1. health and fitness
2. disorders

Macomb County Community Mental Health
Annual Assessment
IDENTIFYING INFORMATION
NAME
CASE #
SSN
DOB
GENDER
DEMOGRAPHIC
DATE OF ASSESSMENT
TIME OF ASSESSMENT
ASSESSED BY
CONSUMER INFORMATION
ADDRESS
CITY
ALTERNATE PHONE
MI
HOME PHONE
COUNTY OF RESIDENCE
DATE OF BIRTH
MICHILD ID#
Macomb
MEDICAID IDENTIFIER
AKA OR OTHER INFORMATION THAT CAN BE USED TO SEARCH FOR A CONSUMER
MARITAL STATUS
HISPANIC OR LATINO / LATINA
ARAB AMERICAN / CHALDEAN
RACE 1
RACE 2
RACE 3
PRIMARY SPOKEN LANGUAGE
RELIGION
VETERAN STATUS
PARENTAL STATUS (Child < 18)
CHILD SERVED BY DHS FOR ABUSE/NEGLECT
CHILD SERVED BY OTHER DHS PROGRAM
REFERRAL SOURCE
ADDITIONAL INFORMATION
MAILING INFORMATION
MAIL RECIPIENT
MAIL RECIPIENT NAME
ADDRESS
CITY
STATE
ZIP
GROUP HOME/RESIDENTIAL FACILITY
MEDICAL INFORMATION
CONSUMER HAS PRIMARY PHYSICIAN
QHP
LAST SEEN
PHYSICIAN NAME
Month
Year
PHONE
CURRENT MEDICAL PROBLEMS
CMHSP PRESCRIBED MEDICATIONS
DRUG
Program: MACInitialIntake
SOURCE
INSTRUCTIONS
Page 1 of 15
IDENTIFYING INFORMATION
NAME
CASE #
SSN
DOB
GENDER
FINANCIAL INFORMATION
STATUS OF ENTITLEMENTS (FUNDING SOURCE)
FINANCIAL INFORMATION
COMMERCIAL INSURANCE
NON TAXABLE INCOME
FIA
MEDICARE
SS
CH SUPPORT
MEDICAID (EXCEPT CHILD WAIVER)
TOTAL MONTHLY INCOME
HABILITATION SUPPORTS WAIVER
TOTAL EARNED INCOME
ADOPTION SUBSIDY
TOTAL ANNUAL TAXABLE INCOME (Line 16-MI Income Tax)
SDA, SSI, SSDI
# OF DEPENDENTS (#CLAIMED ON INCOME TAX)
MI CHILD PROGRAM
MONTHLY MAX CHARGE
MEDICAID CHILDREN'S WAIVER
TOTAL FINANCIAL SITUATION UTILIZED
ABW
LAST REVIEW DATE
MEDICAL INFORMATION
RECIPIENT ID#
MI CHILD ID#
INSURANCE POLICIES
TYPE
POLICY HOLDER
POLICY/CONTRACT #
OTHER INFORMATION
EFFECTIVE DTS.
