This Mississippi Department of Mental Health record guide establishes documentation requirements for all community providers certified by DMH across mental health, intellectual/developmental disabilities, and substance use disorder service lines. Operators must maintain a single case record per individual containing mandatory data elements, completed within specified timelines, and meeting DMH Operational Standards for record-keeping. The guide covers forms for intake, assessment, service planning, progress notes, crisis support, and administrative functions across a broad range of community-based service types including partial hospitalization, crisis stabilization, IDD waiver services, therapeutic foster care, and substance use disorder services.
View official sourceDepartment of Mental Health
Record Guide
For
Mental Health, Intellectual and Developmental Disabilities,
and Substance Use Disorders Community Providers
2016 Revision
Mississippi Department of Mental Health
Diana S. Mikula, Executive Director
239 North Lamar Suite 1101
Jackson, MS 39201
DMH Record Guide Contents i
TABLE OF CONTENTS
Section A – General Information Page 1
Section B – All Records Page 5
Face Sheet
Consent for Receive Services
Rights of Individuals Receiving Services
Acknowledgment of Grievance
Consent to Release/Obtain Information
Medication/Emergency Contact Information
Section C – Required for All Mental Health and Substance Use Page 21
Records
Initial Assessment
Trauma History
Individual Service Plan
Individual Crisis Support Plan
Recovery Support Plan
Progress Note
Weekly Progress Note
Periodic Staffing/Review of the Individual Service Plan
Readmission Assessment Update
Substance Use Disorder Specific Assessment
Section D – As Needed for All Records Page 57
Initial Assessment and Crisis Contact Summary
Serious Incident Report
Medical Examination
Documentation of Healthcare Provider Visit
Self-Administration Medication Log
Telephone/ Visitation Agreement
Search & Seizure Report
Physical Escort Log
Time Out Log
Seclusion Behavior Management Log
Service Termination/Change Summary
Provider Discharge Summary
Section E – Day Service Programs Page 87
Acute Partial Hospitalization Services Summary Note
Individual Recovery Action Plan
Section F – Mental Health Services Page 93
DMH Record Guide Contents ii
Adult Making A Plan (AMAP) Case Summary
Adult Making A Plan (AMAP) Monthly Report
Crisis Stabilization Services Daily Note
Adult Pre-Evaluation Screening
Youth Pre-Evaluation Screening
Violence Risk Assessment for Certified Holding Facility
Suicide Risk Assessment for Certified Holding Facility
Section G – Alzheimer’s and Other Dementia Services Page 118
Life Story Narrative
Section H – Children and Youth Services Page 126
Therapeutic Foster Care Contact Log
MAP Team Report
MAP Team Case Summary
Wraparound Facilitation Individual Support Plan
Section I – Intellectual/Developmental Disabilities Services Page 144
IDD Plan of Services and Supports
IDD Activity Support Plan
IDD Service Note
IDD Weekly Service Note
ID/DD Waiver / IDD CSP Service Authorization
ID/DD Waiver Home and Community Supports Service Agreement
ID/DD Waiver In-Home Respite Service Agreement
ID/DD Waiver In-Home Nursing Respite Service Agreement
ID/DD Waiver In-Home Nursing Respite Service Note
IDD Employment Profile
ID/DD Waiver Job Discovery Profile
ID/DD Request for Behavior Support and/or Crisis Support Services
ID/DD Waiver Medical Verification for BS/ CI Services
ID/DD Waiver Functional Behavior Assessment
ID/DD Waiver Behavior Support Plan
ID/DD Justification for Behavior Support Services
ID/DD Waiver Behavior Support Quarterly Review Report
ID/DD Waiver Request for Additional Behavior Support Services
ID/DD Waiver Request for Additional Crisis Support Services
ID/DD Waiver Request for Crisis Intervention Services
ID/DD Waiver Crisis Intervention Plan
ID/DD Waiver Crisis Intervention Daily Service Note
ID/DD Waiver Crisis Intervention Log- Episodic
ID/DD Waiver Request for Additional Crisis Intervention Services
Section J – Substance Use Disorder Services Page 240
Risk Assessment Interview and Educational Activities for TB/HIV/STD
DMH Record Guide Contents iii
Substance Abuse Monthly Capacity Management & Waiting List Reports
Section K – Administrative Information Page 249
Disaster Preparedness and Response Guidance
Disaster, Fire, and COOP Drills for All Programs
DMH Plan of Compliance Template
Staff Verification of Training on Suspected Abuse or Neglect Reporting
Section A
General Information
DMH Clean 2016 Record Guide Purpose & Guidance
2016 DMH Operational Standards Record Guide
Purpose
Documentation required in the Mississippi Department of Mental Health (DMH) Record Guide
serves as one of the methods for planning and evaluating services and supports provided by
agencies and providers certified by the DMH. The intent of the record system outlined in this
guide is to help ensure compliance with the DMH Operational Standards.
The emphasis of this Record Guide is on guidance needed to satisfy any and all
documentation requirements referenced in the DMH Operational Standards or otherwise
needed to ensure documentation of all services provided by agencies certified by DMH.
Because of the DMH mandatory data collection and reporting requirements, along with the
increasing use of electronic record keeping that many providers are implementing, the need
to maintain paper forms is declining. This guide seeks to describe the type and amount of
documentation that is necessary and provide a sample of a format with all information
needed to satisfy the DMH record keeping requirements.
Additional information may be added and the appearance of the form may be changed
by the local provider. However, if required data or information is deleted in the process of
modifying the form, it will no longer satisfy DMH Operational Standards for record keeping.
General Information
A single case record must be maintained for all individuals served by the agency/provider and
must contain specific mandatory data and information. Additional data or information may be
included to ensure that sufficient information is maintained to protect the privacy of all
individuals receiving services. Two years of documentation must be maintained in the active
record. All completed documentation should be present in the individual’s record no later than
the 10
th day of the following month the service was delivered unless more stringent timelines
are required by DMH.
The Record Guide is divided into sections that allow the user to identify those forms or data
tools required for all individual records, those that are used when the circumstances of the
individual receiving services dictates their use, those that are specific to an area of service,
and those that are administrative documentation that is not maintained in an individual’s
record.
Each form has specific guidance that states the purpose of the form/data tool. Also included
in the guidance are references to the DMH Operational Standards and specific information
regarding the nature and purpose of all forms/data tools.
References to “days” in the Record Guide mean calendar days.
Any section or area of a form that is not applicable must contain a strikethrough line that
clearly indicates the item was not overlooked or omitted and that it does not apply to the
individual receiving services.
DMH Clean 2016 Record Guide Purpose & Guidance
Signatory Authority
Signatures are necessary to verify that information has been correctly and thoroughly shared
with individuals receiving services. Signatures are also necessary to create a legally binding
document. Forms in the Record Guide require signatures necessary for proper authorization
of a particular form. Each signature line provided is clearly marked as to who is expected to
sign. All signature lines on all forms must either be signed or marked as “not applicable” if
that is the correct response. For example, all of the signature lines provided may not be
necessary to document the individuals who participated in development of the Individual
Service Plan or the Periodic Staffing/Review of the Individual Service Plan.
Electronic signatures are allowed on any form in the Record Guide.
Signature of the Individual Receiving Services
The individual receiving services must sign for himself or herself unless one of the following
conditions applies or is present:
1. The individual is under 18 years of age.
2. A legal representative has been appointed for the person by a court of competent
jurisdiction.
3. If a person cannot physically sign or is not mentally/cognitively able to understand the
form, a parent or next of kin can sign if they indicate they are signing as such.
Physical, mental or cognitive ability to sign and understand the form must be
determined by a medical doctor or psychologist. Documentation must be maintained in
the record.
Signature of Individual Authorized to Give Consent or Sign in Lieu of the
Individual Receiving Services
If one of the conditions stated above applies and the person is unable to sign for himself or
herself, the person who is authorized to give consent or sign in lieu of the individual must sign
the form(s). If the individual is under 18 years of age, this authorized representative is the
parent unless a court ordered (legal) guardian or a conservator has been appointed for the
child/youth. If the individual receiving services, regardless of his/her age, has a court ordered
(legal) guardian or a conservator, the guardian/conservator must sign all forms on behalf of
the individual receiving services. In the case of a court ordered (legal)
guardian/conservator, a copy of guardianship/conservatorship papers must be
maintained in the record.
The legal guardian or conservator of an individual receiving service(s) must review and
sign the paperwork required in order for an individual to receive services.
