Delaware Department of Health and Social Services Division of Substance Abuse and Mental Health Consumer Reporting Form Training Manual October 2006 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, theINTRA-AGENCY TRANSFER REPORT and the PSYCHIATRIC DIAGNOSIS. Each ofthese forms is a two part carbonless document. The Admission and Discharge formsare each two pages long (both pages are carbonless two part documents). Allprograms, both mental health and substance abuse, will use the Admission andDischarge reports but only mental health programs are required to use the PsychiatricDiagnosis report. There are only slight differences between the Admission and Discharge reports. . On Page 1 Skills Training and School Participation have different codes. . On Page 2 there are different dates at the top of the form and the far right hand column is different. The reason for repeating so many items at discharge illustrates the major change inpurpose of these forms. In the past the Central Office of DSAMH was primarilyconcerned with statistics on how many people were in their programs. That concernhas been broadened. Not only are we concerned about how many people receivetreatment, but also how effective the treatment is. If a consumer is indicated as beingpotentially eligible for SSI on the Admission form and then eligible and receivingpayment on the Discharge form, we know that your program is fulfilling one of theprimary goals of the Division which is to facilitate the full use of entitlements by ourconsumers. If living arrangement and residential arrangement changes from alone andhomeless to lives with non-relatives in adult foster care or if employment goes fromunemployed-not looking to part time or volunteer, we know that you are meeting theDivision's goals for housing and employment of our consumers. The consumer MCI number is repeated on all sheets so that pages which becomeseparated 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 “notcollected”. Unknown is meant for those situations when you simply do not collect thisinformation. Its use is discouraged. For example, if your organization does notdetermine 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 blankaccidentally but in fact do not collect that information. Use the code for unknown forthose items that you ordinarily collect but which is missing for this one consumer. DSAMH maintains a 95% quality standard for CRF data. Each treatment unit willreceive a monthly report card indicating their score for data accuracy which can rangefrom 0 to 100. For instance, if your organization ordinarily collects date of birth but you don't have thatinformation for this consumer, fill it in with 07/07/77. Text fields can be filled with thewords "NONE", "UNKNOWN" or "NOT COLLECTED". Numbers are filled with 6 or 96for none, 7 or 97 for unknown, and 8 or 98 for not collected. Dates are coded 06/06/66for none, 07/07/77 for unknown, and 08/08/88 for not collected. In alpha coded fields, Zis always not collected, U is always unknown, N is usually none, not applicable, or no butmay occasionally mean something more specific to the question such as “Not of HispanicOrigin” 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. Forsections of the form where only a two character century date is allowed, you shouldenter 06/06/66, 07/07/77 and 08/08/88. Generally the codes "NOT COLLECTED" and “UNKNOWN” should not be used forrequired 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 anorganization that usually resides at a single location(which it may share with other organizations) and is anidentifiable cost center. A distinguishing characteristicof treatment units is that consumers do not movereadily between them and the organization usuallyrequires that some transfer paperwork be generatedfor such a move. Each treatment unit may offer avariety of services such as group therapy, job skillstraining, etc. such that every consumer in the unit maynot receive exactly the same mix of services. Consumers may, in fact, receive services from morethan one treatment unit simultaneously. The key tothis definition is the organization's perception of thatorganizational unit has responsibility for the treatmentof 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 aMental Health consumer, an Alcohol / Drugconsumer, or as a Co-Occurring (MH & AD) consumer. Some treatment units will have all MHconsumers, some all AD consumers, some all Co- Occurring consumers, or some a combination. [ ] MH Mental Health [ ] AD Alcohol / Drug [ ] DU Co-Occurring (MH & AD) [ ] GA Gambling Must be the same for admission and discharge forms. Street (Optional) Consumer's address City (Optional) State (Optional) 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 The date of admission to a DSAMH funded Treatment Date Unit. If a client is being transferred from a Non-DSAMH funded unit to a DSAMH funded unit, use the date of thetransfer, not the original program admission date. No futuredates 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 isfurther 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 aboutan individual’s race and ethnicity, except in instances where observer identification ismore practical (e.g., completing a death certificate).” “do not tell an individual who he or she is, or specify how an individual should classifyhimself 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 aredefined as follows: American Indian orAlaskaNative. A person having origins in any of the original peoples of North and South America (including Central America), and who maintainstribal affiliation or community attachment. Asian. A person having origins in any of the original peoples of theFar 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 groupsofAfrica. Terms such as ``Haitian'' or ``Negro'' can be used in addition to ``Black orAfrican American.'' Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, Cuban, South orCentral 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 theoriginal peoples ofHawaii, Guam, Samoa, or other PacificIslands. White. A person having origins in any of the original peoples of Europe, the MiddleEast, orNorth Africa. Marital Status. (NOTE: Co-habitation is indicated under Living Arrangement.) 