Attachment 15 - Rcdmh Mhp Csi Data Collection - Riverside County Department Of Mental Health Page 2
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2Attachment 15
RCDMH MHP CSI DATA COLLECTION
Pg 2 of 2
Name: ___________________________________________
SSN: ________________________________________
What is the consumer’s education level? _____
_____ 98=other
_____99=Unknown
(State numeric years i.e., 14= High School Grad + 2 additional years)
Smoker/Tobacco
Current every day
Current some days
Former Smoker
Never
Unknown
(Supplemental Screen)
Sexual Orientation
:
Heterosexual
Bi-Sexual
Gay
Lesbian
Questioning
Unreported
Does client self –identify as Transgendered
:
Yes
No
(CSIAdmission Screen)
Consumer’s Place of Birth (County only in CA)
____________________________________________________________________________________________________________
County
State
Country
Ethnicity:
Not Hispanic or Latino
Unknown /Not reported
Hispanic or Latino
Special Population:
Assisted Outpatient Treatment Service(s) (AB 1421)
(AB 3632) Individual Education Plan (IEP)
Governor’s Homeless Initiative (GHI) Service(s)
No Special Population Services
Welfare-to-work Plan Specified Service(s)
Is Substance Abuse Affecting Mental Health?
Yes
No
Unknown
Are Developmental Disabilities Affecting Mental Health?
Yes
No
Unknown
Are Physical Health Disorders Affection Mental Health?
Yes
No
Unknown
Conservator court status:
Temporary conservatorship (W&I Code, Section 5353)
Juvenile Court, Dependent of the Court (W&I Code, Section 300)
Lanterman-Petris-Short (W&I Code, Section 5358)
Juvenile Court, Ward- Status Offender (W&I Code, Section 601)
Murphy (W&I Code, Section 5008)
Juvenile Court, Ward- Juvenile Offender (W&I Code, Section 602)
Probate (Probate Code, Division 4, Section 1400)
Not applicable
PC 2974 (Penal Code, Section 2974)
Unknown, not reported
Representative payee without conservatorship (W&I Code, Section 5686)
Number of children less than 18 yrs of age that the client cares for/ is responsible for at least 50% of the time:
___
Number of dependent adult 18 yrs of age and above that the client cares for/ is responsible for at least 50% of the time:
___
Preferred Language
: ___________________________________________________
Race (select up to five from the choices listed below): _____________________________________________________
American Indian
Asian Indian
Black or African American
Cambodian
Chinese
Filipino
Guamanian
Hmong
Japanese
Korean
Laotian
Mien
Native Hawaiian
Other Asian
Other Pacific Islander
Other
Samoan
Unknown/Not Reported
Vietnamese
White
Is consumer an IRC consumer?
Yes
No
If so, IRC case worker’s name:___________________________________ Phone: _______________________
Provider name: ____________________________________________
Phone: _____________________________
Agency Name: ____________________________________________
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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