Attachment 15 - Rcdmh Mhp Csi Data Collection - Riverside County Department Of Mental Health
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2Attachment 15
RCDMH MHP CSI DATA COLLECTION
Pg 1 of 2
(MH Admission / Admission Screen)
____________________________________________________________________________________________________________
Last Name
First Name
Middle Name
SFX, i.e., Jr., Sr., etc.
_____________________________________________
__________________________________________________
(Enter in CSI Admission
Screen)
Birth Name (If different from above)
Social Security Number
_____________________________________________
Mother’s First Name
(Enter in CSI Admission Screen)
Living arrangement:
Adult Res. Facility, Social Rehab Facility, Crisis Residential,
Inpatient psychiatric hospital, Psychiatric Health Facility (PHF),
Transitional Residential, Drug Facility, Alcohol Facility
or Veteran’s Affairs (VA) Hospital
Justice related (Juvenile .Hall, CYA home, correctional facility,
Board and Care
jail, etc.)
Community Treatment Facility
Mental Health Rehabilitation Center (24 hour)
Foster Family Home
Other
Residential Treatment Center (Includes Levels 13-14 for
Group Home (includes Levels 1-12 for children)
children)
Skilled Nursing Facility (SNF)/Intermediate Care
Homeless, No identifiable residence
Facility/Institute of Mental Disease (IMD)
House or apartment (Includes trailers, hotels, dorms, barracks,
State Hospital
etc.)
House or apartment and requiring daily support & supervision
Supported Housing (applies to adults only)
(applies to adults only)
House or apartment and requiring some support with daily living
Unknown/Not Reported
activities(applies to adults only)
Single/Never married
Separated
Divorced/Annulled
Married
Marital Status
Widowed
Unknown
Remarried
(MH Admission / Demographics Screen)
Employment Status
Full Time 32+ Hours A Week (Not including
Not in Labor Force - Retired
Part Time, less than
Armed Forces)
Part time, less than 35 Hrs Week
Full Time – 35 Hr or more per wk – Non-
Not in Labor Force - Student
Non-Comp
Comp
Not in Labor Force – Unable to Work Due to MH,
Unemployed – On Layoff From Job
In the Armed Forces
Developmental Disability, or A+D
Not in Labor Force – Due to Other Disorder or
Unemployed Seeking Employment
Not in Labor Force - Homemaker
Disability
Part Time (1-15 Hours A Week (Not including
Not in Labor Force – Other Not Seeking
Unknown
Armed Forces)
Employment in Past 30 Days
Part Time (16-32 Hours A Week Not Including
Not in Labor Force – Resident/Inmate of
Volunteer
Armed Forces
Institution
Occupation
Machine Operators and Tenders, except
Production Inspectors, Testers, Samplers,
Administrative Support including clerical
Precision
and Weighers
Mechanics and repairs
Professional Specialty
Construction Trade
Military Occupations
Protective Service Occupation
Executive, Administrative, and Managerial
Never Employed
Sales Occupation
Extractive Occupations
Svc Occupation except Protective and
Precision Production
Fabrication, Assemblers, and Hand-working
Household
Farming, Forestry, Fishing
Preschooler or Student
Technicians & Related Support
Handlers, Equipment Cleaners, Helpers, and
Private household
Transportation and Material Moving
Laborers
Unknown
Con fide ntial
Submit this form to ACT / CARES along with the Initial Assessment / Care Plan, Extension Request, or Quarterly Report
ACT Fax: 951 687-5819
or
CARES Fax: 951 358-5253
February 2012
Confidential Client Information – See CA W& I Code 5328
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