Assessment Form. Seminole Community Mental Health Center Involuntary Outpatient Placement Program Baseline and Follow-up Assessment Form

Transcription

1 Seminole Community Mental Health Center Involuntary Outpatient Placement Program Baseline and Follow-up Assessment Form Assessment Form Instructions for Form Completion: The Assessment Form is used to profile the demographic characteristics, life status, treatment history, service utilization, engagement in services and functioning of consumers under Involuntary Outpatient Placement (IOP). Accurate completion of the Form is essential and every numbered item on the form requires a response. Complete data is needed for accurate data analysis. The IOP Number* is a unique identifier which is assigned to each consumer in the program. This IOP Number will remain constant for each subsequent form filled out for a consumer in the program. Since the cover sheet information will not be made available to program evaluators, the IOP Number is the only way to compare different assessment forms for the same consumer. 1. Consumer First Name 2. M.I. 3. Last Name 4. Date of Birth (mm/dd/yyyy) 5. Social Security # 6. Medical ID 7. Address Street number and name (include apt #) City, State Zip 8. Telephone Number *9. IOP Number (same as #10) Cover

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3 Seminole Community Mental Health Center Involuntary Outpatient Placement Program Baseline and Follow-up Assessment Form 10. IOP Number (same as #9) 11. Assessment (circle one) a. Baseline b. Follow-up 12. a. Effective Date of IOP order (mm/dd/yyyy) b. Expiration Date of IOP order (mm/dd/yyyy) 13. Date of Admission (mm/dd/yyyy) 14. Sex (check) : Male Female 15. English Proficiency (circle one) 18. What is the consumer's race? a.does not speak English (circle all that apply) b.poor a.white c.fair b.black d.good c.american Indian e.excellent d.asian Indian e.chinese 16. Is this consumer Spanish/Hispanic/Latino? (check) f.filipino a.not Spanish/Hispanic/Latino g.japanese b.yes, Cuban h.korean c.yes, Mexican/Mex. American/Chicano i.vietnamese d.yes, Puerto Rican j.native Hawaiian e.yes, Dominican k.other Asian f.yes, other Spanish, Hispanic or Latino l.guanamanian or Chamorro g.unknown m.samoan n.other Pacific Islander o.other 17. Has consumer previously been assessed for p.unknown Involuntary Outpatient Placement? a.consumer received services under a court ordered treatment plan. b.consumer met IOP criteria, but accepted voluntary services. c.consumer met IOP criteria, but did not receive a court order. d.consumer did not meet IOP criteria and accepted voluntary services. e.consumer did not meet IOP criteria and refused services. Page 1 IOP Number

4 19. Current Living Situation (circle one) a. Private residence alone k. Children and youth residential (FBY,RTF,CR,TFH,Crisis) b. Private residence w/spouse or domestic partner l. Inpatient, general hospital or private psychiatric hospital c. Private residence w/parent, child, or other family m. Inpatient at state psychiatric center d. MH supported housing (or SRO) n. DOH adult home e. MH housing support srogram (congregate support or service enriched SRO) o. Drug or alcohol abuse residence or inpatient setting f. MH apartment treatment program p. Correctional facility g. MH congregate treatment program q. Homeless shelter or emergency housing h. MH crisis residence r. Homeless- streets or parks i. MH family care s. Homeless- drop in center or other undomiciled j. State operated residential t. Other (specify) 20a. If the consumer has an IOP court order, what was consumer's living situation at the time that the court order was issued? (circle one) a. Private residence alone k. Children and youth residential (FBY,RTF,CR,TFH,Crisis) b. Private residence w/spouse or domestic partner l. Inpatient, general hospital or private psychiatric hospital (go to 20b) c. Private residence w/parent, child, or other family m. Inpatient at state psychiatric center (go to 20b) d. MH supported housing (or SRO) n. DOH adult home e. MH housing support program (congregate support or service enriched SRO) o. Drug or alcohol abuse residence or inpatient setting (go to 20b) f. MH apartment treatment program p. Correctional facility (go to 20b) g. MH congregate treatment program q. Homeless shelter or emergency housing h. MH crisis residence r. Homeless- streets or parks i. MH family care s. Homeless- drop in center or other undomiciled j. State operated residential t. Other (specify) 20b. If response to 20a is. l. inpatient, general hospital or private psychiatric hospital m. inpatient at state psychiatric hospital o. drug or alcohol abuse residence or inpatient setting p. correctional facility select the option that best describes the consumer's living situation in the community prior to that living situation. (circle one) a. Private residence alone k. Children and youth residential (FBY,RTF,CR,TFH,Crisis) b. Private residence w/spouse or domestic partner l. Inpatient, general hospital or private psychiatric hospital c. Private residence w/parent, child, or other family m. Inpatient at state psychiatric center d. MH supported housing (or SRO) n. DOH adult home e. MH housing support program (congregate support or service enriched SRO) o. Drug or alcohol abuse residence or inpatient setting f. MH apartment treatment program p. Correctional facility g. MH congregate treatment program q. Homeless shelter or emergency housing h. MH crisis residence r. Homeless- streets or parks i. MH family care s. Homeless- drop in center or other undomiciled j. State operated residential t. Other (specify) 21. How long has consumer been in 22. Has consumer ever been homeless? 24. Does consumer own a car? their current living situation? (circle one) a. YES a. YES a. Less than 1 month b. NO b. NO b. 1-3 months c. 4-6 months 23. How many days was the consumer d months homeless in the last 6 months? e. More than 12 months f. Other g. Unknown 25. Current Sources of Income and/or Benefits. (circle all that apply) a. Wages/salary or self-employed i. Any public assistance cash program Fam. Assis. (TANF), safety net,temp.disab. b. Supplemental Security Income (SSI) j. Medicare c. Social Security Disability Income (SSDI) k. Medicaid d. Veterans statute/disability income l. Medication grant e. Workers compensation or disability insurance m. Private insurance, employer coverage, no fault or third party insurance f. Unemployment or union benefits n. Other (specify) g. Social security retirement, survivor's or dependants (SSA) o. Unknown h. Railroad retirement, retirement pension (excluding SSA) Page 2

