Dane County Mental Health Consumer Status Data Form
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2DANE COUNTY MENTAL HEALTH CONSUMER STATUS DATA FORM – 2014*
Last Revised April, 2014
Client: County ID #: ____________________________ Last ____________________________ First ______________________________ M.I. ___
Agency _______________________________________
County Program # _________________________
Report Date ____/____/____
County of Residence (if not Dane) _____________________________
Referral Source (see codes on page 2) ______
Staff Initials ______
Legal/Commitment Status (circle 1 code)
Living Arrangement (circle 1 code)
1.
None (voluntary involvement)
1.
Street, shelter, no fixed address, homeless
2.
Settlement Agreement
2.
Private residence or household; living alone or with others without
3.
Involuntary Civil - Chapter 51
supervision; includes persons age 18 and older living with parents
4.
Involuntary Civil - Chapter 55
(ADULTS ONLY)
5.
Involuntary Criminal
3.
Supported residence (ADULTS ONLY)
6.
Guardianship Only
4.
Supervised licensed residential facility
9.
Unknown
5.
Institutional setting, hospital, nursing home
6.
Jail or correctional facility
Presenting Problem(s) (circle up to 3 codes)
7.
Child under age 18 living with biological or adoptive parents
1.
Marital / Family
8.
Child under age 18 living with relatives, friends
2.
Social / Interpersonal
9.
Foster Home
3.
Coping with daily roles and activities
10. Crisis stabilization home/center
4.
Medical / Somatic
11. Other living arrangement
5.
Depressed mood / Anxious
99. Unknown
6.
Attempt, threat or danger of suicide
7.
Alcohol
Employment Status (circle 1 code)
8.
Drugs
1.
Full-time competitive
9.
Not in the labor force - jail,
9.
Involvement with Criminal Justice System
employment (35 or more
correctional or other
10. Eating disorder
hours/week)
institutional facility
11. Disturbed thoughts
2.
Part-time competitive
10. Not in the labor force -
12. Victim of Abuse, Assault or Rape
employment (less than 35
sheltered non-competitive
13. Runaway behavior
hours/week)
employment
14. Emergency detention
3.
Unemployed (but looking for
11. Not in the labor force - other
99. Unknown
work in past 30 days)
reason
5.
Not in the labor force -
12. Supported competitive
BRC Target Population (circle 1 code)
homemaker
employment
H - Need Ongoing, High Intensity, Comprehensive Services
6.
Not in the labor force –
98. Not applicable - Children 15
L - Need Ongoing, Low Intensity, Comprehensive Services
student
and under
S - Need Short-term Situational Services
7.
Not in the labor force –
99. Unknown
retired
Principal/Primary Diagnosis (ICD-10): _____________________________
8.
Not in the labor force -
Effective October 1st, 2015, all service authorizations with a start date
disabled
on October 1, 2015 or later will need to use the ICD-10 diagnosis codes.
Services authorizations that started prior to October 1 will use the ICD-9
Daily Activity (circle up to 3 codes)
diagnosis codes.
1.
No educational, social or planned activity
If BRC Target Population is "S", stop here. If
2.
Part-time educational activity
BRC is H or L, the entire form must be filled.
3.
Full-time educational activity
4.
Social activity
5.
Volunteer or planned activities
6.
Other respected status
Psychosocial & Environmental Stressors (circle 1 code)
9.
Unknown
0 - Inadequate Information
4 – Severe
1 - None
5 – Extreme
Criminal Justice System Involvement within the last 6 months (circle up
2 - Mild
6 - Catastrophic
to 4 codes)
3 - Moderate
1 - None
5 - On parole
2 - On probation
6 - Juvenile Justice System
3 - Arrest(s)
9 - Unknown
Health Status (circle 1 code)
4 - Jailed / Imprisoned
1 - No health condition
5 - Unstable / Incapable
2 - Stable / Capable
6 - New Symptoms / Capable
Number of Arrests in the Past 30 Days (circle code AND enter number)
3 - Stable / Incapable
7 - New Symptoms / Incapable
0-98 Number of arrests ______
4 - Unstable / Capable
9 - Unknown
99
Unknown
Suicide Risk (circle 1 code)
Number of Arrests in the Past 6 Months (circle code AND enter number)
1 - No risk factors
3 - High potential for suicide
0-98 Number of arrests ______
2 - Presence of risk factors
9 - Unknown
99
Unknown
MH Consumer Status | Page 1
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