Deductible:
Copay:
GUARDIAN/PARENT
PRIMARY GUARDIAN INFORMATION
NAME
TYPE OF GUARDIANSHIP
ADDRESS
RELATIONSHIP
CITY
STATE
ZIP
HOME PHONE
WORK PHONE
CO-GUARDIAN INFORMATION
NAME
TYPE OF GUARDIANSHIP
ADDRESS
RELATIONSHIP
CITY
STATE
ZIP
HOME PHONE
WORK PHONE
ADDITIONAL GUARDIAN NOTES
FAMILY INFORMATION
CHILD'S FIRST NAME
AND LAST INITIAL ONLY
AGE
CHILD'S
GENDER
o
o
o
o
o
M
M
M
M
M
o
o
o
o
o
WHO DOES THE
CHILD LIVE WITH
F
F
F
F
F
BIOLOGICAL
CHILD
o
o
o
o
o
Yes
Yes
Yes
Yes
Yes
o
o
o
o
o
BIOLOGICAL PARENT
FIRST NAME AND LAST
INITIAL ONLY
No
No
No
No
No
ADDITIONAL FAMILY INFORMATION
RESIDENTIAL, EDUCATION & EMPLOYMENT
RESIDENTIAL LIVING ARRANGEMENT
RESIDENTIAL LIVING ARRANGEMENT
Program: MACInitialIntake
NUMBER OF BEDS IN RESIDENTIAL SETTING
Page 2 of 15
IDENTIFYING INFORMATION
NAME
CASE #
SSN
DOB
EDUCATION
EDUCATION (HIGHEST LEVEL ATTENDED)
SCHOOL NAME AND LOCATION
NUMBER OF YEARS OF EDUCATION (e.g. 4 YEARS OF COLLEGE = 16)
CURRENTLY IN TRAINING/EDUCATION?
IF YES
EMPLOYMENT STATUS
EMPLOYMENT STATUS
IF EMPLOYED, OCCUPATION
MINIMUM WAGE
FINANCIAL INFORMATION
TOTAL ANNUAL HOUSEHOLD INCOME
NUMBER OF DEPENDENTS
LEGAL
CORRECTIONS RELATED STATUS
o
o
o
o
o
o
Not under Jurisdiction
Paroled from Prison
Juvenile Detention Center
Awaiting Trial
Minor (under 18) Referred by Court
Diverted from arrest or booking
o
o
o
o
o
o
o
In Prison
In Jail
Probation from Jail
Court Supervision
Awaiting Sentencing
Arrested and Booked
Refused to give any information
DRUG COURT CLIENT
o Yes
o No
INVOLVEMENT, PO, COURT DATE, OFFENSE
ARREST HISTORY
6 MONTHS
5 YEARS
TOTAL ARRESTS
POSSESSION / SALES
DUI / DWI
NARRATIVE
REASON FOR CONTINUING TREATMENT
REASON FOR CONTINUED SERVICE
BIO-PSYCHO-SOCIAL DEVELOPMENT & HISTORY
NARRATIVE
Program: MACInitialIntake
Page 3 of 15
GENDER
IDENTIFYING INFORMATION
NAME
DANGER TO
SELF
CASE #
PAST
o Ideation
o Intent
o Plan
o None
o Action
SSN
RISK ASSESSMENT
CURRENT
o Ideation
o Intent
o Plan
o None
o Action
OTHERS
o
o
o
o
o
Ideation
Intent
Plan
None
Action
o
o
o
o
o
Ideation
Intent
Plan
None
Action
PROPERTY
o
o
o
o
o
Ideation
Intent
Plan
None
Action
o
o
o
o
o
Ideation
Intent
Plan
None
Action
DOB
GENDER
PLEASE EXPLAIN,
OTHER SAFETY ISSUES
SUPPORT NEEDS WORKSHEET
Self - Care
0 = Does Independently
3 = Training
1 = Reminding
4 = Complete Assistance
Eating
Safetly uses utensils, cups
Dressing
Buttons, zippers, etc.
Toileting
Grooming/Hygiene
Combs hair, shaves, teeth, menses care
Bathing
Safetly sets water temp, washes hair, body
2 = Observing/Guiding
0
1
2
3
4
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Receptive and Expressive Language
Expresses basic needs
o
Yes
o
No
o
Yes
o
No
o
Yes
o
No
o
Yes
o
No
o
Yes
o
No
Toileting, hunger, pain
Answers simple questions
How are you? Where is bathroom?
Relates personal experience when asked
What did you do today?
Understands basic questions
What is your name?
Understands simple 1-2 step directions
Stand up, put on your coat
Program: MACInitialIntake
Page 4 of 15
IDENTIFYING INFORMATION
NAME
CASE #
SSN
DOB
GENDER
Mobility
0 = Does Independently
3 = Training
1 = Reminding
4 = Complete Assistance
In-home transfers
Bed to chair, chair to sofa, etc.