Should the individual’s legal guardian or conservator choose to delegate his/her
responsibility and signatory authority to another individual for the completion of daily
paperwork (including delegating signature authority to the individual being served), DMH
will accept the signature of that individual. The legal guardian or conservator must
provide written documentation of such delegation and to whom the signatory authority
is being delegated. This must be maintained in the individual’s record. Daily signature
DMH Clean 2016 Record Guide Purpose & Guidance
authority cannot be delegated to the service provider. However, the legal guardian or
conservator must continue to sign annual paperwork, such as the Consent for Services and
Individual Service Plan.
Signature of Witness/Credential
In the case of some DMH documentation, a witness must sign in order to verify that the
signature(s) are valid, particularly if a person is signing in lieu of the individual receiving
services. Forms requiring the signature of a witness will have a signature line provided for
the witness. This requirement will be reflected in the guidance for that particular form.
If an individual signs with a mark or an “X,” the signature of a witness is required. If the form
does not include a line for a witness, the witness will sign next to the mark or “X.”
If the witness is an employee of the facility or program, he/she must include his/her
credentials or position.
Billing
All questions concerning billing should reference the funding source. Questions concerning
Medicaid billing should reference the Medicaid Guidelines issued by the Division of Medicaid,
Office of the Governor.
Section B
Required For All
Records
Face Sheet
Consent to Receive Services
Rights of Individuals Receiving Services
Acknowledgment of Grievance Procedure
Consent to Release/Obtain Information
Medication/Emergency Contact Information
DMH Face Sheet guidance
Face Sheet
Purpose
The Face Sheet contains relevant data and/or personal information necessary to readily identify
the individual receiving services. Information on the Face Sheet is used for routine service
provision activities such as scheduling, billing, and reference.
Timeline
The Initial Face Sheet must be prepared at admission as part of the intake process. The Face
Sheet must be updated whenever information or data changes and/or at least annually. When
changes in information or data are made, or at the annual update, a new/corrected Face Sheet
must be dated and placed in the individual record.
Face Sheet Information
Each DMH certified provider must maintain current and accurate data for submission of all
reports and data as required by DMH. The Face Sheet can be generated as a report by the
agency’s database system once all the data has been entered into the agency’s system.
Depending on the specific data collection and reporting system that the agency uses, additional
personal information may have to be added to complete the Face Sheet. The Face Sheet must
contain all 44 data elements required in the DMH Manual of Uniform Data Standards.
The required elements of the Face Sheet are provided on the following page. Providers should
reference the DMH Manual of Uniform Data Standards for applicable codes and should consult
with the agency employee responsible for data submission. Providers can also contact DMH
Division of Information Services for additional guidance, 601-359-1288.
DMH Face Sheet Required Elements
Required Data Elements for Face Sheet
1. Record transaction type (add, change, delete)
2. Organization code
3. Unique client ID within organization
4. Client status
5. Admission date (most recent) to organization
6. Admission type (primary, collateral, unregister)
7. Admission referral category
8. Admission referral organization code (referrals to/from a DMH operated program
only)
9. Legal status of client at admission
10. Client last name
11. Client first name
12. Client maiden name (if applicable)
13. Social Security Number (unique client identifier)
14. Birth date
15. Age of client (calculated from birth date)
16. Sex
17. Race
18. Hispanic origin
19. Education level: last grade completed
20. Marital status
21. County of residence prior to admission
22. Living arrangement
23. Type of residence
24. Employment status - Include place of employment if applicable.
25. Primary source of household income
26. Household annual income amount
27. No. of persons in household dependent on income
28. Is the individual pregnant?
29. Eligibility for SSI/SSDI
30. Eligibility for Medicaid
31. Expected principle source of payment
32. Veterans status
33. Physical impairment (1 of 2)
34. Physical impairment (2 of 2)
35. Presenting problem (1 of 2)
36. Presenting problem (2 of 2)
37. Treatment category (MH, MR, SA, dual)
38. Primary treatment category (if dual)
39. Is client seriously mentally ill (Y/N)
DMH Face Sheet Required Elements
40. Is client seriously emotionally disturbed child?
41. Medicaid number
42. State ID (generated by CDR upon 1st submission)
DMH Clean 2016 Consent to Receive Services Guidance
Consent To Receive Services
Purpose
In addition to all rights of individuals receiving services, each individual must provide his/her
consent to receive services from the agency.
Time Line
Individuals receiving services must be informed of and consent to services at the time of the
admission and before services are provided.
Individuals must provide their consent for services at least annually, on or before the
anniversary date of the current consent, as long as the individual continues to receive services.
For ID/DD Waiver Support Coordination Services, individuals must provide their consent for
services at least annually, before the end of the person's certification period
For IDD providers, individuals must provide their consent at the time the Activity Support Plan is
developed and annually thereafter.
Consent to Receive Services
This section can be read by, or if necessary, read to the individual receiving services and/or a
person who is legally authorized to act on his/her behalf. In either case, the Consent To
Receive Services and the limits of confidentiality must be clearly explained to the individual
receiving services and/or a person authorized to act on his/her behalf.
Signatures
If the individual receiving services is unable to sign and the form is being signed by a court
ordered (legal) guardian/conservator, a copy of guardianship/conservatorship papers must be
maintained in the record.
The Consent to Receive Services, Rights of Individuals Receiving Services and
Acknowledgment of Grievance forms can be combined into one document as long as space is
included in the document for signature or initials of the individual receiving services or legal
guardian to acknowledge each separate action.
Clean 2016 Consent to Receive Services form
Consent To Receive
Services
Name
ID Number
Service(s)
The information which I have provided as a condition of receiving services is true and complete to
the best of my knowledge. I consent to receive services as may be recommended by the
professional staff. I understand the professional staff may discuss the services being provided to
me, and that I may request the names of those involved. I further understand that my failure to
comply with therapeutic recommendations of the professional staff may result in my being
discharged.
I understand that I have the freedom of choice to receive services in a setting that is integrated in
and supports full access to the greater community; and is a setting that facilitates individual choice
regarding services and supports, and who provides them.
I understand that State and federal laws and regulations prohibit any entity receiving confidential
information from redistributing the information to any other entity without the specific written
consent of the person to whom it pertains or as otherwise permitted by law and regulations.
I understand that confidential information may be released without my consent when necessary for
continued services; when release is necessary for the determination of eligibility for benefits,
compliance with statutory reporting requirements, or other lawful purpose; if you communicate to
the treating physician, psychologist, master social worker or licensed professional counselor an
actual threat of physical violence against a clearly identified or reasonably identifiable potential
victim or victims; in compliance with reporting requirements under state law of incidents of
suspected child abuse or neglect, or by court order.
Individual/Legal Representative Signature Date
Staff Signature/Credentials Date
DMH Clean 2016 Rights of Individuals Receiving Services guidance
Rights of Individuals Receiving Services
Purpose
Each individual who receives services from a DMH certified agency or provider has legal,
ethical, and privacy rights that must be protected. DMH certified agencies must maintain
documentation showing each individual who receives services has been informed of these
rights. This document also informs the individual receiving services of legal circumstances in
which the provider will be required to release information concerning his/her treatment/services.
After the individual receiving services has been informed of his/her rights, the individual is then
offered the opportunity to consent to receive services.
Time Line
Individuals receiving services must be informed of his/her rights during the admission process
and before services are provided.
Individuals must be informed of his/her rights at least annually, on or before the anniversary
date of the current form, as long as the individual continues to receive services.
For ID/DD Waiver Support Coordination Services, individuals must be informed of their rights at
least annually, before the end of the person's certification period
For IDD providers, individuals must be informed of their rights at the time the Activity Support
Plan is developed and annually thereafter.
Intake/Admission Date
The intake/admission date is the original date of intake/admission to the service. This date
remains the same from year to year as long as the person is continuously enrolled in the
service.
Rights
The rights can be read by, or if necessary, read to the individual receiving services and/or to a
person who is legally authorized to act on his/her behalf. The rights must be clearly explained
to the individual receiving services and/or a person authorized to act on his/her behalf. The
individual must be offered a copy of the form to take with them. Signed documentation of
receipt must be maintained in the record. Providers may omit #18-22 if those service types are
not provided by the agency.
The Consent to Receive Services, Rights of Individuals Receiving Services and
Acknowledgment of Grievance forms can be combined into one document as long as space is
included in the document for signature or initials of the individual receiving services or legal
guardian to acknowledge each separate action.
