began (am/pm) Time Ended (am/pm) Total Time S: A: P: Provider Signature/Credentials Supervisor Signature (if applicable) DMH Strikethrough 2016 Weekly Progress Note guidance Weekly Progress Note Purpose Providers must maintain documentation to verify each individual’s weekly and monthly progress toward the areas of need identified on his/her Individual Service Plan. Time Document the time services began and ended along with the total amount of time services were provided. Indicate if an individual is absent or if it is a weekend. Weekly Documentation The provider must document in SAP format the activities an individual participates in or completes during the week. All activities must be listed including, community integration, job exploration, therapeutic activities, etc. Activities should be related and documented to an individual’s goals/objectives/outcomes stated on the Individual Service Plan. Staff completing the Weekly Progress Note must sign and date the form at the end of each week. Monthly Summary At the end of the month, a summary of progress or lack of progress toward goals/objectives/outcomes must be documented utilizing the SAP format. Staff completing the Weekly Progress Note must sign and date the form at the end of the month. For Day Treatment Services and Psychosocial Rehabilitation Services, the Supervisor may use this form as part of the documentation of the required monthly supervision. DMH Strikethrough 2016 Weekly Progress Note form Weekly Progress Note Name ___________________________________________ ID Number _______________________________________ Service __________________________________________ Attendance during month of in the year of Days Time In Time Out Total Time Weekly Dates Summary of Objective/Activity 1st Week Objective(s): S: A: P: Date: Signature/Credential: 2nd Week Objective(s): S: A: P: Date: Signature/Credential: DMH Strikethrough 2016 Weekly Progress Note form 3rd Week Objective(s): S: A: P: Date: Signature/Credential: 4th Week Objective(s): S: A: P: Date: Signature/Credential: 5th Week Objective(s): S: A: P: Date: Signature/Credential: Monthly Summary S: A: P: Date: Staff Signature/Credential: Date: Supervisor Signature/Credential: DMH Strikethrough 2016 Periodic Staffing Review of ISP guidance Periodic Staffing/Review of the Individual Service Plan Purpose The Periodic Staffing/ Review of the Individual Service Plan (ISP) is used to document periodic review and revision in order to remain continuously current with regard to the goals and outcomes the individual receiving services is seeking to achieve. As with the original ISP, all reviews, revisions, or rewrites of the ISP must be a collaborative effort with the individual and/or legal representative and the appropriate staff. Timelines Review and revision must occur whenever the individual receiving services experiences a change in his/her life that impacts the goals of their current ISP. Life changes can be expected to be initially reported in progress notes and may be in one or more of the areas listed below. At a minimum, the ISP must be reviewed and revised/rewritten annually for adults and every six months for children and youth. Changes Any or all changes in the following areas since the last ISP review must be documented in specific detail: • Change in diagnosis • Change in symptoms • Change(s) in service activities • Change(s) in treatment/treatment recommendations • Other significant life change Plan Modification After documenting any and all changes that have occurred since the last ISP review, careful consideration should be given to the impact these changes have made on the ISP in terms of the needs expressed, goals and outcomes being pursued by the individual. The ISP should be modified or rewritten if needed to ensure ongoing progress toward achievement of the individual’s ISP goals. If the ISP needs to be rewritten, there must be involvement of the treatment team and the Physician, Psychologist, Nurse Practitioner, Licensed Clinical Social Worker, Licensed Marriage and Family Therapist, Licensed Professional Counselor, Physicians Assistance or Alzheimer’s Day Program Supervisor (Alzheimer’s Day programs only) to determine medical necessity. Signatory Authority Each individual who participates in the staffing/review of the Individual Service Plan must sign the Periodic Staffing/Review of the ISP form as evidence of his/her participation in the staffing/review process. DMH Strikethrough 2016 Periodic Staffing Review of ISP form Periodic Staffing/ Review of the Individual Service Plan Name ID Number Current Date Date of Last ISP/Review Time In Time Out Total Change in diagnosis since last review Change in symptoms since last review Change(s) in service activities since last review Change(s) in household since last review Change(s) in treatment/ service recommendations since last review Other significant life change(s) since last review Comments/Recommendations Plan Modification  No  Yes  Rewrite Plan If yes, make additions/ modifications to the existing plan Individual Receiving Services Date Staff Signatures/Credentials Date Staff Signatures/Credentials Date Signature of Parent/Legal Guardian (if applicable) Date DMH Strikethrough 2016 Readmission Assessment Update guidance Readmission Assessment Update Purpose When an individual has been discharged from a provider agency and seeks to resume services within one year of the discharge date, a Readmission Assessment Update may be utilized instead of the Initial Assessment as part of the readmission process to update information that has changed regarding the individual’s needs and status. Instructions Update identifying information and description of need. Document any changes relating to the individual’s history occurring during the lapse of service. Description of