Navigates essential areas of home
Entrances, doorways, stairs, bathroom
Neighbourhood mobility
Navigates within 1-2 block radius, crosses local streets, goes to homes, stores, etc.
Community mobility
Drives/arranges public transportation to and from locations essential to basic needs
2 = Observing/Guiding
0
1
2
3
4
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Self - Direction
0 = Does Independently
3 = Training
1 = Reminding
4 = Complete Assistance
Deciding what to eat
Makes basic food choices
Deciding what to wear
Weather appropriate
Structures time effectively
Engages in daily routine
Finds purposeful things to do
Engages in hobbies, social groups, excercises
Makes reasonable choices regarding long term plans
Future living arrangements, work/school goals, etc.
2 = Observing/Guiding
0
1
2
3
4
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Capacity For Independent Living
0 = No Support Needed
3 = Needs Physical Assistance
1 = Needs Reminding
4 = Cannot Do
Housekeeping
Laundry, vacumming, light cleaning, dishes, trash removal
Food preparation
Can prepare simple meal, e.g. sanwich, cereal, etc.
Budgeting and shopping
Aware of personal income, costs, where to buy goods
Home safety
Careful about household dangers, knows what to do in case of fire/tornado, calls 911
Community and safety laws
Avoids dangerous situations, follows traffic safety, respects laws and rights of others
Travelling in Community
Able to get to desired destination and return
Appropriate community behavior
Public behavior is appropriate diet, symptoms of illness and first aid
Monitors and recognizes health and diet issues
Knows health status, appropriate diet, symptoms of illness and first aid
Medication Administration
Caring for children
Program: MACInitialIntake
Page 5 of 15
2 = Needs Instruction
0
1
2
3
4
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
IDENTIFYING INFORMATION
NAME
CASE #
SSN
DOB
GENDER
Economic Self - Sufficiency
0 = Does Independently
3 = Training
2 = Observing/Guiding
1 = Reminding
4 = Complete Assistance
Maintains competitive employment
Handling money/purchasing
Paying bills/budgeting
0
1
2
3
4
N/A
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Information Sources
o
Self-Report
o
Family
o
Landlord
o
Roomate
o
Observation
o
Other:
Conclusions/Formulations About Support Service Needs/Desires Identified
CULTURAL CONSIDERATIONS
COMPONENTS OF CONSUMER'S CULTURAL IDENTITY
IMPACT
STRENGTHS
NARRATIVE
BARRIERS TO SERVICE
NARRATIVE
MENTAL STATUS
GENERAL BEHAVIOR
o Cooperative
o Passive
o Dramatic
o Hostile
o Agitated
o Withdrawn
o Restless
o Guarded
o Isolative
o Other:
SPEECH
o Unremarkable
o Pressured
o Soft
o Slurred
o Loud
o Immature
o Delusions
o Hallucinations
PERCEPTIONS
o Normal
THOUGHT PROCESS
o
o
o
o
Unremarkable
Associations
Grandiose
Rumination
o
o
o
o
Tangential
Obsessive
Circumstantial
Loose
o Delusions
o Ideas of References
o Paranoid
MOOD
o Normal
o Angry
o Apathetic
Program: MACInitialIntake
o Fearful
o Anxious
o Expansive
Page 6 of 15
o Dysphonic
o Euphoric
IDENTIFYING INFORMATION
NAME
CASE #
SSN
DOB
GENDER
JUDGEMENT
IF POOR, EXPLAIN
IMPULSE CONTROL
IF POOR, EXPLAIN
INSIGHT
SLEEP
APPETITE
MH TREATMENT HISTORY
PSYCHIATRIC AND SUBSTANCE ABUSE HISTORY
o Consumer Denies MH Treatment
SA TREATMEN HISTORY
o Consumer Denies SA Treatment
