Delaware Department of Health and Social Services Division of Substance Abuse and Mental Health Consumer Reporting Form Training Manual January 2011 CONSUMER REPORTING FORM TRAINING MANUAL GENERAL INFORMATION There are six forms in the set - the ADMISSION REPORT, the DISCHARGE REPORT, the DETOX DISCHARGE REPORT, the HOSPITAL DISCHARGE REPORT, the INTRA-AGENCY TRANSFER REPORT and the PSYCHIATRIC DIAGNOSIS. Each of these forms is a two part carbonless document. The Admission and Discharge forms are each two pages long (both pages are carbonless two part documents). All programs, both mental health and substance abuse, will use the Admission and Discharge reports but only mental health programs are required to use the Psychiatric Diagnosis report. The reason for repeating so many items at discharge illustrates the major change in purpose of these forms. In the past, the Central Office of DSAMH was primarily concerned with statistics on how many people were in their programs. That concern has been broadened. Not only are we concerned about how many people receive treatment, but also how effective the treatment is. If a consumer is indicated as being potentially eligible for SSI on the Admission form and then eligible and receiving payment on the Discharge form, we know that your program is fulfilling one of the primary goals of the Division which is to facilitate the full use of entitlements by our consumers. If living arrangement and residential arrangement changes from alone and homeless to lives with non-relatives in adult foster care, or if employment goes from unemployed-not looking to part time or volunteer, we know that you are meeting the Division's goals for housing and employment of our consumers. The consumer MCI number is repeated on all sheets so that pages which become separated may be matched to each other. What follows is a brief description of each item. Most items have codes for “unknown” and infrequently a code for “not collected”. It may not be clear when to use “not collected”. “Unknown” is meant for those situations when you simply do not collect this information. Its use is discouraged. For example, if your organization does not determine someone's Medicaid number, this field would be filled in with 999998 (making 999999998M). This allows us to know that you did not leave the field blank accidentally but in fact do not collect that information. Use the code “unknown” for those items that you ordinarily collect but which are missing for this one consumer. DSAMH maintains a 95% quality standard for CRF data. Each treatment unit will receive a monthly report card indicating their score for data accuracy which can range from 0 to 100. For instance, if your organization ordinarily collects date of birth but you don't have that information for this consumer, fill it in with 07/07/77. Text fields can be filled with the words "NONE", "UNKNOWN" or "NOT COLLECTED". Numbers are filled with 6 or 96 for none, 7 or 97 for unknown, and 8 or 98 for not collected. Dates are coded 06/06/66 for none, 07/07/77 for unknown, and 08/08/88 for not collected. In alpha coded fields, Z is always not collected, U is always unknown, N is usually none, not applicable, or no but may occasionally mean something more specific to the question such as “Not of Hispanic Origin” under Ethnicity, “Lives with Non-relatives” under Living Arrangements, “Homeless” under Residential Arrangements etc. NOTE: With the exception of Alert Information, check only one item for each box. IMPORTANT TIPS FOR COMPLETING THE CRF FORM: The acceptable default date fields are 06/06/2666, 07/07/2777 and 08/08/2888. For sections of the form where only a two character century date is allowed, you should enter 06/06/66, 07/07/77 and 08/08/88. Generally the codes "NOT COLLECTED" and “UNKNOWN” should not be used for required fields. If you don't use an "optional" field, fill in a default value, such as "NONE" or "UNKNOWN." DATA ITEMS Page 1 of Admission and Discharge Forms - Header Treatment Unit Name Your organization’s name. A treatment unit is defined as an identifiable organization or unit of an organization that usually resides at a single location (which it may share with other organizations) and is an identifiable cost center. A distinguishing characteristic of treatment units is that consumers do not move readily between them and the