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 housing type where the client lives) PU Private house or residence - Unsupervised PS Private house or residence - Supervised FC adult Foster Care BH Boarding House/Single Room Occupancy (SRO), YMCA GU Group setting/community residence - Unsupervised GS Group setting/community residence - Supervised 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 housingarrangement, not supervision of the consumer in their residence by an unrelatedCommunity 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 Veteran status – any active military service Y Yes N No U Unknown Primary Health Insurance The consumer's primary health insurance carrier; choose only one. If the consumer has more than one, chose theone most likely to pay for the majority of the services yougive that will be paid for by any insurance. (Check theappropriate insurance carrier even if they will only pay forlimited 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 3 Education – Write in the Highest Grade Completed 01-08 Completed first through Eighth respectively 09 Completed Freshman year of High School 10 " " Sophomore year of High School 11 " " Junior year of High School 12 " " Senior year of High School -or- (GED) 13 " " Freshman in College/9 months-1 yr. post secondary 14 " " Sophomore in College/2 yrs. post secondary 15 " " Junior in College/3 yrs. post secondary 16 " " Senior in College/4 yrs. post secondary 17 " " Graduate school at the masters level 18 " " Graduate school at the Ph.D./MD. level 19 " " Post doc. work 96 never completed any grade higher than preschool or kindergarten 97 unknown 98 not collected NOTE: Post secondary programs that last less than a year should not be counted. Ifthe person completed his senior year of high school and then 6 months of technicaltraining, they would still be coded as 12. If he spent 9 months to a year in training, hewould be coded as a 13. If the person completed 9th grade but no more and later gotinto a specialized training program, the highest grade they completed is still consideredto be 9th and should be coded as 09. Obviously this scheme cannot cover the many ways a person may acquire aneducation. Your judgment as to their level of accomplishment will have to be the finaldeterminant. Skills Training Participation Is or was the consumer in job skills training? C Current Involvement F Finished during treatment (discharge only) D Dropped out during treatment (discharge only) N None U Unknown School Participation Is or was the consumer in school? C Current Involvement F Finished during treatment (discharge only) D Dropped out during treatment (discharge only) N None U Unknown Primary Employment During The Past 30 Days The consumer's current primary employment or source of earned income during the past 30 days. Ifthere is no earned income, use their primary dailyactivity. If they are a student and work part time, mark part time here and student under secondaryemployment. If they are a student and don't work, mark student here and secondary employment asnone. F Full time (37.5 hours a week or more) P Part time (less than 37.5 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 Secondary Employment During The Past 30 Days The consumer's current secondary employment or source of earned income during the past 30 days. If there is no earnedincome, use the primary employment field to indicate thestatus and mark this field as none. If they are a student andwork part time, mark student here and part time under primary employment. If they are a student and don't work, mark student under primary and this field becomes none. P Part time (less than 37.5 hours per week) M Military Armed Forces, active duty (active reserves, reserves) S Student V Volunteer 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 SI SSI SD SSDI VD VA - Disability VR VA - Retirement UI Unemployment Insurance IL ILlegal E Employment S Spouse F Family/friends A TANF (Temporary Assistance to Needy Families - formerly AFDC) G General assistance P Pension/retirement income (IRA, KEOGH, SEP, ESOP) W Workman's comp. D private Disability insurance I Investments/savings O Other N None U Unknown Consumer’s Gross See Consumer’s Primary Source of Income. Take Income per Year 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 Number Dependent See Consumer’s Primary Source of Income. Report on Consumer’s Income an average number if the consumer’s dependents vary regularly. 01 - 20 97 unknown Substance Abuse – Designated Codes Only This is completed by A&D treatment DSM-IV-TR Diagnosis programs only. Enter up to three Axis I: Clinical Disorders substance abuse DSM-IV-TR diagnosis codes / and Gambling code asappropriate. The most important Axis Idiagnosis should be written first. Thecode is 3 digits or the letter V followed by 2 digits, decimal point, 2 digits. Use the DSM-IV-TR manual forcorrect 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 Currently Pregnant Y Yes N No U Unknown Injection Drug Use Ever (History of needle use to consume illicit drugs in lifetime) Y Yes N No U Unknown Alert Information MARK ALL THAT APPLY WITH AN "S" FOR SELF REPORT OR A "C" FOR CLINICIAN REPORT. Admissioninformation is assumed to be by consumer report. If aclinician has confirmed the information, you may indicatethat by writing a C in the [ ]'s. At discharge, the informationis assumed to be by clinician's report. If a clinician has notconfirmed the information, indicate this by writing an S (forSelf report) between the [ ]'s. S Yes - Self Report C Yes - Clinician Report N No U Unknown - not collected for this consumer Z Not Collected for any consumer TB Active TB History History of substance abuse (may or may not have been treated) History of mental illness (may or may not have been treated) Psychiatric disability (may or may not be designated as disabled by the CMHC) None of the above 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 thesame as the admission date. Contact may have been by phone or face-to-face but waswith the consumer himself, not a third party. No future dates and no unreasonably olddates are allowed. 