Clean 2016 Rights of Individuals Receiving Services form
Rights of Individuals
Receiving Services
Name
ID Number
I, began receiving services provided by
Name Name of Provider
on and have been informed of the following:
Intake/Admission Date
1. My options within the program and of other services available
2. The program’s rules and regulations
3. The responsibility of the program to refer me to another agency if this program becomes unable to serve me or
meet my needs
4. My right to refuse treatment and withdraw from this program at any time
5. My right not to be subjected to corporal punishment or unethical treatment which includes my right to be free from
any forms of abuse, neglect, exploitation or harassment and my right to be free from restraints of any form that are
not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff
6. My right to voice my opinions, recommendations and to file a written grievance which will result in program review
and response without retribution
7. My right to be informed of and provided a copy of the local procedure for filing a grievance at the local level or with
the DMH Office of Consumer Support
8. My right to privacy and confidentiality in respect to facility visitors in day programs, residential treatment programs,
and community living programs as much as physically possible
9. My right regarding the program’s nondiscrimination policies related to HIV infection and AIDS
10. My right to be treated with consideration, respect, and full recognition of my dignity and individual worth
11. My right to have reasonable access to the clergy and advocates and have access to legal counsel at all times
12. My right to review my records, except when restricted by law
13. My right to fully participate in and receive a copy of my Individual Service Plan/Plan of Services and Supports or
Activity Plan. This includes: 1) having the right to make decisions regarding my care, being involved in my care
planning and treatment and being able to request or refuse treatment; 2) having access to information in my case
records within a reasonable time frame (5 days) or having the reason for not having access communicated to me;
and, 3) having the right to be informed about any hazardous side effects of medication pr escribed by staff medical
personnel
14. My right to retain all Constitutional rights, except when restricted by due process and resulting court order
15. My right to have a family member or representative of my choice notified should I be admitted to a h ospital
16. My right to receive care in a safe setting
17. My right to confidentiality regarding my personal information involving receiving services as well as the compilation,
storage, and dissemination of my individual case records in accordance with standards outlined by the Department
of Mental Health and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), if applicable
Additionally, rights for individuals in supervised and residential treatment arrangements:
18. My right to be provided a means of communicating with persons outside the program
19. My right to have visitation by close relatives and/or significant others during reasonable hours unless clinically
contraindicated and documented in my case record
20. My right to be provided with safe storage, accessibility, and accountability of my funds
21. My right to be permitted to send/receive mail without hindrance unless clinically contraindicated and documented in
my case record
22. My right to be permitted to conduct private telephone conversations with family and friends, unless clinically
contraindicated and documented in my case record
I have been informed of, understand, and have received a written copy of the above information.
Individual Receiving Services Date Legal Representative Date
Staff/Credentials Date
DMH Clean 2016 Acknowledgment of Grievance guidance
Acknowledgment of Grievance Procedures
Purpose
The provider’s grievance procedures must be provided to the individual and/or legal
representative during the admission process. The information can be read by, or if necessary,
read to the individual receiving services and/or a person who is legally authorized to act on
his/her behalf.
Time Line
Individuals receiving services must be informed of and provided a copy of the provider’s
Grievance Procedures at the time of the admission and before services are provided. Each
individual receiving services must be presented with the provider’s Grievance Procedures when
they are being asked to give his/her consent to receive services.
Individuals acknowledge receipt of the Grievance Procedures at least annually, on or before the
anniversary date of the current acknowledgment, as long as the individual continues to receive
services. A copy of the Grievance Procedures given to the individual receiving services should
be attached and kept with the signed form.
For ID/DD Waiver Support Coordination Services, individuals must sign the acknowledgment at
least annually, before the end of the person's certification period
For IDD providers, individuals must sign the acknowledgment at the time the Activity Support
Plan is developed and annually thereafter.
The Consent to Receive Services, Rights of Individuals Receiving Services and
Acknowledgment of Grievance forms can be combined into one document as long as space is
included in the document for signature or initials of the individual receiving services or legal
guardian to acknowledge each separate action.
DMH Clean 2016 Acknowledgment of Grievance form
Acknowledgment of
Grievance Procedures
Name
ID Number
I have been informed of the policies and procedures for reporting a grievance concerning any
treatment or service that I receive.
Individual/Legal Representative Signature Date
Staff Signature/Credentials Date
DMH Clean 2016 Consent to Release-Obtain Information guidance
Consent to Release/Obtain Information
Purpose
Providers must have prior written authorization before information regarding an individual
receiving service can be released. A fully executed Consent to Release/Obtain Information
must be in place in order to legally exchange, release, or obtain information between
individuals, agencies and/or providers. The original Consent to Release/Obtain Information
form must always be maintained in the individual’s case record.
Release/Obtain Information
Enter the name and address of the agency from which the action is required.
Complete the Release Information To when requesting a provider to send confidential
information about an individual to another entity.
Complete the Obtain Information From section when confidential information regarding an
individual receiving/requesting to receive services needs to be obtained from another entity.
The specific purpose for which the information is needed must be indicated. Staff must specify
the exact reason for obtaining/releasing the information.
Extent/Nature of Information
The specific extent and/or nature of the information to be disclosed must be checked. If ‘Other’
is checked, the specific extent/nature of the disclosure must be described in detail. A generic
authorization for the non-specific release of medical or other personal information is not
sufficient for this purpose.
Date/Event/Condition
In order to clearly show the point in time when the Consent will expire, the following information
must be provided: 1) the month, day, and year, or 2) an event, or; 3) a condition that will deem
the Consent form expired; meaning no further action can be taken once the specific
date/event/condition is satisfied. An example of an event or condition may be, “30 days after
discharge or termination of services”.
For children and youth receiving services in a school setting, a date period that covers a specific
school year must be used.
The actions, conditions and limits of the consent must be clearly explained to the individual
receiving services and/or to a person who is legally authorized to act on his/her behalf.
The provider must clearly explain the conditions under which confidential information may be
released without consent. Confidential information may be released without consent when
necessary for continued services; when release is necessary for the determination of eligibility
for benefits, compliance with statutory reporting requirements, or other lawful purpose; if you
communicate to the treating physician, psychologist, master social worker or licensed
professional counselor an actual threat of physical violence against a clearly identified or
reasonably identifiable potential victim or victims; in compliance with reporting requirements
under state law of incidents of suspected child abuse or neglect or by court order.
DMH Clean 2016 Consent to Release-Obtain Information guidance
Witness
The Consent to Release/Obtain Information requires the signature of a witness. If the witness
is an employee of the program, he/she must include his/her credentials (if applicable). If the
individual receiving services can only make their mark (for example “X”), place the mark in
quotations and write out beside it, John Doe’s Mark substituting individual’s name. A second
witness to the individual’s signature is required in this case.
DMH Clean 2016 Consent to Release-Obtain Information form
Consent to
Release/Obtain Information
Name
ID Number
Date
I hereby give my consent/permission for
(Agency Name and Address)
To release information to:
(Agency/Person Name/Title and Address)
To obtain information from:
(Agency/Person Name/Title and Address)
For the specific purpose of:
Treatment
Coordination of Services
Other
The extent and nature of the information to be disclosed/obtained must be indicated (check all that apply):
Evaluations Diagnosis/Prognosis/Recommendations
Progress Notes Psychiatric Records
Substance Abuse Records Admission/ Discharge Summary
Contact Summaries Activity Support Plan
Identifying Information
Individual Service Plan/ Plan of Services &
Supports
Other
I understand that I may revoke this consent at any time except to the extent that action has been taken. I
further understand that this consent will expire upon
(Specific Date/Event/Condition)
and cannot be renewed without my consent. I understand that to revoke this authorization, Individual or Legal
Representative must provide a written request and the revocation will not apply to action or information that has
already been released/obtained in response to this authorization. Any information obtained as a result of this
release is confidential. State and federal laws and regulations prohibit any entity receiving confidential
information from redistributing the information to any other entity without the specific written consent of the
person to whom it pertains or as otherwise permitted by law and regulations. I understand the information I
authorize for release may include information related to history/diagnosis and/or treatment of HIV, AIDS,
communicable or sexually transmitted diseases and alcohol/drug abuse or dependency.
I understand that confidential information may be released without my consent when necessary for continued
services; when release is necessary for the determination of eligibility for benefits, compliance with statutory
reporting requirements, or other lawful purpose; if you communicate to the treating physician, psychologist,
master social worker or licensed professional counselor an actual threat of physical violence against a clearly
identified or reasonably identifiable potential victim or victims; in compliance with reporting requirements under
state law of incidents of suspected child abuse or neglect or by court order.