organization usually requires that some transfer paperwork be generated for such a move. Each treatment unit may offer a variety of services such as group therapy, job skills training, etc. such that every consumer in the unit may not receive exactly the same mix of services. Consumers may, in fact, receive services from more than one treatment unit simultaneously. The key to this definition is the organization's perception of that organizational unit has responsibility for the treatment of this consumer. Treatment Unit ID # Treatment unit identification - CMHS number or CSAT number plus 2 digits assigned by DSAMH. Last Name Consumer's last name (use formal name - Thomas) First Name Consumer's first name (use formal name - William) M.I. Consumer's middle initial (use formal name) Must be the same for admission and discharge forms. Modality (Select Only One) Check the appropriate box to indicate whether the consumer is admitted to the treatment unit as a Mental Health consumer, an Alcohol / Drug consumer, or as a Co-Occurring (MH & AD) consumer. Some treatment units will have all MH consumers, some all AD consumers, some all Co-Occurring consumers, or some a combination. Must be the same for admission and discharge forms. [ ] MH Mental Health [ ] AD Alcohol / Drug [ ] DU Co-Occurring (MH & AD) [ ] GA Gambling Street (Optional) Consumer's address City Consumer’s City of residence State Consumer’s State of residence Zip The first 5 digits are required; the last 4 are optional but appreciated if available. 99999-9996 none 99999-9997 unknown 99999-9998 not collected County (Required) Indicate the county of residence at admission or discharge N New Castle K Kent S Sussex O Out of state U Unknown Z not collected Home phone (Optional) (999)999-9996 none (999)999-9997 unknown (999)999-9998 not collected DSAMH Admission Date The date of admission to a DSAMH funded Treatment Unit. If a client is being transferred from a Non-DSAMH funded unit to a DSAMH funded unit, use the date of the transfer, not the original program admission date. No future dates and no unreasonably old dates are allowed. Must be the same on both admission and discharge forms. 06/06/66 in the unlikely event that there is none 07/07/77 in the less likely event that it is unknown 08/08/88 in the improbable event that you do not collect it Birth Date Consumer's date of birth. No future dates and no unreasonably old dates are allowed. Must be the same on both admission and discharge forms. 07/07/2777 unknown 08/08/2888 not collected MCI # MCI ID number (also called PACT number) 9999999996 none 9999999997 unknown Must be the same on both admission and discharge forms. S.S.# Social Security number 999-99-9996 none 999-99-9997 unknown 999-99-9998 not collected Must be the same on both admission and discharge forms. Medicare # Medicare number. 999999996N (1 blank on the end) None 999999997U (1 blank on the end) Unknown, not collected for this consumer 999999998Z (1 blank on the end) not collected for any consumer Expected to be the same on both admission and discharge records. Page 1 of Admission and Discharge Forms - Column 1 Gender Consumer's gender M Male F Female Must be the same on admission and discharge forms. Racial Identification AA American Indian/Alaskan Native AP AA plus other races BL BLack/African American BP BL plus other races CA white/Caucasian CP CA plus other races HA Native Hawaiian/Other Pacific Islander HP HA plus other races MU Multiracial, Unspecified PA Asian PP PA plus other races U Unknown Z Not Collected Ethnicity (Hispanic or Latino) P Puerto Rican M Mexican C Cuban O Other Hispanic N Not of Hispanic origin U Unknown NOTE: The Race and Ethnicity fields are completed based on self-report. This is further clarified by the following quotes from the Federal Register (Vol. 62, No. 210, October 30, 1997, p. 58785). “underscore that self-identification is the preferred means of obtaining information about an individual’s race and ethnicity, except in instances where observer identification is more practical (e.g., completing a death certificate).” “do not tell an individual who he or she is, or specify how an individual should classify himself or herself.” Background information on Race and Ethnicity from the Federal Register (Vol. 62, No. 210, October 30, 1997, p. 58789) The minimum categories for data on race and ethnicity for Federal statistics, program administrative reporting, and civil rights compliance reporting are defined as follows: American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as ‘‘Haitian’’ or ‘‘Negro’’ can be used in addition to ‘‘Black or African American.’’ Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race. The term, ‘‘Spanish origin,’’ can be used in addition to ‘‘Hispanic or Latino.’’ Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Marital Status. (NOTE: Use the legal definition of marriage) M Married S Single - never married D Divorced X Separated W Widowed U Unknown Primary Language Consumer's primary language Must be the same on admission and discharge forms. E English S Spanish M sign (Manual) language O Other U Unknown Page 1 of Admission and Discharge Forms - Column 2 Residential Arrangement (The type of housing where the client lives) PU Private house or residence - Unsupervised PS Private house or residence – Supervised (e.g. a 24 hour supervised apartment) FC adult Foster Care BH Boarding House/Single Room Occupancy (SRO), YMCA GU Group setting/community residence - Unsupervised GS Group setting/community residence – Supervised (e.g. a licensed Mental Health Group Home or Substance Abuse ½ way house) NH Nursing Home/ICF or SNF Facilities CJ Corrections facility/Jail I other Institution (Includes acute care hospital, institution for mental diseases, etc.) greater than thirty (30) days O Other N None - on the street/in a shelter/homeless U Unknown (NOTE: Supervised housing means that supervision is provided as a part of the housing arrangement, not supervision of the consumer in their residence by an unrelated Community Support Program (CSP). Support is 7 days by 24 hours.) Homeless at any time during the past 30 days Was the consumer homeless at any time during the 30 days prior to admission? Y Yes N No U Unknown Veteran Status The consumer’s or immediate family member’s current Military Service or Service history VP Veteran/Previous Military Service (includes active National Guard and Reserve Duty) AD Active Duty FM Immediate Family Member of Military or Veteran (Immediate family member is a partner, spouse, child, parent, or sibling.) NA None of the Above U Unknown Page 1 of Admission and Discharge Forms - Column 3 Education Write in the Highest Grade Completed 01-12 Elementary/High School 13-16 College/post secondary 17 Graduate school at the masters level 18 Graduate school at the Ph.D./MD. level 19 Post doctoral work 96 never completed any grade higher than preschool or kindergarten 97 unknown NOTE: Post secondary programs that last less than a year should not be counted. If the person completed his senior year of high school and then 6 months of technical training, they would still be coded as 12. If he spent 9 months to a year in training, he would be coded as a 13. If the person completed 9th grade but no more and later got into a specialized training program, the highest grade they completed is still considered to be 9th and should be coded as 09. Obviously this scheme cannot cover the many ways a person may acquire an education. Your judgment as to their level of accomplishment will have to be the final determinant. Primary Employment During The Past 30 Days The consumer's current primary employment or source of earned income during the past 30 days. If there is no earned income, use their primary daily activity. If they are employed and a student, select the appropriate employment category, not student. F Full time (35 hours a week or more) P Part time (less than 35 hours per week) M Military Armed Forces, active duty (active reserves, reserves) L unemployed - Looking for work N unemployed - Not looking D Disabled/unable to work means that the consumer is so impaired by their disability that they are unable to engage in any form of part time or volunteer activity. H Homemaker S Student R Retired I Inmate or resident of an institution (This includes an acute care hospital, institution for mental diseases, nursing home, jail, prison, etc.) for over thirty (30) days. V Volunteer O Other U Unknown Primary Health Insurance The consumer's primary health insurance carrier; choose only one. If the consumer has more than one, chose the one most likely to pay for the majority of the services you give that will be paid for by any insurance. (Check the appropriate insurance carrier