06/06/66 none 07/07/77 unknown Page 2 of Admission & Discharge Forms - Common Items - Column 1 Alcohol & Drug Use Matrix This information is required from both mental health and substance abuse providers. The codes appear inthe box surrounding the matrix. The Primary column isfor the drug deemed the primary cause of problems forthe user. If the consumer does not have a drug oralcohol problem, place an N (none) in the SubstanceType under each column heading, Primary, Secondary, Tertiary, and draw a line down through theremaining boxes in each column, Frequency of Use, Route of Administration, Age of First Use. This itemdoes not apply to drugs given legally for therapeuticreasons. 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-likeeffects.) 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) andKetamine (Special K) here} BE BEnzodiazepine (This includes Diazepam, Flunitrazepam (Rohypnol), Flurazepam, Chlordiazepoxide, Clorazepate, Lorazepam, Alprazolam, Oxazepam, Temazepam, Prazepam, Triazolam, Clonazepam andHalazepam.) 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 Z not collected 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 Z not collected 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 Z not collected Age of first use -1 newborn/addicted at birth 1 - 95 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 Previous treatment for mental health at any treatment unit during lifetime Y Yes N No U Unknown Previous alcohol and/or drug abuse treatment at any treatment unit during lifetime (This does not include AA/NA etc.) Y Yes N No U Unknown Source/Agency Code This is the number for the agency that referred the consumer to you. The five character code comes fromthe Referral Agency List. This code list will be updatedquarterly. As you identify agencies that are not on thislist, we would appreciate it if you contact the MIS unitof DSAMH (577-4460). In the meantime, you shouldbe able to use the more generic major category, suchas 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? (The expanded federal definition is - Participation in social support of recovery activitiesis defined as attending self-help group meetings, attending religious/faith affiliatedrecovery or self help group meetings, attending meetings of organizations other than theorganizations described above or interactions with family members and/or friendssupportive of recovery - Source the 2007 SAPTBG application package (Measure T6)). Y Yes N No U Unknown Page 2 of Admission Form - Column 3 Presenting problem Presenting problem is the problem deemed most significant or the major reason for the person seekinghelp. List the three top problems at time of admission, starting with the primary problem. 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 numberingsystem 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 unreasonablyold 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. Atreatment unit is defined as a unit which provides treatment or prevention services to aconsumer population. It typically has an identified location(s), dedicated staff and aseparate budget or cost center. An Agency may have one or more Programs whichoperate one or more Treatment Units. Examples of a treatment unit include adetoxification 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 Functioning improved Answer "YES" if the consumer's functioning, based on the substance abuse or mental health problem for which theywere admitted, improved during the course of treatment? Answer "NO" if the consumer's functioning remained thesame or worsened. Y Yes N No U Unknown Was the Consumer's drug dependence reduced? Answer "YES" if the consumer's dependence on or abuse of drugs and/or alcohol lessened during the course oftreatment. Answer "NO" if the dependence remained thesame or worsened. DEPENDENCE is defined as the stateof being determined, influenced, or controlled by somethingelse (e.g. drugs & alcohol). 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. TheReferral Agency List is now available on the DSAMHweb 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 AgencyList. This code list will be updated quarterly. As you identifyagencies that are not on this list, we would appreciate it ifyou contact us. In the meantime, you should be able to usethe more generic major category. The Primary agencyshould be the one you transferred the consumer to or the one that will have the most to do with the consumerscontinued treatment. Enter N followed by four blanks fornone 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, andcontinues his/her treatment in another program by referral, complete the CRF asfollows... 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 completetreatment, 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, allA&D CTT 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 forcorrect 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 diagnosisis the condition that was chiefly responsible for occasioning the evaluation or admissionto clinical care. In most cases this condition will be the main focus of attention ortreatment. The principal diagnosis may be an Axis I or an Axis IIdiagnosis..." (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) (text) [ ] Problems related to the social environment (Specify) (text) [ ] Educational problems(Specify) (text) [ ] Occupational problems(Specify) (text) [ ] Housing problems(Specify) (text) [ ] Economic problems(Specify) (text) [ ] Problems with access to health care services(Specify) (text) [ ] Problems related to interaction with the legal system/crime(Specify) (text) [ ] Other psychosocial and environmental problems (Specify) (text) 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 their 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.