By signing below, I acknowledge receipt of a copy of the signed authorization
Individual Receiving Services Date Legal Representative Date
Witness/Credentials Date
DMH Clean 2016 Medication-Emergency Contact Information guidance
Medication/Emergency Contact Information
Purpose
Documentation of medications must be maintained while the individual is receiving services
from a DMH certified agency or provider. The Medication/Emergency Contact Information is not
to be used for the regular dispensing of medication. An important component is the
documentation of all the individual’s known allergic and/or adverse reactions. Emergency
contact information must be completed to ensure immediate and appropriate response in the
event of an emergency.
Timeline
The medications the individual is taking and the emergency contact information are recorded
during the admission process. The information must be updated when medications are
discontinued or added and at least annually.
Updates
The person entering updated information (new medications/changes to existing
medications/discontinuation of a medication) must write the date the changes were made and
sign the form in the designated space. The same form can be used until all spaces for
medications are filled. At that time, a new form must be completed to ensure clarity. Any time
the emergency contact information changes, a new form must be completed and placed in the
individual’s record.
Staff Signature/Date Initiated
Each medication entry must be signed by the person completing the form. If known, enter the
date the individual began taking the medication. If this information is unavailable, signify such
by entering “NK” in the “Date Initiated” column.
Current Medication
All sections must be addressed. ALL known and/or reported medications the individual is
currently taking must be listed, regardless of type or purpose, including over-the-counter (OTC)
medications the individual may be taking. The name of the medical professional prescribing
each medication must be listed. All known or reported prescribed medications must be
documented. Medication information regarding dosage and frequency must be listed exactly as
prescribed. If there are no prescribed or OTC medications, the person completing the form
must write “no prescription or OTC meds” and his/her initials.
Previous Medications/ Dietary Needs
Previously prescribed or taken medications listed; including any adverse reactions as reported
by the individual; any special dietary needs.
Date Terminated/Changed/Staff Signature
If a medication dosage or frequency is changed, enter the date in the column. This space is
also to be used if a medication is discontinued. The staff person entering the information must
sign the form.
Allergies/ Adverse Reactions
Each of the individual’s known allergies and his/her reactions to them must be documented.
Include reactions if applicable. Allergies may include, but not be limited to, medications, insect
bites, plants, foods, fragrances/aromas, or anything else that produces an allergic or adverse
reaction.
DMH Clean 2016 Medication-Emergency Contact Information form
Medication/Emergency
Contact Information
Name
ID Number
Name/Credentials of Staff Initially Completing the form:
Date Initially Completed:
CURRENT MEDICATIONS
List ALL known and/or reported medications the individual is currently taking regardless of type or
purpose to include over-the-counter (OTC) medications (use additional pages, if needed):
Staff
Signature/
Credential
Date
Initiated Name of Medication Prescribed by
Dosage/
Frequency
Date
Terminated/
Changed
Staff
Signature/
Credential
Known Allergies/Reactions:
PREVIOUS MEDICATIONS
Medication Directions Comments
(to include adverse reactions if applicable)
DMH Clean 2016 Medication-Emergency Contact Information form
Special Dietary Needs (if applicable):
Emergency Information:
In case of emergency (when parent/legal representative cannot be reached) contact:
Name:
Phone Number:
(primary) (secondary)
Address:
Primary Doctor:
Doctor’s Phone:
Doctor’s Address:
Hospital Preference:
Insurance Carrier(s):
Policy Number(s):
Section C
Required For All
Mental Health and
Substance Use Records
Initial Assessment
Trauma History
Individual Service Plan
Individual Crisis Support Plan
Recovery Support Plan
Periodic Staffing/ Review of the Individual Service Plan
Progress Note
Weekly Progress Note
Readmission Assessment Update
Substance Use Disorder Specific Assessment
Clean 2016 Initial Assessment guidance
Initial Assessment
Purpose
The Initial Assessment is used to document pertinent information that will be used as part of the
process for determining what service or combination of services might best meet an individual’s
stated/presenting need(s). The information gathered is both historical as well as what is currently
happening in an individual’s life.
Responses of “No” or “Not Present”, are acceptable. If an entire section does not apply to
someone, the recorder can enter “Not Applicable.” However, if the answer is “Yes” or “Present”,
then additional narrative and explanation is required.
Timeline
The Initial Assessment is part of the intake process and must be completed within the service
specific timeline requirements.
Admission Date
Enter the date the individual was admitted to service(s).
Assessment Date
Enter the date the Initial Assessment was started.
Informant
If assessment information is provided by someone other than the individual recei ving services,
enter the person’s relationship to the individual requesting services. A Consent to Release/
Obtain Information must be completed if applicable.
Guardianship Information
If individual has a legal guardian record name and contact information.
Confidentiality
Mark yes if limits of confidentiality are discussed with individual/guardian. If not, mark no with an
explanation.
Description of Need
Record the reason(s) the individual gives as to why he/she is seeking services, current needs,
goals etc. If substance use disorder is indicated in this section, a Substance Use Specific
Assessment must be completed.
Social / Cultural
Complete social information, current living situation, and family history sections as applicable with
information provided by the informant.
Clean 2016 Initial Assessment guidance
History
Complete the history section as applicable with information provided by informant.
The developmental history section should be completed for Children and Youth up to age 21 and
all individuals with IDD.
The education section and additional information section should be completed for all Children
and Youth up to age 21.
The employment section should be completed for adults not employed at the time of the
assessment.
All items in the history sections must be completed. Responses of “No” or “Not Present”, are
acceptable. If an entire section does not apply to someone, the recorder can enter “Not
Applicable.” However, if the answer is “Yes” or “Present”, then additional narrative and
explanation is required.
Medical History
Complete the additional medical information as applicable with information provided by
informant.
All items in the history sections must be completed. Responses of “No” or “Not Present”, are
acceptable. If an entire section does not apply to someone, the recorder can enter “Not
Applicable.” However, if the answer is “Yes” or “Present”, then additional narrative and
explanation is required.
Individual Mental Health History
Complete the outpatient mental health and psychiatric hospitalization/ residential treatment
sections as applicable with information provided by informant.
All items in the history sections must be completed. Responses of “No” or “Not Present”, are
acceptable. If an entire section does not apply to someone, the recorder can enter “Not
Applicable.” However, if the answer is “Yes” or “Present”, then additional narrative and
explanation is required.
Initial Behavioral Observation
Record observations for all areas listed. All areas must be evaluated. Comments must be
included to further explain or clarify the specific observed behaviors.
Indication of Functional Limitation(s)
An assessment must be conducted and the results documented for the major life areas specified
for each individual seeking readmission to services.
The Child and Adolescent Functional Assessment Scale (CAFAS) is required for all
children/youth receiving mental health services. The CAFAS must be completed within 30 days
for all children/youth receiving mental health services or within timelines as required by service.
Clean 2016 Initial Assessment guidance
An approved functional assessment is required for all adults receiving mental health services. An
approved functional assessment must be completed within 30 days for all adults receiving mental
health services or within timelines as required by service. DMH will review and approve a
functional assessment for use with the adult SMI population.
An approved functional assessment is required for all individuals receiving substance use
disorder services. DMH will review and approve a functional assessment for use with the SUD
population.
Summary/Recommendations
The person conducting the Initial Assessment must summarize the observations and findings to
include an analysis of the individual’s strengths and needs, both expressed and observed. Based
on the results of the Initial Assessment, services must be recommended and offered to the
individual. Referrals to other appropriate providers must also be offered to the individual.
Observations, findings and recommendations should support a life of recovery related to the
following dimensions:
Health- managing one’s disease; making informed, healthy choices that support physical and
emotional well-being
Home- having a stable and safe place to live
Community- having relationships and social networks that provide support, friendship, love and
hope
Purpose- conducting meaningful daily activities to participate in society
Initial Diagnostic Impression
Give the written diagnostic impression and appropriate codes.
Staff Qualifications
The Initial Assessment must be completed by an individual with at least a Master’s degree in
mental health or intellectual/developmental disabilities, or a related field and who has either (1) a
professional license or (2) a DMH credential as a Mental Health Therapist,
Intellectual/Developmental Disabilities Therapist or Substance Abuse Therapist (as appropriate
to the population being served).
For Alzheimer’s Day Programs only, the program supervisor must complete the Initial
Assessment. A copy of the individual’s current history and physical, signed by an MD or
Psychologist must be provided to confirm diagnosis.