even if they will only pay for limited benefits and DSAMH will cover the rest.) M Medicare A medicAid E mEdicaid MCO C TRICARE (Tricare is the regionally manage Health care program for Active and Retired members of the Military and their families.) B Blue Cross/Blue Shield V VA H HMO (service contract) G other Government funds for care P other Private commercial health insurance O Other N None U Unknown Page 1 of Admission and Discharge Forms - Column 4 Number of Arrests 30 Days Prior to Admission - Write in the Number of Arrests Current Legal Involvement Consumer's involvement in the legal system. If more than one applies, chose the most relevant. CP Charges Pending SP convicted - Sentence Pending UP sentenced - Unsupervised Probation (SENTAC I) FS sentenced - Field Supervision (SENTAC II) IS sentenced - Intense Supervision (SENTAC III) QI sentenced - Quasi-Incarceration (SENTAC IV) CJ sentenced - prison/Corrections/Jail (SENTAC V) HX History of legal involvement but not current N No current involvement or history U Unknown Consumer’s Primary Source of Income Enter the source of income for the consumer during the last 12 months, if available, or if not, the last calendar year. SS Social Security G General assistance SI SSI SD SSDI P Pension/retirement income (IRA, KEOGH, SEP, ESOP) VD VA - Disability W Workman's comp. VR VA - Retirement UI Unemployment Insurance D private Disability insurance IL ILlegal I Investments/savings E Employment O Other S Spouse N None F Family/friends U Unknown A TANF (Temporary Assistance to Needy Families – formerly AFDC) Number Dependent on Consumer’s Income See Consumer’s Primary Source of Income. Report an average number if the consumer’s dependents vary regularly. 01 - 20 97 unknown Consumer’s Gross Income per Year See Consumer’s Primary Source of Income. Take the total from the last 12 months, if available, or if not, the last calendar (tax) year. "999999" is not allowed 999996 none 999997 unknown Screening for History of Trauma (Only applies to Community Mental Health Clinics): P Positive screen for History of Trauma N Negative screen for History of Trauma U Unknown Assessment for History of Trauma (Only applies to Community Mental Health Clinics): P Positive screen for History of Trauma N Negative screen for History of Trauma U Unknown Page 2 of Admission Form - Header Date of First Contact This is the date the person first came in contact with your treatment unit. It might be before or after the screening date but should be before or the same as the admission date. Contact may have been by phone or face-to-face but was with the consumer himself, not a third party. No future dates and no unreasonably old dates are allowed. 06/06/66 none 07/07/77 unknown Page 2 of Admission & Discharge Forms Currently Pregnant Y Yes N No U Unknown Injection Drug Use Ever History of needle use to consume illicit drugs ever in lifetime Y Yes N No U Unknown Substance Abuse – Designated Codes DSM-IV-TR Diagnosis Axis I: Clinical Disorders This is completed by A&D treatment programs only. Enter up to three substance abuse DSM-IV-TR diagnosis codes and/or Gambling code as appropriate. The most important Axis I diagnosis should be written first. The code is 3 digits or the letter V followed by 2 digits, decimal point, 2 digits. Use the DSM-IV-TR manual for correct codes. Intoxication Withdrawal Abuse Dependence Alcohol 303.00 291.81 305.00 303.90 Amphetamine 292.89 292.0 305.70 304.40 Cannabis 292.89 -- 305.20 304.30 Cocaine 292.89 292.0 305.60 304.20 Hallucinogen 292.89 305.30 304.50 Inhalant 292.89 305.90 304.60 Opioid 292.89 292.0 305.50 304.00 Phencyclidine 292.89 305.90 304.90 Sedative, Hypnotic, Anxiolytic 292.89 292.0 305.40 304.10 Polysubstance -- 292.0 -- 304.80 Other (Unknown) 292.89 292.0 305.90 304.90 Pathological Gambling 312.31 Alcohol & Drug Use Matrix This information is required from both mental health and substance abuse providers. The codes appear in the box surrounding the matrix. The Primary column is for the drug deemed the primary cause of problems for the user. If the consumer does not have a drug or alcohol problem, place an N (none) in the Substance Type under each column heading, Primary, Secondary, Tertiary, and draw a line down through the remaining boxes in each column, Frequency of Use, Route of Administration, Age of First Use. This item does not apply to