o No Family History
FAMILY HISTORY OF MENTAL ILLNESS AND SUBSTANCE ABUSE
FAMILY MEMBER
MI
o
o
o
o
o
o
SA
o
o
o
o
o
o
DIAGNOSIS (TEXT)
o No Abuse History
ABUSE HISTORY
PHYSICAL ABUSE
ONGOING
PAST
PS INVOLVEMENT
CURRENT
PS INVOLVEMENT PAST
EVER REPORTED
o Yes
SEXUAL ABUSE
o No
o Yes
NARRATIVE
Program: MACInitialIntake
Page 7 of 15
o No
IDENTIFYING INFORMATION
NAME
CASE #
SSN
DOB
GENDER
ASAM DIMENSIONS
Dimension 1: Alcohol Intoxication and/or Withdrawal Potential
Dimension 2: Biomedical Conditions & Complications
Dimension 3: Emotions/Behavioral Conditions and Complications
Dimension 4: Readiness to Change
Dimension 5: Relapse / Continued Use or Continued Problem Potential
Dimension 6: Social support system or significant others increase the risk of personal conflict about alcohol or drug use
ASAM RESULT
Level 0.5:
OMT:
Level I:
Level II.1:
Level II.5:
Level III.1:
Level III.3:
Level III.5:
Level III.7:
Level IV:
COMMENTS
SUBSTANCE ABUSE CHART
Key
Drug of Choice: 1 = First Choice - 10 = Last Choice
Number of Days used in the Last 30 Days:
0 = Not Used; 1-29 = No. of Days; 30 = Daily
Method Of Current Dosing:
1 = Oral; 2 = Smoking; 3 = Snorting; 4 = IV; 5 = Other
TYPE OF DRUG AND
NAME
Alcohol
Heroin
Methadone
Opiates
Barbiturates
Sedatives or Hypnotics
Tranquilizers
Benzodiazepines
GHB, GBL
Cocaine
Crack Cocaine
Methamphetamines
Program: MACInitialIntake
DRUG OF
CHOICE
AGE AT USE
FIRST
USE
PROBLEMATIC
USE
INIT.
RX
1) HEAVIEST AMOUNT
CONSUMED AND WHEN
2) CURRENT
CONSUMPTION
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
Page 8 of 15
DATE OF
LAST USE
NUMBER
OF DAYS
DRUG
USED IN
THE
LAST 30
DAYS
METHOD
OF
CURRENT
DOSING
IDENTIFYING INFORMATION
NAME
CASE #
SSN
Methcathinone
Hallucinogens
PCP
Marijuana/Hashish
Ecstasy (MDMA, MDA)
Ketamine
Inhalants
Antidepressants
Over-the-counter
Steroids
Talwin and PBZ
Other
ICD-9
Axis II
Axis III
DSM-IV
DIAGNOSIS
DESCRIPTION
Primary
Secondary
Tertiary
SA Primary
SA Secondary
Primary
Secondary
Primary
Secondary
Tertiary
Axis IV
Axis V
GENDER
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
1)
2)
Amphetamines
Axis I
DOB
o
o
o
o
o
Problem with primary support group
Problem related to social environment
Educational problems
Occupational problems
Housing problems
CURRENT GAF
o
o
o
o
o
Economic problems
Problem accessing healthcare
Problem related to interaction with legal system
Other psychological and environmental problems
Behavioral/personality problems
DATE
DIAGNOSTIC SUMMARY
DIAGNOSIS MADE BY
LAST UPDATE
CAFAS SCORE
PECFAS SCORE
SERVICE ELIGIBILITY CRITERIA (MI)
Program: MACInitialIntake
Page 9 of 15
IDENTIFYING INFORMATION
NAME
CASE #
SSN
DOB
GENDER
SERVICE ELIGIBILITY CRITERIA FOR ADULTS WITH MENTAL ILLNESS (MUST SERVE)
o A. Age 18 or over
o B. Has a serious mental illness based upon ANY ONE of the following combinations:
o A qualifying diagnosis and significant functional disability
o A qualifying diagnosis and certain prior service utilization
o A qualifying diagnosis and sufficient duration of the illness
o A non-qualifying diagnosis AND functional impairment AND sufficient
duration of illness AND prior service utilization
o
C. Substance use/abuse is not deemed to be the sole basis of psychiatric
symptomatology or need for treatment
QUALIFYING DIAGNOSIS
