Behavioral Health CareConnection Data Collection Form: Outpatient (Tier II)
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- Aleesha Mathews
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1 DEMOGRAPHICS Ethnicity Not of Hispanic Origin Race American Indian Puerto Rican Select Alaska Native Mexican One or Asian Cuban More: Black/African American Other Specific Hispanic Native Hawaiian/Pacific Islander Hispanic--Specific Origin Not Collected White Not Available/Unknown/Not Collected Other Race Not Listed Above Developmentally Disabled without DSM or ICD diagnosis? Current Level of Education: Grade 0 Zero Years 11 Eleven Years Type of Alternative School Kindergarten Level: 1 One Year 12 Twelve Years School: College (2 or 4 year program) 2 Two Years 13 Thirteen Years GED Program 3 Three Years 14 Fourteen Years Graduate School 4 Four Years 15 Fifteen Years Headstart 5 Five Years 16 Sixteen Years Homebound 6 Six Years 17 Seventeen Years Not in School 7 Seven Years 18 Eighteen Years Post Graduate School 8 Eight Years 19 Nineteen Years Preschool Program 9 Nine Years 20 Twenty Years Regular Education 10 Ten Years 21 > Twenty Years Special Education Trade, Vocational or Technical Financial and Household Information Gross Monthly Income $.00 # of Household Dependents: NO YES Employment Information Employment Status Supportive Work Not Employed, But Looking Sheltered Work Volunteer In Employment Training Competitive Employment--full time Not In Labor Force--Homemaker Competitive Employment--part time Not In Labor Force--Student Not In Labor Force--Inmate of Institution Not In Labor Force--Retired Not In Labor Force--Disabled Not In Labor Force--Physically Impaired Not In Labor Force--Other Not Employed, Not Looking Current Living Arrangement: Indicate the ConMember's Current Living Arrangement. Acute Care Psychiatric Facility Other Adoptive Home Own or Rent Non-Subsidized House/Apt Adult Correctional Facility Personal Care Home Adult Drug/Alcohol Rehabilitation Center Private Boarding House Adult Family Care Home Psychiatric Residential TX Facility (<22yrs) Dependent Living (includes Halfway Houses) Regular Foster Home Family Emergency Shelter Residential Group Treatment Home of Biological Parents Rest Home Home of Friend Rooming House - Hotel - YMCA Home of Relative Small Group Board & Care Home (<=( 8) Homeless/Homeless Shelter Specialized Family Care Home ICF-ID/DD Group Home Subsidized Rental House/Apartment Independent Living Group Home Supported Housing - Staff Supported Inpatient Psychiatric Facility Treatment Foster Home Individual Support Setting (ISS) Wilderness Camp Large Group Board & Care Home (>8) Youth Correctional Facility Long-Term Psychiatric Facility Youth Drug/Alcohol Rehabilitation Center Medical Hospital Youth Emergency Shelter Nursing Home Months in Current Living Arrangement Risk of Losing At Risk Current Living Currently Out of Home Placement Arrangement: Not at Risk Outpatient (Tier II) CareConnection(R) of 6
2 Legal Information Member Currently Does the Member have a legal guardian? Protective In the Past Yes No Services Never Current Adjudicated Delinquent - Youth Only Lifetime Adjudicated Delinquent - Youth Only Legal Adjudicated Status Offender - Youth Only Legal Adjudicated Status Offender - Youth Only Status Dependent (Abuse, Neglect, Abandonment) - Youth Status Dependent (Abuse, Neglect, Abandonment) - Youth Involuntary Commitment (Civil) Involuntary Commitment (Civil) Involuntary Commitment (Criminal Justice) Involuntary Commitment (Criminal Justice) Mental Health/Drug Court Mental Health/Drug Court No Legal Problems - Youth or Adult No Legal Problems - Youth or Adult Non-Adjudicated(Delinquent or Status Offender)--Youth Non-Adjudicated(Delinquent or Status Offender)--Youth One or More Arrests - Adult Only One or More Arrests - Adult Only Treatment and Service History Indicate services the consumer has previously received: Guardianship Information Psychiatric Inpatient Hospitalization Psychiatric Partial Hospitalization Crisis Stabilization or Crisis Support Services Substance Abuse Outpatient Services Substance Abuse Inpatient/Residential Services Psychiatric Residential Treatment Facility (PRTF) Intensive Outpatient Services Behavioral Health Residential Services Guardianship Description: Both Parents Other Choose which best describes Court Appointed Guardian Relative the Guardian: Father Only State Ward - Youth Only Mother Only Temporary State Custody-Youth Only Guardian's First Name Address Last Name City State Zip Code Phone ( ) - Presenting Problems Please place a number beside each Problem that represents the presenting problem(s) from the list below Primary Problem Secondary (2) Problem Tertiary (3) Problem 1 - Abandonment 14 - Divorce / Marital Problems 27 - Physical Disability / Handicap 2 - Abuse: Physical, Psychological &/or Sexual 15 - Fire Setting 28 - Physical Health Problems 3 - Acting Out: Aggression 16 - Housing 29 - Physical Health Problems related to SA 4 - Acting Out: Sexual 17 - Job / Job Loss / Work