drugs given legally for therapeutic reasons. Substance Type (“Club Drugs” are highlighted) AL ALcohol CO COcaine CR CRack ME MEthamphetamine AM other AMphetamines (This includes MDMA (methylenedioxymethamphetamine) – ECSTASY, Benzedrine, Dexedrine, Preludin, Ritalin, and any other amines and related drugs.) OS Other Stimulants HE Heroin OP other OPiates and synthetics (This includes OxyContin, codeine, Dilaudid, morphine, Demerol, opium, and any other drug with morphine-like effects.) MD non-prescription MethaDone BA BArbiturates (This includes Phenobarbital, Seconal, Nembutal, etc.) SE other SEdatives or hypnotic (This includes chloral hydrate, Placidyl, Doriden, etc.) {Until a better classification system is developed put (GHB/GBL gamma-hydroxybutyrate, gamma-butyrolactone) and Ketamine (Special K) here} BE BEnzodiazepine (This includes Diazepam, Flunitrazepam (Rohypnol), Flurazepam, Chlordiazepoxide, Clorazepate, Lorazepam, Alprazolam, Oxazepam, Temazepam, Prazepam, Triazolam, Clonazepam and Halazepam.) TR major TRanquilizers CS Cough Syrups and mixtures MA MArijuana/hashish (This includes THC and any other cannabis sativa preparations.) PC PCP (Phencyclidine) LS LSD HA other HAllucinogens (This includes DMT, STP, mescaline, psilocybin, peyote, etc.) IN INhalants (This includes ether, glue, chloroform, nitrous oxide, gasoline, paint thinner, etc.) ST STeroids OC Over-the-Counter (This includes aspirin, Sominex, and any other legally obtained, non-prescription medication.) O Other N None U Unknown Frequency of use N No use in past month I Infrequent (1-3 times in past month) O Often (1-2 times per week/4-8 times per month) F Frequently (3-6 times per week/12-24 times per month) D Daily M More frequently than daily (2 or more times per day) U Unknown Route of administration M Mouth (swallow) S Smoke B Breathe/inhale/snort V intraVenous I other Injection (intramuscular or skin pop) O Other N None U Unknown Age of first use -1 newborn/addicted at birth 1 - 95 age in years 96 none 97 unknown 98 not collected Admission Type (Leave blank until admitted) V Voluntary admission C Civil order (Involuntary commitment without a criminal charge) J Judicial (court) order with a criminal charge - sentencing U Unknown N None Alert Information MARK ALL THAT APPLY. Admission information is assumed to be by consumer report. At discharge, the information is assumed to be by clinician's report. TB Active TB History History of mental illness (may or may not have been treated) Previous tx for mental illness History of alcohol and/or substance abuse (may or may not have been treated) Previous tx for alcohol and/or substance abuse (does not include AA/NA, etc.) Psychiatric disability (may or may not be designated as disabled by the CMHC) History of Pathological Gambling None of the above Source/Agency Code This is the number for the agency that referred the consumer to you. The five character code comes from the Referral Agency List. This code list will be updated quarterly. As you identify agencies that are not on this list, we would appreciate it if you contact the MIS unit of DSAMH (577-4460). In the meantime, you should be able to use the more generic major category, such as AA000 for Individual, Employer, Church, or School. T Transferred - responsibility for this consumer's treatment was relinquished by the transferring treatment unit and acquired by this treatment unit. R Referred - the referring treatment unit called to set up the first appointment and informed the consumer of same S Self-referred - the consumer was primarily responsible for establishing contact with this treatment unit U Unknown Social Support/Connectedness Was consumer enrolled in a support program, such as AA, NA, etc., 30 days prior to admission or 30 days prior to discharge, as is appropriate? NOTE: (The expanded federal definition is - Participation in social support of recovery activities is defined as attending self-help group meetings, attending religious/faith affiliated recovery or self help group meetings, attending meetings of organizations other than the organizations described above or interactions with family members and/or friends supportive of recovery – Source the 2007 SAPTBG application package (Measure T6)). Y Yes N No U Unknown Frequency of attendance at Self-help programs 30 days prior to admission or 30 days prior to discharge, as