DMH Initial Assessment form Page 1 of 6
Initial Assessment
Name:______________________________________________
ID Number:__________________________________________
Admission Date:______________________________________
Assessment Date:____________________________________
Time In: Time Out: Total Time:
Informant: □ Individual Receiving Services □ Other: Relationship to Individual______________________
Does the person seeking services have an Outpatient Commitment Order? □ Yes □ No
GUARDIANSHIP INFORMATION
Name of Guardian / Custodian:
Guardianship Documentation Verified:
□ Yes □ No
Guardian / Custodian Address:
Guardian / Custodian Phone Number:
Is the family involved with the Department of Human Services? □ Yes □ No
If yes, has a consent to release information been obtained? □ Yes □ No
If yes, please explain and indicate the name of the assigned case worker: __________________________
CONFIDENTIALITY
Were the limits of confidentiality reviewed with Individual and/or Guardian? □ Yes □ No
If NO, please explain.
DESCRIPTION OF NEED
What is your reason for seeking services today? What specific needs do you currently have?
(Include a description/perception of difficulties according to the individual seeking services and any applicable family
members/legal guardian.)
Is the reason for seeking services today related to substance use? □ Yes □ No
If yes, the substance use specific assessment must also be completed.
What previous coping skills have been helpful in the past?
Thoughts of Suicide: □ Yes (If yes, explain) □ No
Attempts of Suicide: □ Yes (If yes, explain) □ No
DMH Initial Assessment form Page 2 of 6
Thoughts of Homicide: □ Yes (If yes, explain) □ No
(Indicate the need for “duty to warn”)
Acts of Self-Harm: □ Yes (If yes, explain) □ No
SOCIAL / CULTURAL
Identification of Support Systems:
(Address family relationships, interpersonal relationships, and community support systems)
Meaningful Activities, Cultural / Ethnic / Spiritual interests, Supports:
(Address hobbies, leisure activities, etc.)
Living Situation
What is your current living arrangement (strengths and concerns)? Who lives with you? What are your views
on your current arrangement?
Needs Related to Living Situation
(money management, benefits, living arrangements, clothing, personal care, child care, rent, other)
Developmental History
(Complete only for Children & Youth up to age 21 and everyone with ID/DD)
During pregnancy, did mother use alcohol or other drugs? □ Yes □ No
Describe any problems with the pregnancy or birth:
Were there any developmental issues? □ Yes □ No (If no, explain)
Describe any childhood accidents or injuries:
Education (Children & Youth up to age 21)
Name of school:
Does child/youth receive Special Education Services?
□ Yes (If yes, complete release of information to obtain a copy of the current Individualized Education Plan (IEP) )
□ No
DMH Initial Assessment form Page 3 of 6
Additional Information (Children & Youth up to age 21)
Educational Issues/ Needs ( grades, attendance, suspensions, expulsions)
Employment (adults only)
Are you employed? □ Yes □ No
If no, do you want to be employed?
Employment Barriers/ Related Needs?
Current Legal Status
Has the individual been involved with the legal system within the past twelve months?
□ Yes □ No
Arrests: □ Yes □ No
If yes, indicate type and number of arrest(s):
Number of arrests in the past 30 days:
Pending Charges: □ Yes □ No
If yes, indicate type and number of pending charges:
Substance Use Related Legal Issues:
Is this person currently on parole and/or probation? □ Yes □ No
If applicable, indicate to whom reports should be submitted: ______________________________________
MEDICAL HISTORY
Appetite Issues:
Sleep Issues:
Current or Chronic
Diseases
□ high blood pressure □ diabetes □ thyroid □ other ____________________
Family History
□ high blood pressure □ diabetes □ thyroid □ other ____________________
Additional Medical History or Health and Safety Issues:
Health-Related Needs:
DMH Initial Assessment form Page 4 of 6
INDIVIDUAL MENTAL HEALTH HISTORY
Previous Assessment History
Have psychological, educational or functional assessments been completed in the last twelve months?
□ Yes (If yes, complete release of information to obtain a copy of the applicable assessment.)
If yes, indicate type of assessment__________________________________________________________________
□ No
Previous or Current Diagnoses:
Mental Health Needs:
Family History of Psychiatric or Substance Use Disorder(s) □ Yes □ No
If yes, please describe.
Outpatient Behavioral Health Agency
□ None Reported
Treatment Agency Services Received Dates of Service
Has Consent to
Release
Information
Been
Requested?
□ Yes □ No
□ Yes □ No
□ Yes □ No
Psychiatric Hospitalizations / Residential Treatment
□ None Reported
Treatments Reason (suicidal, depressed, etc.) Dates of Service
Has Consent to
Release
Information
Been
Requested?
□ Yes □ No
DMH Initial Assessment form Page 5 of 6
□ Yes □ No
□ Yes □ No
Initial Observations
General
Observations
Appearance:
□ Appropriate □ Disheveled □ Unclean □ Other __________________________________
Speech:
□ Appropriate □ Slow □ Mechanical □ Rapid □ Other _______________________________
Affect:
□ Appropriate □ Flat □ Labile □ Other __________________________________________
Delusions:
□ N/A
□ Description:
Hallucinations:
□ N/A
□ Description:
Mood
□ Appropriate □ Manic □ Depressed □ Labile □ Irritable □ Other _________________________
Orientation
□ Person □ Place □ Time □ Situation □ Other ________________________________________
Indication Of Functional Limitation(s):
(Check Major Life Areas Affected)
Basic living skills (eating, bathing, dressing, etc.)
Instrumental living skills (maintain a household, managing money, getting around the community,
taking prescribed medications, etc.)
Social functioning (ability to function within the family, vocational or educational function, other social
contexts, etc.)
SUMMARY / RECOMMENDATIONS
Health:
Home:
Community:
Purpose:
Other:
DMH Initial Assessment form Page 6 of 6
INITIAL DIAGNOSTIC IMPRESSION
Codes: Description:
SIGNATURES / CREDENTIALS
X Date: X Date:
X Date: X Date:
DMH Trauma History guidance
Trauma History
Purpose
The Trauma History is a screening tool designed to determine whether or not an individual
receiving services has experienced trauma in the past. This tool is not a standardized measure
and there are no scoring guidelines. This assessment should be administered in an interview
format that allows the clinician to explain questions in a developmentally appropriate manner to
ensure the client understands what is being asked. The interview process also allows the
clinician to observe nonverbal responses to questions that might indicate a trauma response
such as anxiety, fear, avoidance, shame, etc.
General
The timeline for completion of the Trauma History is determined by the type of service or
program the individual is entering.
All individuals receiving services must complete a trauma history questionnaire. Outpatient
Services must complete the trauma history questionnaire within 30 days, Day programs must
complete the trauma history questionnaire within 3 days of admission. Primary Residential
Services within 5 days of admission to the services. Crisis Stabilization Services must complete
the trauma history questionnaire within 48 hours. Results of trauma history questionnaire
should be incorporated into ISP and subsequent services.
The Trauma History Assessment is not a tool for gathering information or details about the
traumatic event. The clinician should maintain a neutral tone when asking each question. If the
client indicates he/she has experienced an event, then the therapist only asks at what age the
traumatic event(s) started and ended. If the client offers more information, the clinician
captures that content but does not attempt to elicit more details than offered, challenge nor
process the information shared.
If the client reports a positive trauma history, the clinician asks the client to identify the trauma
that is most distressing at that time. The identified trauma is then incorporated into the
Individual Service Plan and subsequent services and can be referred to when administering
formal trauma assessments.
DMH Trauma History form
Trauma History
Name
ID Number
Date
Time In: Time Out: Total:
Page 1 of 2
Please indicate if any of the following have happened to you and how it may have affected you.
Have you ever served in the military, law enforcement or as a first responder? □ Yes □ No
If yes, indicate the capacity in which you served.
Have you ever seen or been in a really bad accident?
Has someone close to you ever been so badly injured or sick that s/he almost died?
Has someone close to you ever died?
Have you ever been so sick that you or the doctor thought you might die?
Have you ever been unexpectedly separated from someone who you depend on for love or security for
more than a few days?
Has someone close to you ever tried to kill or hurt him/herself?
Has someone ever physically hurt you or threatened to hurt you?
DMH Trauma History form
Trauma History
Name
ID Number
Page 2 of 2
Have you ever been mugged or seen someone you care about get mugged?
Has anyone ever kidnapped you?
Have you ever been attacked by a dog or other animal?
Have you ever seen or heard people physically fighting or threatening to hurt each other? (In or outside
of the family)?
Have you ever witnessed a family member who was arrested or in jail?
Have you ever had a time in your life when you did not have a place to live or enough food?
Has someone ever made you see or do something sexual? Or have you seen or heard someone else
being forced to do sex acts?
Have you ever watched people using drugs, like smoking drugs or using needles?