Related Problems 30 - Pregnancy 5 - Behavioral Problems 18 - Legal Reason / Legal Problem 31 - Relationship Problems 6 - Catastrophic Loss (I.e., theft, flood, fire) 19 - Mental Illness 32 - School / Education Problems 7 - Change in Family Circumstance 20 - Moved to New Residence 33 - Serious Illness Diagnosed 8 - Concern About Sexual Orientation 21 - ID/DD 34 - Sibling Conflict 9 - Co-Occurring MH & SA Problem 22 - Neglect 35 - Social Problems 10 - Criminal Charges: Drug Related 23 - No Additional Presenting Problem 36 - Substance Abuse: Alcohol 11 - Criminal Charges: Other, Not Drug Related 24 - Other Mental Health Problems 37 - Substance Abuse: Drugs 12 - Death / Bereavement 25 - Other Substance Abuse Problem 38 - Substance Abuse: Pregnancy 13 - Developmental Disability (DD) 26 - Parent/Child Conflict 39 - Suicidal/Suicide Attempt Yes No Outpatient (Tier II) CareConnection(R) of 6
3 Additional Clinical Information: Evaluation and Assessment Diagnosis/Medical Conditions. Other Factors/Diagnosis NONE No other factors V15.41 Personal history of abuse in childhood or Spousal/partner violence V15.49 other personal history of psychological trauma V15.59 personal history of self harm V15.89 other personal risk factors V15.81 Noncompliance with medical treatment V40.31 Wandering associated with a mental disorder V60.0 homelessness V60.1 inadequate housing V60.2 Lack of adequate food or safe drinking water, extreme poverty, low income insufficient social insurance or welfare support V60.3 problem related to living alone V60.89 Discord with Neighbor, Lodger, or Landlord V60.6 Problem related to living in a residential institution V60.9 Unspecified Housing or economic problems V61.03 Disruption of Family by separation or divorce V61.10 Relationship Distress with Spouse or Intimate Partner V61.11 Counseling for victim of spousal and partner abuse (physical, sexual, neglect, psychological) V61.12 Counseling for perpetrator of spousal and partner abuse (physical, sexual, neglect, psychological) V61.20 Parent-child Relational problem Encounter for MH services for victim of child physical, sexual, psychological abuse or neglect by parent or non-parent V61.22 Counseling for perpetrator of parent child abuse (physical, sexual, neglect, psychological) V61.29 Child Affected by Parental Relationship Distress V61.5 Multiparity V61.7 problems related to unwanted pregnancy V61.8 Sibling Relational problem / Upbringing Away from Parents / High Expressed Emotion Level within family V62.21 problem related to Current Military Deployment Status V62.22 Exposure to disaster, war, or other hostilities OR personal history of military deployment V62.29 Other problem related to employment V62.3 Academic or Educational problem V62.4 Acculturation difficulty, social exclusion or rejection, target of (perceived) adverse discrimination or persecution V62.5 Problems related to conviction with or without imprisonment, legal circumstances or release from prison. V62.82 Bereavement, uncomplicated V62.83 Counseling for perpetrator of nonparental (child) or nonspousal (adult) physical/sexual abuse/neglect/psychological abuse V62.89 Borderline Intellectual Functioning or Other Problems Related Psychosocial circumstances V62.9 Unspecified problem related to social environment or psychosocial circumstances V63.8 unavailability or inaccessibility of other helping agencies V63.9 unavailability or inaccessibility of other health care facilities V65.2 Malingering V65.40 other counseling or consultation V65.49 Other circumstances to Adult Abuse by Nonspouse or Nonpartner; Sex counseling; V69.9 problems related to lifestyle V71.01 Adult antisocial behavior V71.02 Childhood and adolescent antisocial behavior Additional Diagnosis. Outpatient (Tier II) CareConnection(R) of 6
4 Mental Status Examination: Check the most appropriate response to each item: Level of Orientation: Yes No Speech: Blocked Rapid Person: check all Incoherent Slurred Place: that apply Mutism Stuttering Time: Pressured Within Normal Limits Situation: Appearance: Bizarre Recall/Memory: Normal check one Disheveled Deficient In: Short term/working Unkempt check one Remote Within Normal Limits Meticulous Thought Content: Conceptual Disorganization Sociability: Gregarious Loose Association check one Flight of Ideas check one Inappropriate Uninhibited Loose Association Inhibited Withdrawn Perseveration Isolation Within Normal Limits Tangential Thought Blocking Within Normal Limits Affect: Appropriate Flat Coping Ability: Normal Exhausted check one Blunted Broad check one Resilient Overwhelmed Labile Restricted Deficient supports Improving Medication Deficient skills Is the consumer currently prescribed any psychotropic medication? NO YES Please list prescribed medications below and answer the following two questions Anti-Depressant Medication: Anti-Cholinergics Medication: Mood Stabilizer Medication: Anti Psychotic Medication: Anti Anxiety Medication: Anti Convulsant Medication: Hypnotic Medication: Stimulant Medication: Other Medication: Medication Efficacy: Indicate the level at which the current medication protocol has produced the desired results 1 - Current medication protocol effectively reduces symptoms and aids improvement in functioning 2 - Current medication protocol has demonstrated a degree of efficacy but continued monitoring and/or adjustments required. 