Need Record the reason(s) the individual is seeking services. Status Updates Any changes relating to individual’s status areas (medical, mental health, substance abuse/use, social/cultural, educational/vocational) that have occurred during the gap in service must be documented in detailed narrative format. Responses of “Yes”, “No”, “Present”, “Not Present” are not acceptable. Indication of Functional Limitation(s) An assessment must be conducted and the results documented for the major life areas specified for each individual seeking readmission to services. The Child and Adolescent Functional Assessment Scale (CAFAS) is required for all children/youth receiving mental health services. The CAFAS must be completed within 60 days for all children/youth receiving mental health services. An approved functional assessment is required for all adults receiving mental health services. An approved functional assessment must be completed within 60 days for all adults receiving mental health services. DMH will review and approve a functional assessment for use with the adult SMI population. An approved functional assessment is required for all individuals receiving substance use disorder services. DMH will review and approve a functional assessment for use with the SUD population. Staff Requirement The Readmission Assessment Update must be completed by an individual with at least a Master’s degree in mental health or intellectual/developmental disabilities, or a related field and who has either (1) a professional license or (2) a DMH credential as a Mental Health Therapist or Intellectual/Developmental Disabilities Therapist (as appropriate to the population being served) or Alzheimer’s Day Program Supervisor (Alzheimer’s Day Programs only). DMH Readmission Assessment Update form Readmission Assessment Update Name ID Number Readmission Date Informant:  Individual receiving services  Other Relationship to individual: LEGAL INFORMATION Name of Guardian / Custodian: Guardianship Documentation Verified: □ Yes □ No Guardian / Custodian Address: Guardian / Custodian Phone Number: DESCRIPTION OF NEED What is your reason for seeking services today? What specific needs are you currently having? Why was the record closed? Status Updates Medical Status (Record current medications on the Medication/Drug Use Profile): Allergies Physical impairments Surgeries Special diets Appetite issues or problems Sleep issues or problems Current or chronic diseases (high blood pressure, cancer, other) Other pertinent medical information (For women only) Are you pregnant? DMH Readmission Assessment Update form Mental Health Status: Recent psychiatric issues Homicidal behavior Suicidal behavior Other counseling and/or therapeutic experiences Traumatic Event Or Exposure Status (Note Or Describe As Appropriate): Serious accidents Natural disaster Witness to a traumatic event Sexual assault Physical assault (with or without weapon) Close friend or family member murdered Homeless Victim of stalking or bullying Other (specify) Substance Use Status: Use or abuse by the individual Age of onset Patterns of use/abuse: How much? How often? Methods of use: smoke  snort  inject  insert  inhale  Resulting circumstances? DMH Readmission Assessment Update form Social/Cultural Status: Immediate household/family configuration Marital status Relationship with family members Type of family support available Type of social support available Types and amounts of social involvement/leisure activities Any religious/cultural/ethnic aspects that should be considered Educational/Vocational Status: Highest grade completed If currently in school (child or youth), regular classroom placement?  Yes  No List all additional educational services child is receiving Any repeated grades?  No  Yes Explain: Suspensions/expulsions?  No  Yes Describe: Other education issues Vocational training, if any Current employment Previous employment Comments: Indication Of Functional Limitation(s): (Check Major Life Areas Affected) Basic living skills (eating, bathing, dressing, etc.) Instrumental living skills (maintain a household, managing money, getting around the community, taking prescribed medications, etc.) Social functioning (ability to function within the family, vocational or educational function, other social contexts, etc.) Signature/Credentials Date DMH Substance Use Disorder Specific Assessment guidance Substance Use Disorder Specific Assessment Purpose This information must be documented if substance use disorder services are provided or if substance use disorder is suspected. This form must be completed in addition to the Initial Assessment and is applicable to youth and adults. This form should specifically address how substance use history has created impairment. Treatment Modality Abbreviations OP Outpatient Services IOP Intensive Outpatient Services PR Primary Residential TR Transitional Residential PHP Partial Hospitalization Detailed Substance Use History This section of the assessment allows the evaluator to document details of the individual’s history of substance use. The evaluator should document the substance use; include the age of onset, and the pattern of use. Prior Substance Use Disorder Treatment This section of the assessment allows the evaluator to document the individual’s prior history of substance use disorder treatment. Location, date, completion of prior treatment, outcome and length of treatment should all be documented in this section. Evaluator’s Assessment of Attitude This part of the assessment allows the evaluator to document the individual’s level of denial and/or willingness to change with regard to their use of alcohol and other drugs. Family History of Alcohol and/other Drugs This section of the assessment allows the evaluator to document the individual’s family