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1 Enrollment Document Number (Auto generated by CMBHS system) Enrollment Date Funding Source HHSC RSS LBHA MM/DD/YYYY Other Funding Source CHILDREN How many children are living with someone else due to a child protection court order? For how many children have you lost parental rights? Education/Employment Education Completed? Are you currently employed? Less than high school diploma High school diploma or GED Some college, no degree Associate's Degree Bachelor's degree or higher VoTech Training Employed, Full time Employed, Part time Unemployed, looking for work Unemployed, Disabled Unemployed, Volunteer Work Unemployed, Retired Unemployed, Not looking for work If Employed Other, Please Specify: During the past 30 days, how much money did you receive from: 2013 Clinical Management for Behavioral Health Services (CMBHS), Texas Department of State Health Services. All rights reserved. Page 1
2 Wages Public Assistance Disability Criminal Justice In the past year, how many times have you been arrested? In the past year, how many nights have you spent in jail/prison? Are you currently under legal supervision? If yes, please specify type of supervision: Parole Probation Drug Court Type of Legal Supervision If yes for Other Type of Legal Supervision, Please specify In the past 30 days, where have you been living most of the time? If housed, where? Please Specify Other Housing Type Shelter Street/Outdoors Institution Housed Own/Rent Someone else's Dormitory/College Residence Halfway House Sober Living Residence Residential Treatment Substance Use Disorder (SUD) Treatment Are you currently? In SUD Treatment On waiting list for SUD treatment In transition from SUD treatment Not engaged in treatment Self-Help/Social Support How many times in the past 30 days have you: Attended Self-Help Groups for Recovery (such as, AA, NA, etc.) 2013 Clinical Management for Behavioral Health Services (CMBHS), Texas Department of State Health Services. All rights reserved. Page 2
3 Met with a Sponsor Affiliated with a Self-Help Group Met with a Peer Recovery Coach Other Type of Self-Help? Health Care Are you currently covered by No insurance Private Insurance Medicaid Medicare VA CHIP - Children's Health Insurance Program If other, please specify: During the past 30 days, did you receive Inpatient Treatment in: Hospital for Physical Complaint Mental Health Facility Substance Use Disorder Facility During the past 30 days, did you receive Outpatient Treatment for: Physical Complaint Mental Health Issues Alcohol or Substance Abuse 2013 Clinical Management for Behavioral Health Services (CMBHS), Texas Department of State Health Services. All rights reserved. Page 3
4 During the past 30 days, did you receive Emergency Room Treatment for: health Physical Complaint Mental Health Issues Alcohol or Substance Abuse In the past 30 days, how many days did you use the following? Any Alcohol Alcohol to Intoxication Illegal Drugs Primary Illegal Drug Secondary Illegal Drug Tertiary Illegal Drug Prescription Drug - Not as Prescribed Primary Prescription Drug Not as Prescribed Secondary Prescription Drug Not as Prescribed Tertiary Prescription Drug Not as Prescribed Mental Health In the past 30 days, how many days did you experience the following? Serious Depression Anxiety or Tension Trouble Understanding, Concentrating, or Remembering Trouble Controlling Violent Behavior Taken prescribed medication for mental health issues 2013 Clinical Management for Behavioral Health Services (CMBHS), Texas Department of State Health Services. All rights reserved. Page 4
5 Mental Health Services In the past 30 days, how many times have you met with the following people in order to address mental health issues in your life? Psychiatrist Psychologist, Mental Health Therapist/Counselor, or Social Worker Mental Health Peer Specialist In the past 30 days, how many times have you attended a support group for mental health recovery? Name(s) of mental health support group Recovery Stage Stage of Recovery (Interviewer Rating) Precontemplation Contemplation Preparation Action Maintenance/Relapse Prevention 2013 Clinical Management for Behavioral Health Services (CMBHS), Texas Department of State Health Services. All rights reserved. Page 5
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