o Schizophrenic Disorders (Paranoid, Shizoaffective, Undifferentiated, etc)
o Major Depression
o Bipolar Disorder
o Psychosis NOS
o Dementia with delusions, dementia with depressed mood and/or dementia with behavioral disturbance
o Personality Disorder
NON-QUALIFYING DIAGNOSIS
o Panic Disorder without Agoraphobia
o Dysthymic Disorder
o Generalized Anxiety Disorder
o Depersonalization Disorder
o Conversion Disorder
o Hypochondriasis
o Dissociative Amnesia
o Body Dysmorphic Disorder
o Dissociative Fugue
o Somatization Disorder
o Panic Disorder with Agoraphobia
o Anorexia Nervosa
o Agoraphobia without history of Panic Disorder
o Bulimia Disorder
o Obsessive Compulsive Disorder
o Post Traumatic Stress Disorder
o Major Depression with 5th digit severity specifier of 1 or 2 (mild or moderate) or 5 (partial remission) or 6 (full remission)
DEGREE OF DISABILITY
o
personal hygiene and self-care
o
self-direction
o
activities of daily living
o
learning and recreation
o
social transactions and interpersonal relationships
In persons 55 or older, loss of functional capacity might also include:
o
loss of mobility
o
sensory impairment
o
physical stamina to perform activities of daily living or ability to communicate immediate needs as the
result of medical conditions requiring professional supervision
SUFFICIENT DURATION
o six continuous months of illness, symptomatology, and/or dysfunction, or six cumulative months of
sumptomatology/dysfunction in a 12 month period
--OR-o based upon current condition and diagnosis, there is a reasonable expectation that the symptoms/impairments will
continue for more than six months
--OR-o prior history of a severe mental illness (e.g., full criteria not met during the past year but has been met at some
previous time) with continued significant residual symptoms or impairments
Program: MACInitialIntake
Page 10 of 15
IDENTIFYING INFORMATION
NAME
CASE #
SSN
DOB
GENDER
CERTAIN PRIOR SERVICE UTILIZATION
o two or more admissions to a community psychiatric inpatient unit/facility in a calendar year
--OR-o community psychiatric inpatient hospital days of care in a calendar year exceeding 30 days
--OR-o state hospital utilization within the calendar year
--OR-o utilization of 20 or more outpatient mental health visits in a calendar year
DD PROXY MEASURES
DD PROXY ASSESSMENT DATE
NATURE OF SUPPORT SYSTEM
STATUS OF EXISTING SUPPORT SYSTEM
PREDOMINANT COMMUNICATION STYLE
ASSISTANCE FOR INDEPENDENCE NEEDED
Mobility Assistance (e.g. wheelchairs)
o Yes
o No
Medication Administration (administering, observing, etc)
o Yes
o No
Personal Assistance (bathing, dressing, etc)
o Yes
o No
Household Assistance (cooking, shopping, etc)
o Yes
o No
Community Assistance (transportation, money handling, etc)
o Yes
o No
HEALTH STATUS (LEVEL OF ASSISTANCE NEEDED)
VISION (BEYOND GLASSES)
HEARING (BEYOND HEARING AID)
OTHER PHYSICAL/MENTAL CHARACTERISTICS
ASSISTANCE FOR ACCOMMODATING CHALLENGING BEHAVIORS
o No Assistance Needed
o Moderate Assistance Needed
o Limited Assistance Needed
o Extensive Assistance Needed
COMMENTS
CHALLENGING BEHAVIORS
CHALLENGING BEHAVIORS ASSESSMENT DATE
Program: MACInitialIntake
Page 11 of 15
IDENTIFYING INFORMATION
NAME
CASE #
SSN
DOB
GENDER
BEHAVIOR FREQUENCY
For each behavior indicate how often the behavior occurs. Rate the behavior for the last year.