history of substance use. DMH Substance Use Disorder Specific Assessment form Substance Use Disorder Specific Assessment Name ID Number Date Time In: Time Out: Total: Admission Date: Treatment Service: OP___ IOP ___PR ___TR ___ PHP ___ DUI Specific History DUI Offender? First time 2+Offenses Not applicable Is the individual’s driver’s license currently suspended? Yes No If yes, was the individual enrolled in or referred to a certified DUI Treatment Program? Yes No Substance Use History (Explain use, drug of choice, include age of onset, and pattern of use) How much money would you say you’ve spent on substances during the past 30 days? _________________________ What was your longest period of abstinence? __________ How was abstinence maintained? ___________________ On a scale of 1-5, how important is treatment to you now? (5 being most important) ____________ Prior Substance Use Disorder Treatment (Location, date, completion status, outcome, length of recovery after treatment) Evaluator’s Assessment of Individuals Attitude Regarding Use of Alcohol and/or Other Drugs Level of Denial: (circle one) None Low Moderate High Unsure Willingness to Change: (circle one) None Low Moderate High Unsure Family History of Alcohol and/or Other Drugs SIGNATURES / CREDENTIALS Staff Signatures/Credentials Date Section CD As Needed Substance Use Disorder Specific Assessment Initial Assessment and Crisis Contact Summary Readmission Assessment Update Serious Incident Report Medical Examination Documentation of Healthcare Provider Visits Self-Administration Medication Log Telephone/ Visitation Agreement Search and Seizure Report Physical Restraint/Escort Log Time Out Log Seclusion Behavior Management Log Service Termination/ Change Summary Provider Discharge Summary DMH Initial Assessment and Crisis Contact Summary for Crisis Response Contacts guidance Initial Assessment and Crisis Contact Summary for Crisis Response Contacts Purpose The Initial Assessment and Contact Log for Crisis Response Contacts is used to document the provision of emergency/crisis contacts with individuals seeking services from a provider who are not already receiving other mental health services from the provider. Identifying Information Record the name of the individual receiving crisis services. Issue and record a client identification number. The Date of Contact will also be the Date of Admission. Enter the individual’s Social Security and Medicaid numbers. Record the time the contact began and ended. Indicate the type of crisis service delivered (Mobile Crisis Services, Telephone Crisis Response, or Walk-in Crisis Response). If the contact was made Face to Face, include the location where the contact took place and if the contact was made by phone, include the phone number of the caller. List by relationship any other individuals involved with the emergency/ crisis or any referral source (i.e. sister). Presenting Need Document the reason(s) the individual is seeking emergency/crisis services. Actions Taken by Staff Document the steps taken to assess and resolve the emergency/crisis. Record if anyone was contacted on behalf of the individual in crisis. If no one else was notified, indicate why it was not necessary. Initial Behavioral Observations Document the staff’s impressions of the individual’s behaviors. Include additional comments at the end of the section. Resolution Document the condition of the individual at the end of the contact; indicate where the individual and/or family were referred and if a subsequent appointment was made for the individual with the provider, note the date and time of the appointment. Required Data This information is required by the Department of Mental Health and is to be submitted to the Central Data Repository. If you are unable to obtain this information, please mark as “unknown.” The staff person responding to the individual in crisis and documenting the contact must sign this form and include their professional credentials. DMH Initial Assessment and Crisis Contact Summary for Crisis Response Contacts form Initial Assessment and Crisis Contact Summary for Crisis Response Contacts Name:_____________________________________________ ID Number:_________________________________________ Contact/ Admit Date:_________________________________ Medicaid #:_______________ SS#______________________ Time In: Time Out: Total Time: Type of Contact: □ Mobile Crisis Service Location: _________________________ □ Telephone Crisis Response Number: __________________________ □ Walk-in Crisis Response Others Involved: Presenting Needs (the factors indicating a need for Crisis ResponseServices) Actions Taken by Staff: Initial Behavioral Observations Speech:  Appropriate  Slowed  Mechanical  Rapid  Other Behavior:  Appropriate  Withdrawn  Bizarre  Volatile  Other Appearance:  Appropriate  Disheveled  Unclean  Inappropriately dressed  Other  Phone Contact Mood:  Appropriate  Manic  Depressed  Labile  Irritable  Other Affect:  Appropriate  Flat  Labile  Other Oriented to:  Place  Time  Person  Situation  Other Thought Content:  Appropriate  Incoherent  Obsessive  Delusional  Paranoid  Other Memory:  Appropriate  Repressed  Confused  Other Intelligence:  Average  Above Average  Below Average Judgment/Insight:  Appropriate  Impaired  Suicidal  Homicidal  Other Hallucinations:  Auditory  Visual  Tactile  Other Comments: DMH Initial Assessment and Crisis Contact Summary for Crisis Response Contacts form Resolution Condition of the Individual at Conclusion of Contact Referrals Made by Staff Appointment with the Provider Date: Time: Required Data (Please mark as Unknown if Information is Unavailable) Birth Date: Age: Gender: Race: Education Level: Marital Status: County of Residence: Living Arrangement: Type of Residence: Employment Status: Legal Status: Primary Income