is appropriate. Write in number of times the client attended Self-help programs 30 days prior to admission or 30 days prior to discharge, as is appropriate. The allowed values range from 00 to 99. Presenting problem Presenting problem is the problem deemed most significant or the major reason for the person seeking help. List the primary problem at the time of admission. SU SUicide threat/attempt DS Danger to Self (non suicide) DO Danger to Others PC Parent-Child problem MA MArital problem FA FAmily problem FI FInancial problem GA GAmbling SR Social Relations (other than family) AC ACting out/uncontrollable AL ALcohol DR DRug AX AnXiety/fears/phobias DE DEpression or mood disorder OB OBsessions/compulsions PA PAranoid feelings IM IMpaired memory/disoriented HA HAllucinations/delusions SO SOmatic concerns MD MeDical problems SX SeXual problems FD physical Function Disturbance DL problems coping with Daily Living roles and activities CJ Criminal Justice EA EAting disorder TH THought disorder AB ABuse/assault/rape victim RU RUnaway behavior O Other N None U Unknown Expected source of payment This is the party expected to pay the major portion for the consumer's care. D DSAMH I Individual resources (patient's or patient's family) B Blue Cross/Blue Shield H HMO (service contract) P other Private commercial health insurance M Medicare A MedicAid E Medicaid MCO V Veterans Administration C CHAMPUS W Worker's compensation G other Government sources S SENTAC O Other N None, provider absorbs total cost (charity, research, teaching) U Unknown Page 2 of Admission and Discharge Forms - Common Items - Footer Primary therapist or case manager - enter their name and ID. If an existing numbering system doesn't exist, the last six digits of the person's SSN is recommended. Person completing form - enter their name and ID. Date of completion - This is the date the form was completely filled in. Page 2 of Discharge Form - Header Date of Last Service Must be a face-to-face contact. No future dates and no unreasonably old dates are allowed. 06/06/66 none 07/07/77 unknown 08/08/88 not collected DSAMH Discharge Date The date of discharge or discontinuation from a DSAMH funded treatment unit. No future dates and no unreasonably old dates are allowed. 06/06/66 none 07/07/77 unknown 08/08/88 not collected Page 2 of Discharge Form - Column 2 Discharge Reason Indicate the discharge reason which best describes why this person was discharged from the treatment unit. (NOTE: The "treatment unit" is key concept used in the completion of this form. A treatment unit is defined as a unit which provides treatment or prevention services to a consumer population. It typically has an identified location(s), dedicated staff and a separate budget or cost center. An Agency may have one or more Programs which operate one or more Treatment Units. Examples of a treatment unit include a detoxification center, residential program, continuous treatment team, halfway house, outpatient counseling clinic, etc. G Program at this facility completed - All Goals met. S Program at this facility completed - Some goals met. E Eligibility has lapsed, no longer eligible D consumer Died F Failure to meet treatment unit requirements, broke the rules A Administrative discontinuation, lost contact C Corrections, jail R Refused service (ex. refused counseling, left against medical advice) T Treatment continued in another treatment unit (didn't complete treatment) O Other U Unknown Was the Consumer's drug use reduced? Answer "YES" if the consumer's use of drugs and/or alcohol lessened during the course of treatment. Answer "NO" if the use remained the same or worsened. Y Yes N No X not Applicable U Unknown Destination Agency Code (Please write in the five (5) character code listed in the current version of the Referral Agency List. The Referral Agency List is now available on the DSAMH web site. http://www.state.de.us/dhss/dsamh/dmhhome.htm) These are the agencies that you referred the consumer to. The five character code comes from the Referral Agency List. This code list will be updated quarterly. As you identify agencies that are not on this list, we would appreciate it if you contact us. In the meantime, you should be able to use the more generic major category. The Primary agency should be the one you transferred the consumer to or the one that will have the