Property Damage (Breaking windows, furniture, tearing clothes, careless smoking etc.)
Fire Setting (Intentional)
Self Injurious Behavior (Hitting head against wall, cutting/biting self, excessive fluid intake)
Socially Inappropriate Undressing (Removing clothes in public when clearly inappropriate)
Physical Violence (Violent episodes involving attacks on others)
Inappropriate Sexual Behavior (Public masterbation, solicitation, touching, exposing self, etc.)
Temper Tantrums (Emotional outbursts, shouting, rage, pounding, kicking walls, etc.)
Distracting/Disruptive Behavior (Constant questioning, repetitive statments, plays TV/radio
too loud etc.)
Verbal Assaults (Use of offensive, threatening, profane, demeaning language toward others)
Running Away (Planned intent and action that leads to leaving residence)
Wandering Away (Unplanned leaving of residence due to confusion, etc.)
Homicidal Threats or Gestures (Seriously stated verbal intention/physical overture toward
killing someone)
Suicidal Threat (Seriously states verbal intention/physical overture toward killing themself)
Suicide Attempt
Stealing
Pica (Consumption of dangerous non-food items like paper, metal, dirt, etc.)
NOTES
Program: MACInitialIntake
Page 12 of 15
IDENTIFYING INFORMATION
NAME
CASE #
SSN
DOB
GENDER
ELIGIBILITY CRITERIA (DD)
Service Eligibility Criteria for Individuals with Developmental Disabilities (Must Serve)
Strict adherence to the Mental Health Code definition of developmental disability:
o
A. If applied to an individual older than 5 years, a severe, chronic condition that meets ALL of the following
requirements:
o 1. Is attributable to a mental or physical impairment or a combination of mental and physical
impairments.
o 2. Is manifested before the individual is 22 years old
o 3. Is likely to continue indefinitely
o 4. Results in SUBSTANTIAL FUNCTIONAL LIMITATIONS in 3 or more of the following areas of major life
activity:
o
o
o
o
o
o
o
a. Self-care
b. Receptive and expressive language
c. Learning
d. Mobility
e. Self-Direction
f. Capacity for independent living
g. Economic self-sufficiency
o 1) the individual has obtained SSI or SSD on the basis of a disability
--OR-o 2) school testing establishes that the individual is EMI or SMI and has an IQ of 69 or lower
--OR-o 3) a CMH psychologist confirms it through psychological testing
o 5.
o B.
Reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic
care, treatment, or other services that are of a lifelong or extended duration and are individually planned
and coordinated.