Staff Signature/Credential Date
Individual Service Plan guidance
Individual Service Plan
Purpose
Each individual who receives services must have an Individual Service Plan that is based on the
identified strengths and needs of the individual, the goals that will help address his/her needs, the
services to be provided, and the activities that will take place toward achieving measurable
individual outcomes. The individual seeking/ receiving services must be involved in the
development of his/her service plan. For individuals under the age of eighteen (18) or who are
unable to effectively participate in the planning process, a parent, legal guardian or conservator
must participate in planning on the individual’s behalf.
The timeline for completion of the Individual Service Plan is determined by the type of service or
program the individual is entering.
The Individual Service Plan must be reviewed and revised when goals or objectives are achieved,
as needs of the individual change, or according to specific service requirements but at least
annually.
Individual Strengths
List strengths the individual possesses and/or demonstrates that will assist and promote
successful achievement of outcomes.
Goals
The individual receiving services establishes the long term goals. Staff helps the individual set
short term goals which will contribute to achievement of the long term goal(s).
Identified Barriers
List barriers that may prevent the individual from achieving successful outcomes. Barriers must
include but are not limited to functional impairments in basic living skills, instrumental living skills
or social skills, as indicated by an assessment instrument/ approach approved by DMH.
Individualized Areas of Need
Refer to the Initial Assessment to identify symptoms, observable behaviors, clinical areas of need
and elaborate on duration (how long the symptoms/behaviors have been present or observed),
frequency (how often the symptoms/behaviors are present or observed), and how the
symptoms/observable behaviors create a functional impairment for the individual. Symptoms,
behaviors and clinical areas of need should serve as the focus of treatment, services and
supports for individuals.
Interventions, Criteria/Outcomes, Initiation and Target Dates
In order to effectively work toward achieving the long term and short term goal(s) identified by the
individual receiving services, the objectives and interventions must be measurable. Each
objective and intervention must have specific criteria or outcomes which clearly indicate an
objective has been reached or an intervention has been completed. Each intervention must be
Individual Service Plan guidance
numbered, assigned to a service area (eg. Peer Support Services, Therapy Services, Community
Support Services, etc) and have a specified target date for achievement or completion. Services
identified and certified as necessary must be provided to the individual. All services that the
individual is receiving must be indicated in relation to an objective/ intervention.
Diagnosis
Give the written diagnosis and appropriate codes for the individual receiving services.
Community Supports
Community Support Services must be made available to the following populations: adults with
serious mental illness and children/youth with serious emotional disturbance. If the individual
refuses Community Support Services, the refusal must be documented in writing. Community
Support Services must be offered to these specified individuals during the intake process and at a
minimum of every twelve (12) months while they remain in services.
Signatory Authority
Each individual who participates in the development of the Individual Service Plan must sign the
plan as evidence of his/her participation in plan development. If the Individual Service Plan is
developed for adults with a serious mental illness (SMI), individuals with intellectual/
developmental disabilities, children and youth with serious emotional disturbance (SED), or
individuals with a substance use disorder, a licensed Physician, a licensed Psychologist, a
Psychiatric/Mental Health Nurse Practitioner, a Licensed Clinical Social Worker, Licensed
Marriage and Family Therapist, Licensed Professional Counselor, Physician Assistant or
Alzheimer’s Day Program Supervisor (for Alzheimer’s Day programs only) must sign the Individual
Service Plan, certifying the planned services are medically/therapeutically necessary.
DMH Individual Service Plan form
Individual
Service Plan
Name:_______________________________________________
ID Number:___________________________________________
Admission Date:_______________________________________
Date of Plan Implementation_____________________________
□ New □ Re-Write □ Addendum
INDIVIDUAL’S STRENGTHS
LONG TERM GOALS
(include hopes/dreams/goals) SHORT TERM GOALS
IDENTIFIED BARRIERS
(Based on Functional Assessment)
DMH Individual Service Plan form
INDIVIDUAL’S AREAS OF NEED
INDIVIDUALIZED PLAN FOR SERVICES
Objective #1:
Interventions Service Area
Assigned
Criteria / Outcomes for
Completion
Initiation
Date:
Target
Date:
1.
2.
3.
Objective #2:
Interventions Service Area
Assigned
Criteria / Outcomes for
Completion
Initiation
Date:
Target
Date:
1.
2.
3.
Objective #3:
Interventions Service Area
Assigned
Criteria / Outcomes for
Completion
Initiation
Date:
Target
Date:
1.
2.
3.
DMH Individual Service Plan form
DIAGNOSIS
Primary
Diagnosis(es)
Secondary
Diagnosis(es)
Community Support has been offered to me and I choose:
□ YES, I do want to participate (see Recovery Support Plan)
______(initials of individual receiving services)
□ NO, I do NOT want to participate
______ (initials of individual receiving services)
_____________________________ ___________ _____________________________ ___________
Individual Receiving Services Date Parent / Legal Guardian Date
_____________________________ ___________ _____________________________ ___________
Signature / Credentials Date Signature / Credentials Date
_____________________________ ___________ _____________________________ ___________
Signature / Credentials Date Signature / Credentials Date
_____________________________ ___________ _____________________________ ___________
Signature / Credentials Date Signature / Credentials Date
_____________________________ ___________ _____________________________ ___________
Signature / Credentials Date Signature / Credentials Date
_____________________________ ___________ _____________________________ ___________
Signature / Credentials Date Signature / Credentials Date
__________________________________________________________________________ ___________
Physician / Clinical Psychologist / Nurse Practitioner, LCSW, LMFT, Date
LPC, PA, Alzheimer’s Day Program Supervisor
Clean 2016 Individual Crisis Support Plan guidance
Individual Crisis Support Plan
Purpose
Providers must develop an Individualized Crisis Support Plan for individuals receiving
services in the following priority groups:
• Individuals discharged from an inpatient psychiatric facility;
• Individuals discharged from an institution;
• Individuals discharged or transferred from Crisis Stabilization Services; and,
• Individuals referred from Crisis Response Services.
Identifying Information
Record the individual’s name, record number, date the plan was developed and the local toll-
free crisis phone number.
Treatment Information
Record the individual’s diagnosis as indicated on the Individual Service Plan. Explain relevant
history and current potential for crisis situation. List all medications the individual is currently
prescribed. Explain what may be a potential trigger for the individual to regress into a crisis
situation.
Action Steps
List the action steps the individual, crisis response team and family (if indicated) will take in
the event the individual is experiencing a crisis at home or in the community. Include who is
responsible for initiating the response with their phone number.
Requirements
The Crisis Support Plan must be developed within 30 days of admission for all individuals
receiving services except those individuals admitted through crisis services. Crisis Support
Plans must be developed for individuals admitted through crisis services within 72 hours of
admission.
The Crisis Support Plan must be developed by the team of individuals who will have
responsibilities for implementing the Plan in the event of a crisis. The Plan development
team members must have at least a Bachelor’s degree in mental health or a related field and
must sign the Crisis Support Plan where indicated.
The Crisis Support Plan identifies what could go wrong and how people should respond.
Crisis planning includes opportunities for family and team members to practice crisis
response by simulating a crisis in a safe, controlled environment. The Crisis Support Plan
must include who will notify who and when. The Crisis Support Plan must be portable in the
sense that all team members must have a copy to refer to when needed. The Individual
receiving services should also maintain a copy of the plan for reference.
DMH Clean 2016 Individual Crisis Support Plan form
Individual Crisis Support
Plan
Name
ID Number
Date Plan
Developed
Toll-free Crisis
Phone Number
Diagnosis: Current Medications:
Relevant History and Potential Crisis: Known Triggers:
Action Steps for Home Person(s) Responsible and
Phone Number(s)
Action Steps for Community
Locations (specify)
Person(s) Responsible and
Phone Number(s)
Signature of Individual Receiving Services Date Signature/Position Date
Signature/Position Date Signature/Position Date
Recovery Support Plan guidance
Recovery Support Plan
Purpose
The Recovery Support Plan should be completed with the Individual Receiving Services and is
used as a tool to assist the individual in making plans to engage in activities and access
resources designed to help support him/her in achieving and maintaining recovery/resiliency.
The Recovery Support Plan replaces the previous Community Support Plan and the Substance
Abuse Recovery Support Plan. This plan is meant to be a flexible document that expounds
upon the information provided in the Individual Service Plan (ISP). This documentation is
required for individuals receiving Community Supports Services, Recovery Supports Services
and Peer Support Services but can be used in conjunction with any individual’s ISP.
The Recovery Support Plan must be developed within 30 days of admission for all individuals
receiving services.