5 26. Highest Level of Education Completed (circle one) 27. Current Education Activity (circle one) a. No formal education g. Associates degree a. None b. Grammar school (thru grade 6) h. Bachelor's degree b. Enrolled in GED program c. Junior high (thru grade 8) i. Graduate degree c. Non-credit adult education d. High school (thru grade 12/GED) j. Other (specify) d. Community college e. Business, technical training e. Vocational/technical school f. Some college, no degree k. Unknown f. College/university g. Other (specify) h. Unknown 28. Current Employment Status (circle one) 29. Average hours of 30. Number of weeks employment or non-paid at current job a. No employment of any kind work experience per week (circle one) b. Competitive employment (employer-paid) with no formal supports c. Competitive employment (employer-paid) with on-going supports a. None d. Community-integrated employment run by state or local agency b e. Sheltered, non-integrated workshop run by state or local agency c Total monthly income f. Sporadic or casual employment for pay (includes odd jobs) d (enter 0 if none) g. Non-paid work experience (includes volunteer positions) e. Over 30 h. Other (specify) $ i. Unknown 32. Most recent competitive employment 33. Criminal Justice Status (circle all that apply) (circle one) a. Never a. Consumer is not a criminal justice recipient g. On bail, released on own recognizance b. Within last year b. Under arrest, in jail, lockup, or court detention or conditional discharge or other c. 1-2 years ago c. In FL Dept. of Correctional Svcs. (state prison) alternative to incarceration status d. 3-5 years ago d. Released from jail or prison within last 30 days h. Other (specify) e years ago e. Under probation supervision i. Unknown f. 11 or more years ago f. Under parole supervision g. Unknown 34. Relationship Status (circle one) 35. Child Custody Status (circle one) a. Single, never married a. No children b. Married b. Has children, all over 18 years old c. Cohabitating with significant c. Minor children currently in consumer's care other / domestic partner d. Minor children not in consumer's custody (have access) d. Divorced / Separated e. Minor children not in consumer's custody (no access) e. Widowed f. Other (specify) f. Other (specify) g. Unknown Additional Comments for Problems and Strategies Page 3