most to do with the consumers continued treatment. Enter N followed by four blanks for none and U followed by four blanks for unknown. N None U Unknown For each agency you will indicate what kind of transfer or referral was made. T Transferred - responsibility for this consumer's treatment was relinquished by this treatment unit and acquired by another treatment unit. R Referred - this treatment unit called to set up the first appointment and informed the consumer of same. A Additional services were advised but a transfer or referral was not done. N No additional services were advised. U Unknown. EXAMPLE 1: The consumer completes the program, completes treatment, and continues his/her treatment in another program by referral, complete the CRF as follows... Discontinuation Reason = G (Program here completed, all goals met) Primary Destination Agency Code = [ NA005 ] BCI Lancaster Outpatient Clinic "R" Referred Secondary Destination Agency Code = [ FA018 ] NCC CMHC 809 Washington Street "R" Referred Tertiary Destination Agency Code = [ AB010 ] Alcoholics Anonymous "A" Advised Further Service EXAMPLE 2: The consumer does not complete the program, does not complete treatment, and continues his/her treatment in another program by direct transfer, complete the CRF as follows... Discontinuation Reason = T (Treatment Continued in another program) Primary Destination Agency Code = [ EA020 ] Delaware Psychiatric Center – K3 "T" Transferred Secondary Destination Agency Code = [ FA018 ] NCC CMHC 809 Washington Street "R" Referred Tertiary Destination Agency Code = [ AB011 ] Narcotics Anonymous "A" Advised Further Service PSYCHIATRIC DIAGNOSIS FORM: REQUIRED for all MH programs and all A&D CCCP programs, and OPTIONAL for all other A&D programs Last Name Consumer's last name First Name Consumer's first name M.I. Consumer's middle initial MCI # MCI ID number (also called PACT number) 9999999996 none 9999999997 unknown Treatment Unit ID # Treatment unit identification - CMHS number or CSAT number plus 2 digits assigned by DSAMH. Axis I The most important Axis I diagnosis should be written first. The code is 3 digits or the letter V followed by 2 digits, decimal point, 2 digits. Use the DSM-IV-TR manual for correct codes. 999.97 unknown 999.98 not collected V71.09 none Axis II The most important Axis II diagnosis should be written first. 999.97 unknown 999.98 not collected V71.09 none NOTE: Please indicate which is the Primary Diagnosis by placing a check in the [ ]'s after it. "When a person receives more than one diagnosis, the principal diagnosis is the condition that was chiefly responsible for occasioning the evaluation or admission to clinical care. In most cases this condition will be the main focus of attention or treatment. The principal diagnosis may be an Axis I or an Axis II diagnosis..." (Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition – Text Revision), American Psychiatric Association) Axis III Physical Disorders or Conditions 999.96 none 999.97 unknown 999.98 not collected Axis IV Psychosocial and Environmental Problems [ ] Problems with primary support group (Specify)______________________________________ [ ] Problems related to the social environment (Specify)________________________________ [ ] Educational problems(Specify)_____________________________________________________ [ ] Occupational problems(Specify)____________________________________________________ [ ] Housing problems(Specify)_________________________________________________________ [ ] Economic problems(Specify)_______________________________________________________ [ ] Problems with access to health care services(Specify)_______________________________ [ ] Problems related to interaction with the legal system/crime(Specify)__________________ [ ] Other psychosocial and environmental problems (Specify)___________________________ Axis V Global Assessment of Functioning Scale Score 997 unknown 998 not collected Time Frame: Current, Last Month, Last Quarter, Last Year, Other Physician Formulating/Confirming Diagnosis - Print his/her name and ID. Date of completion This is the date the diagnosis was done. Signature This is the signature of the physician formulating/confirming the diagnosis. Consumer Reporting Form - Training Manual – January, 2011 Page 21 of 21 Consumer Reporting Form Instruction Manual – January 2011 Page 2 of 21