The Recovery Support Plan must be developed by the team of individuals who will have
responsibilities for implementing the Plan during service delivery. The Plan development team
members must have at least a Bachelor’s degree in mental health or a related field and must
sign the Recovery Support Plan where indicated.
Needs Statement from Initial Assessment and ISP
Record the individual’s Needs Statement from their Initial Assessment and Individual Service
Plan.
Long Term Goal(s) from the ISP
Record the individual’s Long Term Goal(s) from the Individual Service Plan.
Objectives:
All Recovery Support Plans must have individualized objectives and they must be measurable.
Record what the individual hopes to accomplish or achieve while receiving Support Services.
Strategies:
Describe the strategies or activities that the individual will complete to achieve the desired
outcome.
Who is responsible?
Who is responsible for assisting with the completion of these objectives? This can be the
individual themselves, a natural support, or a staff member. Record the person or persons
responsible.
Target completion date
Explain how often activities will be conducted and the expected completion date.
Recovery Support Plan guidance
Signatures
The date, signature, and credentials (if applicable) of all persons responsible for completing
objectives should be recorded.
DMH Recovery Support Plan form
Recovery Support
Plan
Name:_____________________________________________
ID Number:_________________________________________
Needs Statement(s) from Initial Assessment and ISP:
Long Term Goal(s) from ISP:
Objectives:
Strategies:
Who is responsible:
Target Completion Date:
_____________________________ ___________ _____________________________ ___________
Individual Receiving Services Date Parent / Legal Guardian Date
_____________________________ ___________ _____________________________ ___________
Direct Service Provider Date Direct Service Provider Date
Clean 2016 Progress Note guidance
Progress Note
Purpose
All programs must document single therapeutic support interventions and activities that take place
with/for an individual. The Progress Note can also be used “as needed” to provide supplemental
documentation that cannot be adequately captured in the Weekly Progress Note.
Location
Document the location where services were provided.
Time
Document the time services began and ended along with the total amount of time services were
provided.
General
Providers must document therapeutic interventions and activities (such as outpatient therapy,
community support services, supported and supervised living services) utilizing the SAP format.
Summary should address the summary of activities related to the service being provided for eac h
contact/ service event.
Assessment should address the progress made, or lack of progress made, toward the goals and
objectives on the plan directing the treatment, services and/or supports for the individual (ex.
ISP).
Plan should address the plan for future activities related to the service. This can include staff or
individual activities.
Signatures
Staff completing the Progress Note must sign and date the form at the end of each note. The
signature of a supervisor is not required but can be used to document supervision of provisionally
credentialed staff.
DMH Clean 2016 Progress Note form
Progress Note
Name __________________________________
ID Number _____________________________
Service Type ____________________________
Day / Date Location Time Began
(am/pm)
Time Ended
(am/pm)
Total Time
S:
A:
P:
Provider Signature/Credentials
Supervisor Signature (if applicable)
Day / Date Location Time Began
(am/pm)
Time Ended
(am/pm)
Total Time
S:
A:
P:
Provider Signature/Credentials
Supervisor Signature (if applicable)
DMH Clean 2016 Weekly Progress Note guidance
Weekly Progress Note
Purpose
Providers must maintain documentation to verify each individual’s weekly and monthly
progress toward the areas of need identified on his/her Individual Service Plan.
Time
Document the time services began and ended along with the total amount of time services
were provided. Indicate if an individual is absent or if it is a weekend.
Weekly Documentation
The provider must document in SAP format the activities an individual participates in or
completes during the week. All activities must be listed including, community integration, job
exploration, therapeutic activities, etc. Activities should be related and documented to an
individual’s goals/objectives/outcomes stated on the Individual Service Plan.
Staff completing the Weekly Progress Note must sign and date the form at the end of each
week.
Monthly Summary
At the end of the month, a summary of progress or lack of progress toward
goals/objectives/outcomes must be documented utilizing the SAP format.
Staff completing the Weekly Progress Note must sign and date the form at the end of the
month. For Day Treatment Services and Psychosocial Rehabilitation Services, the
Supervisor may use this form as part of the documentation of the required monthly
supervision.
DMH Clean 2016 Weekly Progress Note form
Weekly Progress Note
Name ___________________________________________
ID Number _______________________________________
Service __________________________________________
Attendance during month of in the year of
Days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Time
In
Time
Out
Total
Time
Weekly
Dates Summary of Objective/Activity
1st Week
Objective(s):
S:
A:
P:
Date: Signature/Credential:
2nd Week
Objective(s):
S:
A:
P:
Date: Signature/Credential:
DMH Clean 2016 Weekly Progress Note form
3rd Week Objective(s):
S:
A:
P:
Date: Signature/Credential:
4th Week Objective(s):
S:
A:
P:
Date: Signature/Credential:
5th Week
Objective(s):
S:
A:
P:
Date: Signature/Credential:
Monthly
Summary
S:
A:
P:
Date:
Staff Signature/Credential:
Date: Supervisor Signature/Credential:
DMH Clean 2016 Periodic Staffing Review of ISP guidance
Periodic Staffing/Review of the Individual Service Plan
Purpose
The Periodic Staffing/ Review of the Individual Service Plan (ISP) is used to document periodic
review and revision in order to remain continuously current with regard to the goals and
outcomes the individual receiving services is seeking to achieve. As with the original ISP, all
reviews, revisions, or rewrites of the ISP must be a collaborative effort with the individual and/or
legal representative and the appropriate staff.
Timelines
Review and revision must occur whenever the individual receiving services experiences a
change in his/her life that impacts the goals of their current ISP. Life changes can be expected
to be initially reported in progress notes and may be in one or more of the areas listed below.
At a minimum, the ISP must be reviewed and revised/rewritten annually for adults and every six
months for children and youth.
Changes
Any or all changes in the following areas since the last ISP review must be documented in
specific detail:
• Change in diagnosis
• Change in symptoms
• Change(s) in service activities
• Change(s) in treatment/treatment recommendations
• Other significant life change
Plan Modification
After documenting any and all changes that have occurred since the last ISP review, careful
consideration should be given to the impact these changes have made on the ISP in t erms of
the needs expressed, goals and outcomes being pursued by the individual. The ISP should be
modified or rewritten if needed to ensure ongoing progress toward achievement of the
individual’s ISP goals. If the ISP needs to be rewritten, there must be involvement of the
treatment team and the Physician, Psychologist, Nurse Practitioner, Licensed Clinical Social
Worker, Licensed Marriage and Family Therapist, Licensed Professional Counselor, Physicians
Assistance or Alzheimer’s Day Program Supervisor (Alzheimer’s Day programs only) to
determine medical necessity.
Signatory Authority
Each individual who participates in the staffing/review of the Individual Service Plan must sign
the Periodic Staffing/Review of the ISP form as evidence of his/her participation in the
staffing/review process.
DMH Clean 2016 Periodic Staffing Review of ISP form
Periodic Staffing/
Review of the
Individual Service Plan
Name
ID Number
Current Date
Date of Last
ISP/Review
Time In Time Out Total
Change in diagnosis since last review
Change in symptoms since last review
Change(s) in service activities since last review
Change(s) in household since last review
Change(s) in treatment/
service recommendations since last review
Other significant life change(s) since last review
Comments/Recommendations
Plan Modification No Yes Rewrite Plan
If yes, make additions/ modifications to the existing plan
Individual Receiving Services
Date
Staff Signatures/Credentials Date
Staff Signatures/Credentials
Date
Signature of Parent/Legal Guardian (if applicable) Date
DMH Clean 2016 Readmission Assessment Update guidance
Readmission Assessment Update
Purpose
When an individual has been discharged from a provider agency and seeks to resume services
within one year of the discharge date, a Readmission Assessment Update may be utilized
instead of the Initial Assessment as part of the readmission process to update information that
has changed regarding the individual’s needs and status.
Instructions
Update identifying information and description of need. Document any changes relating to the
individual’s history occurring during the lapse of service.
Description of Need
Record the reason(s) the individual is seeking services.
Status Updates
Any changes relating to individual’s status areas (medical, mental health, substance abuse/use,
social/cultural, educational/vocational) that have occurred during the gap in service must be
documented in detailed narrative format. Responses of “Yes”, “No”, “Present”, “Not Present”
are not acceptable.
Indication of Functional Limitation(s)
An assessment must be conducted and the results documented for the major life areas
specified for each individual seeking readmission to services.
The Child and Adolescent Functional Assessment Scale (CAFAS) is required for all
children/youth receiving mental health services. The CAFAS must be completed within 60 days
for all children/youth receiving mental health services.
An approved functional assessment is required for all adults receiving mental health services.