6 36. Current DSM-IV 37. Current DSM-IV 38. Current Medical Problems (Axis II Diagnoses) Axis I Diagnosis(es) Axis II Diagnosis(es) (circle all that apply) a.. a.. a. None m. Hyperlipidemia (high cholesterol) b.. b.. b. Arthritis/joint disorder n. Hypertension (high blood pressure) c.. c.. c. Asthma o. Neurological d.. d.. d. Cancer p. Obesity e. Coronary artery disease q. Osteoporosis 39. Global Assessment of Functioning (GAF) f. Dementia/organic brain disorder r. Sexually transmitted disease is found at the back of the form. Please g. Diabetes s. Sleep disorder rate the consumer's level of current functioning h. Female reproductive problem t. TB in the space provided. (1-99) i. Genital / urinary disorder u. Ulcer / gastrointestinal disorder j. Head injury v. Other (specify) k. Hepatitis / cirrhosis w. Unknown l. HIV / AIDS 40. Does consumer have a Health Care Proxy? 41. Does consumer have an Advance Directive? a. YES b. NO c. Unknown a. YES b. NO c. Unknown 42. Describe the psychotropic medication regimen in the consumer's current treatment plan. (If no medications prescribed, indicate by writing NONE in the first line) Medications Total Daily Dose 1 mg cc 2 mg cc 3 mg cc 4 mg cc 5 mg cc 43. Side Effects from Medications 44. Describe the consumer's current adherence (circle all that apply) to medication regimen (circle one) a. None h. Sexual dysfunction a. Medication not prescribed b. EPS severity i. Galactorrhea b. Rarely or never takes medication as prescribed c. Tardive dyskinesia j. New onset evaluated c. Sometimes takes medication as prescribed d. Tremor glucose or DM d. Takes medication as prescribed most of the time e. Sedation k. Other (specify) e. Takes medication exactly as prescribed f. Weight gain f. Other (specify) g. Hypertension l. Unknown g. Unknown 45. Number of visits to medical doctor in the last 6 months 46. Number of psychiatric hospitalizations in last 6 months 47. Number of psychiatric hospitalizations in last 12 months 48. Number of psychiatric hospitalizations in lifetime 49. Total number of DAYS hospitalized due to psychiatric illness in last 6 months 50. Total number of DAYS hospitalized due to psychiatric illness in last 12 months 51. Number of Access Center visits in last 6 months 52. Number of Access Center visits in last 12 months 53. Number of Emergency Room visits in last 6 months 54. Number of Emergency Room visits in last 12 months 55. Number of arrests in last 6 months 56. Number of arrests in last 12 months 57. Number of incarcerations in last 6 months 58. Number of incarcerations in last 12 months 59. Lifetime number of incarcerations 60. Number of DAYS incarcerated in last 6 months 61. Number of DAYS incarcerated in last 12 months Page 4

7 Additional Comments on Medical and Psychiatric Problems and Strategies. Treatment Plan Complete the table below for all services in consumer's treatment plan. Fill out 62-1 and 62-2 only for baseline assessment, not follow-up. Fill out 62-3 for ALL assessments. (circle) Prior to IOP, was service Prior to IOP, was service Are services in current IOP or Treatment Plan offered? used? post-iop treatment plan? a. Case management Yes No Yes No Yes No b. Care management Yes No Yes No Yes No c. Medication (for psychiatric condition) Yes No Yes No Yes No d. Alcohol or substance abuse services Yes No Yes No Yes No (not including self-help services) e. Housing and housing support services Yes No Yes No Yes No f. Family psychoeducation Yes No Yes No Yes No g. Supported employment Yes No Yes No Yes No h. Wellness self-management Yes No Yes No Yes No i. Vocational, technical, or trade school Yes No Yes No Yes No j. Other educational services Yes No Yes No Yes No 63. Circle the option best characterizes consumer's current engagement in services. a. Not engaged. (No contact with provider(s), does not participate in services at all.) b. Poor. (Relates poorly to provider(s), avoids independent contact with provider (s). c. Fair. (No independent use of services or only in extreme need.) d. Good. (Able to partner and can use resources independently.) e. Excellent. (Independently and appropriately uses services.) Strength Satisfactory Problem 64. How typical is it for the consumer to : Highly Somewhat Highly Typical Typical Typical Atypical Atypical a. Communicate clearly b. Ask for help when needed c. Respond to other's initiation of social contact d. Form/maintain support network e. Engage in social and/or family activities f. Effectively handle conflict g. Manage assertiveness/anger effectively h. Manage leisure time to own satisfaction i. Trust at least one other person Additional Comments on Treatment Plan, Engagement in Services, and Social / Interpersonal / Family Problems and Strategies. Page 5