If applied to a minor from birth to age 5, a substantial developmental delay or a specific congenital or acquired
condition with a high probability of resulting in developmental disability as defined above if services are not
provided
SERVICE ELIGIBILITY CRITERIA (CHILD)
Service Eligibility Criteria for Children and Adolescents with Serious Emotional Disturbance - Age 7-17 (Must Serve)
o A. Qualifying Behavioral or Emotional Diagnosis/Disorder
o B. Substantial Functional Impairment/Limitation of Major Life Activities
o C. Sufficient Duration of Condition
QUALIFYING DIAGNOSIS
o 295 (all) Schizophrenia
o 296 (all) Major Depressive Disorder, Bipolar Disorder
o 300.4
Dysthymic Disorder, when coexisting with one additional Axis I or Axis II diagnosis, not including
alcohol or drug disorders, a developmental disorder or V code
o 297 (all) Delusional Disorder, Shared Psychotic Disorder
o 313.89
Reactive Attachment Disorder
o 302.6
Gender Identity Disorder - Child
o 302.85
Gender Identity Disorder - Adolescent
o 312.8
Conduct Disorder
o 313.81
Oppositional Defiant Disorder
o 307.23
Tourette's Disorder
o 307.7
Encopresis
o 307.6
Enuresis
o 314 (all) Attention-Deficit/Hyperactivity Disorder
Program: MACInitialIntake
Page 13 of 15
IDENTIFYING INFORMATION
NAME
CASE #
SSN
DOB
OTHER HIGH PRIORITY DIAGNOSIS
(not "must" serve, but serious consideration should be given when criteria are met for both substantial
function impairment and sufficient duration)
o 299.80
o
o
o
o
o
o
o
o
o
o
o
o
300.02
300.21
300.01
300.22
300.23
300.29
300.30
307.1
307.50
307.51
309.21
309.81
Asberger's Disorder
Anxiety Disorders:
Generalized Anxiety Disorder
Panic Disorder with Agoraphobia
Panic Disorder without Agoraphobia
Agoraphobia (without History of Panic Disorder)
Social Phobia
Specific Phobia
Obsessive-Compulsive Disorder
Anorexia Nervosa
Eating Disorder NOS
Bulemia Nervosa
Separation Anxiety Disorder
Posttraumatic Stress Disorder
SUBSTANTIAL FUNCTIONAL IMPAIRMENT
o Two or more elevated scores (rated at 20 or 30) on the eight CAFAS sub-scales of the Child/Adolescent
section below
--AND-o 1)
o 2)
A total impairment score sum = to or > 50 on the following 8 sub-scales:
School/Work
Home
Community
Behavior towards others
Moods/Emotions
Self-Harmful Behavior
Substance Use
Thinking
--OR-a total impairment score sum = to or > 40 on the following 5 sub-scales:
Role performance
Behavior towards others
Moods/Self-Harm
Substance Use
Thinking
SUFFICIENT DURATION OF CONDITION
o evidence of six continuous months of illness, sumptomatology, or dysfunction
--OR-o six cumulative months of symptomatology/dysfunction in a twelve month period
--OR-o on the basis of a specific diagnosis (e.g., schizophrenia), disability is likely to continue for more than one year
SERVICE ELIGIBILITY CRITERIA (IMH)
Referral Criteria
o
o
o
o
o
o
o
Reside in Macomb County
Infant residing with permanent primary caregiver
Finances/resources inadequate for meeting basic needs
First or second pregnancy
Infant 0-18 months at time of admission
No active substance/alcohol abuse
No open protective service cases unless infant has not been removed,
or if removed, reunification or adoption is imminent
o Willingness to participate: acknowledgement of concern for self & baby's well-being
Program: MACInitialIntake
Page 14 of 15
GENDER
IDENTIFYING INFORMATION
NAME
CASE #
SSN
DOB
GENDER
Mark the Following Based on Level of Concern
1 = Some Concern
2 = Moderate Concern
3 = Great Concern
1
2
3
N/A
o
o
o
o
o
o
o
o
o
o
o
o
Isolation
Lack of car or access to bus route; inability to use public transportation; dependence on
unreliable sources of transportation (people & vehicles)
Lack of Social Support
Adult relationships negative & stressful; no support from extended family & friends; lack of
knowledge about availability of community services
Parent / Infant Relationship is (or feared to be, if pregnant)
Negative, unresponsive, harsh, dyssynchronous, or enmeshed
RECOMMENDATIONS FOR CONTINUED TREATMENT
NARRATIVE
DISCHARGE PLANNING
SIGNATURE
Electronically Signed By
Date
SUPERVISOR SIGNATURE
Electronically Signed By
Date
PSYCHIATRIST SIGNATURE
Electronically Signed By
Program: MACInitialIntake
Date
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