3 - Current medication protocol is not effective and is being modified/discontinued by the physician 4 - Current medication protocol has not been implemented due to consumer non-compliance Medication Compliance: Indicate the level at which the consumer complies with their medication protocol: 1- Consumer takes medication without prompts or direct assistance (Independent) 2- Consumer takes medication with prompts and/or direct assistance from natural support systems (family, friends) 3- Consumer takes medication with prompts from behavioral health provider (minimal assistance) 4- Consumer takes medication with direct assistance from behavior health provider (direct assistance) 5- Consumer is non-compliant with the medication protocol Symptom Acuity & History Enter the present acuity exhibited and symptom history within the last 6 months. CURRENT ACUITY HISTORY (in the past 6 mo.) Safety Current Acuity Not Present Mild (2) Moderate (3) Severe (4) Acute/Crisis (5) Suicidal * Homicidal * *If Suicidal or Homicidal Acuity is Moderate or Greater, Please fill out the attached Risk Assessment Form Hostility Violence Self Neglect Self Injurious History Days Symptom Never Present Outpatient (Tier II) CareConnection(R) of 6
5 CURRENT ACUITY HISTORY (in the past 6 mo.) Thought Hallucinations Delusions Paranoia Poor Concentration Suspiciousness Circumstantial thinking Obsessions / intrusive thoughts Current Acuity Not Present Mild (2) Moderate (3) Severe (4) Acute/Crisis (5) History Days Symptom Never Present Socialization Oppositional/Defiant Behavior Withdrawal/Isolating Impulsivity Bizarre Behavior Compulsions Sexually Acting Out Sexually reactive behaviors Verbal Aggression Physical Aggression Affect, Energy and Somatic Concerns Depression Anxiety Panic Phobias Mania/Hypomania Hyperactivity Guilt Hope/Helplessness Apathy Agitation Change in Energy Distractibility Loss of Interest Weight change Change in sleep patterns Motivation/Engagement Level: Minimal Moderate High Substance Use Current use of substances? Yes No History of substance use? Yes No Type of substance used: (mark all that apply) Cannabis CNS depressants Alcohol Stimulants Opioid and Morphine Derivatives Hallucinogens Other Frequency of Use: Daily Periodic Binge Use Date of last use of substance: Withdrawal potential: SA Relapse Potential Low Risk High Risk No mm/dd/yyyy LEVEL OF FUNCTIONING Rate to reflect the Member's level of functioning as compared to same age peers. 1 - Not Applicable 3 - Limited impairment 2 - No impairment/independent 4 - Significant Impairment Yes School-Youth or Work Adult Maintains Relationships Maintains Personal Safety Activities of Daily Living** Interacts appropriately in social situations Ability to access community Services **If Activities of Daily Living rated 3 (Limited Impairment) or 4 (Significant Impairment) Check all that Apply: Nutritional Awareness Meal Preparation and Clean Up Personal Hygiene Childcare/Parenting Household Tasks/Care of Living Space Treat Minor Physical Problems Outpatient (Tier II) CareConnection(R) of 6
6 TREATMENT PLAN SUMMARY Indicate the areas that best describe the problems addressed in the Member's current treatment plan. TX Plan Summary Two TX Plan Summary Three 1 = ADL Skill Building 7 = Psychiatric Symptoms 2 = Interpersonal relations 8 = Psychological Distress 3 = Maintaining ADL 9 = Self-injurious or suicidal behaviors 4 = Maladaptive, antisocial behaviors 10 =Substance abuse behaviors 5 = No Additional Problems/Focus 11 = Co-occuring MI/SA Symptoms 6 = Physical Health 12 = Sexualized Behaviors LEVEL OF SUPPORT Evaluate available natural supports, Check all that apply: Family / Friends Self Help Network Involvement Peer-Oriented Services Recreation / Community Activities None Currently Available Other Indicate significant clinical issues addressed in treatment that are not presented in CareConnection. Include any justification of treatment needs to maintain functioning/symptom reduction if the Member is currently functioning well and/or is asymptomatic. Outpatient (Tier II) CareConnection(R) of 6
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*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process.
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Joanna C. Ioannides, LCSW *Lowry Counseling, LLC *7581 E. Academy Blvd. Ste 209 * Denver, CO 80230*Ph. (720)319-7319 Fax (303)379-4607* counseldenver@aol.com* COUNSELING ASSESSMENT REFERRAL AND BACKGROUND
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Prince of Peace Center P. O. Box 89 502 Darr Ave. Farrell, PA 16121 724-346-5777 www.princeofpeacecenter.org Program Application for: 1 Referred by HOPE FAITH Head of Household Information Gender Male