8 Self-Care and Community Living Strength Satisfactory Problem Acts Needs some Needs some Needs Unable/unwilling independently verbal advice physical help substantial to act independently 65. How much support does the consumer typically need to : self-sufficient or guidance or assistance help totally dependent a. Maintain adequate personal hygiene b. Maintain adequate diet c. Recognize/avoid common dangers (e.g. traffic, fire personal safety, adequate and appropriate clothing) d. Make/keep necessary appointments (e.g., school, work, attendance, punctuality) e. Follow through on health care advice f. Manage medication g. Take care of own living space (e.g., household responsibilities, cooking, cleaning) h. Take care of own possessions i. Handle personal finances j. Shop for food, clothing, personal needs k. Prepare or obtain meals l. Access and use available transportation m. Access and use community services 66. High Risk Behavior Never How recently has the consumer: a. Expressed suicide threat b. Physically harmed self and/or attempted suicide c. Taken property without permission d. Damaged or destroyed property e. Created public disturbance f. Verbally assaulted another person g. Threatened assault or physical violence h. Been suspected of sexual abuse of child and/or adult i. Physically abused and/or assaulted a child and/or adult j. Engaged in arson k. Was a victim of physical or sexual abuse l. Wandered or run away 67. Substance Abuse Never a. Alcohol b. Cocaine c. Amphetamines d. Crack e. PCP f. Inhalants g. Heroin/opiates h. Marijuana/cannabis i. Hallucinogens j. Sedative/hypnotic/anxiolytics k. Other prescription drug (s) l. Other (specify) More than 6 months ago 3-6 months ago 1-3 months ago 1-4 weeks ago This week Unknown More than 6 months ago 3-6 months ago 1-3 months ago 1-4 weeks ago This week Unknown 68. Other co-occurring disabilities, if any 69. Consumer's current level of 70. Consumer's current stage of treatment for (circle all that apply) substance use (circle one) substance abuse (circle one) a. Dementia a. Abstinent a. Pre-engagement f. Late active treatment b. Cognitive disorder b. Use without impairment b. Engagement g. Relapse prevention c. Mental retardation/develop. disabilities c. Abuse c. Early persuasion h. Remission or recovery d. Blindness d. Dependence d. Late persuasion i. Does not apply e. Impaired ability to walk e. Dependence with e. Early active treatment j. Unknown f. Hearing impairment treatment program g. Speech impairment f. Unknown h. Other (specify) Page 6

9 Psychosocial, Self Care and Community Living Include comments and problems/strategies High Risk Behavior Include comments and problems/strategies Substance Abuse Include comments and problems/strategies Discharge Information 71. Reason for discharge (circle one) a. Significant improvement in ability to function independently e. Incarcerated for at least 3 months b. Planned move to new geographic location f. Recipient requests discharge c. Required placement, as determined by physician, into nursing home g. Lost to follow-up for > 3 months d. Hospitalized for at least 3 months h. Other (specify) 72. If recipient has had an IOP court order expire, what was the reason that the court order was not renewed? (circle one) a. The recipient has improved and is no longer in need of IOP. e. The recipient relocated b. The recipient is missing and cannot be located at the time the order expires. f. The recipient died. c. The recipient is in the hospital and a long stay hospitalization is anticipated. g. The recipient is not benefitting from IOP d. The recipient is incarcerated (explain) h. Other (specify) PREPARER'S NAME (PRINT) PREPARER'S SIGNATURE DATE Page 7

10 Additional Comments Page 8

11 Use this instrument to complete question 39, page 4, Global Assessment of Functioning. Please rate this consumer's overall current level of functioning and enter the number from 1 to 99 on the form in the designated boxes corresponding to question 39, page 4. GLOBAL ASSESSMENT OF FUNCTIONING Please rate this consumer's overall current level of functioning. Consider the consumer's psychological, social and occupational functioning on a hypothetical continuum of mental health - illness, using the categories below as your reference, where 99 = the highest level of functioning and 1 the lowest. Do not include impairment in functioning due to physical or environmental limitations. CODE Note: use intermediary codes when appropriate. DESCRIPTORS Superior functioning in a wide range of activities; life's problems never seem to get out of hand; is sought out by others because of his or her many positive qualities. No symptoms Absent or minimal symptoms (e.g. mild anxiety before an exam); good functioning in all areas; interested and involved in a wide range of activities; socially effective; generally satisfied with life, no more than everyday problems or concerns (e.g. an occasional argument with family members) If symptoms are present, they are transient and expectable reactions to psychological stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork) Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well; has some meaningful interpersonal relationships Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational or school functioning (e.g., few friends, conflicts with peers or co-workers) Serious symptoms (e.g. suicidal ideation, severe obsession rituals, frequent shoplifting) OR any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job) Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing in school) Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends) Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute) Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent liability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death. Page 9