An approved functional assessment must be completed within 60 days for all adults receiving
mental health services. DMH will review and approve a functional assessment for use with the
adult SMI population.
An approved functional assessment is required for all individuals receiving substance use
disorder services. DMH will review and approve a functional assessment for use with the SUD
population.
Staff Requirement
The Readmission Assessment Update must be completed by an individual with at least a
Master’s degree in mental health or intellectual/developmental disabilities, or a related field and
who has either (1) a professional license or (2) a DMH credential as a Mental Health Therapist
or Intellectual/Developmental Disabilities Therapist (as appropriate to the population being
served) or Alzheimer’s Day Program Supervisor (Alzheimer’s Day Programs only).
DMH Readmission Assessment Update form
Readmission
Assessment Update
Name
ID Number
Readmission Date
Informant: Individual receiving services Other Relationship to individual:
LEGAL INFORMATION
Name of Guardian / Custodian:
Guardianship Documentation Verified:
□ Yes □ No
Guardian / Custodian Address: Guardian / Custodian Phone Number:
DESCRIPTION OF NEED
What is your reason for seeking services today?
What specific needs are you currently having?
Why was the record closed?
Status Updates
Medical Status (Record current medications on the Medication/Drug Use Profile):
Allergies
Physical impairments
Surgeries
Special diets
Appetite issues or problems
Sleep issues or problems
Current or chronic diseases (high blood pressure, cancer, other)
Other pertinent medical information
(For women only) Are you pregnant?
DMH Readmission Assessment Update form
Mental Health Status:
Recent psychiatric issues
Homicidal behavior
Suicidal behavior
Other counseling and/or therapeutic experiences
Traumatic Event Or Exposure Status (Note Or Describe As Appropriate):
Serious accidents
Natural disaster
Witness to a traumatic event
Sexual assault
Physical assault (with or without weapon)
Close friend or family member murdered
Homeless
Victim of stalking or bullying
Other (specify)
Substance Use Status:
Use or abuse by the individual
Age of onset
Patterns of use/abuse: How much?
How often?
Methods of use: smoke snort inject insert inhale
Resulting circumstances?
DMH Readmission Assessment Update form
Social/Cultural Status:
Immediate household/family configuration
Marital status
Relationship with family members
Type of family support available
Type of social support available
Types and amounts of social involvement/leisure activities
Any religious/cultural/ethnic aspects that should be considered
Educational/Vocational Status:
Highest grade completed
If currently in school (child or youth), regular classroom placement? Yes No
List all additional educational services child is receiving
Any repeated grades? No Yes Explain:
Suspensions/expulsions? No Yes Describe:
Other education issues
Vocational training, if any
Current employment
Previous employment
Comments:
Indication Of Functional Limitation(s):
(Check Major Life Areas Affected)
Basic living skills (eating, bathing, dressing, etc.)
Instrumental living skills (maintain a household, managing money, getting around the community, taking
prescribed medications, etc.)
Social functioning (ability to function within the family, vocational or educational function, other social
contexts, etc.)
Signature/Credentials Date
DMH Substance Use Disorder Specific Assessment guidance
Substance Use Disorder Specific Assessment
Purpose
This information must be documented if substance use disorder services are provided or if
substance use disorder is suspected. This form must be completed in addition to the Initial
Assessment and is applicable to youth and adults. This form should specifically address how
substance use history has created impairment.
Treatment Modality Abbreviations
OP Outpatient Services
IOP Intensive Outpatient Services
PR Primary Residential
TR Transitional Residential
PHP Partial Hospitalization
Detailed Substance Use History
This section of the assessment allows the evaluator to document details of the individual’s
history of substance use. The evaluator should document the substance use; include the age of
onset, and the pattern of use.
Prior Substance Use Disorder Treatment
This section of the assessment allows the evaluator to document the individual’s prior history of
substance use disorder treatment. Location, date, completion of prior treatment, outc ome and
length of treatment should all be documented in this section.
Evaluator’s Assessment of Attitude
This part of the assessment allows the evaluator to document the individual’s level of denial
and/or willingness to change with regard to their use of alcohol and other drugs.
Family History of Alcohol and/other Drugs
This section of the assessment allows the evaluator to document the individual’s family history
of substance use.
DMH Substance Use Disorder Specific Assessment form
Substance Use Disorder
Specific Assessment
Name
ID Number
Date
Time In: Time Out: Total:
Admission Date: Treatment Service: OP___ IOP ___PR ___TR ___ PHP ___
DUI Specific History
DUI Offender? First time 2+Offenses Not applicable
Is the individual’s driver’s license currently suspended?
Yes No
If yes, was the individual enrolled in or referred to a certified DUI Treatment Program? Yes No
Substance Use History (Explain use, drug of choice, include age of onset, and pattern of use)
How much money would you say you’ve spent on substances during the past 30 days? _________________________
What was your longest period of abstinence? __________ How was abstinence maintained? ___________________
On a scale of 1-5, how important is treatment to you now? (5 being most important) ____________
Prior Substance Use Disorder Treatment (Location, date, completion status, outcome, length of recovery after treatment)
Evaluator’s Assessment of Individuals Attitude Regarding Use of Alcohol and/or Other Drugs
Level of Denial: (circle one) None Low Moderate High Unsure
Willingness to Change: (circle one) None Low Moderate High Unsure
Family History of Alcohol and/or Other Drugs
SIGNATURES / CREDENTIALS
Staff Signatures/Credentials Date
Section D
As Needed
Initial Assessment and Crisis Contact Summary
Serious Incident Report
Medical Examination
Documentation of Healthcare Provider Visits
Self-Administration Medication Log
Telephone/ Visitation Agreement
Search and Seizure Report
Physical Restraint/Escort Log
Time Out Log
Seclusion Behavior Management Log
Service Termination/ Change Summary
Provider Discharge Summary
DMH Initial Assessment and Crisis Contact Summary for Crisis Response Contacts guidance
Initial Assessment and Crisis Contact Summary for Crisis
Response Contacts
Purpose
The Initial Assessment and Contact Log for Crisis Response Contacts is used to document the
provision of emergency/crisis contacts with individuals seeking services from a provider who are
not already receiving other mental health services from the provider.
Identifying Information
Record the name of the individual receiving crisis services. Issue and record a client
identification number. The Date of Contact will also be the Date of Admission. Enter the
individual’s Social Security and Medicaid numbers. Record the time the contact began and
ended. Indicate the type of crisis service delivered (Mobile Crisis Services, Telephone Crisis
Response, or Walk-in Crisis Response). If the contact was made Face to Face, include the
location where the contact took place and if the contact was made by phone, include the phone
number of the caller. List by relationship any other individuals involved with the emergency/
crisis or any referral source (i.e. sister).
Presenting Need
Document the reason(s) the individual is seeking emergency/crisis services.
Actions Taken by Staff
Document the steps taken to assess and resolve the emergency/crisis. Record if anyone was
contacted on behalf of the individual in crisis. If no one else was notified, indicate why it was not
necessary.
Initial Behavioral Observations
Document the staff’s impressions of the individual’s behaviors. Include additional comments at
the end of the section.
Resolution
Document the condition of the individual at the end of the contact; indicate where the individual
and/or family were referred and if a subsequent appointment was made for the individual with
the provider, note the date and time of the appointment.
Required Data
This information is required by the Department of Mental Health and is to be submitted to the
Central Data Repository. If you are unable to obtain this information, please mark as “unknown.”
The staff person responding to the individual in crisis and documenting the contact must sign
this form and include their professional credentials.
DMH Initial Assessment and Crisis Contact Summary for Crisis Response Contacts form
Initial Assessment
and Crisis Contact
Summary for Crisis
Response Contacts
Name:_____________________________________________
ID Number:_________________________________________
Contact/ Admit Date:_________________________________
Medicaid #:_______________ SS#______________________
Time In: Time Out: Total Time:
Type of Contact:
□ Mobile Crisis Service Location: _________________________
□ Telephone Crisis Response Number: __________________________
□ Walk-in Crisis Response
Others Involved:
Presenting Needs (the factors indicating a need for Crisis ResponseServices)
Actions Taken by Staff:
Initial Behavioral Observations
Speech: Appropriate Slowed Mechanical Rapid Other
Behavior: Appropriate Withdrawn Bizarre Volatile Other
Appearance: Appropriate Disheveled Unclean Inappropriately dressed
Other Phone Contact
Mood: Appropriate Manic Depressed Labile Irritable Other
Affect: Appropriate Flat Labile Other
Oriented to: Place Time Person Situation Other
Thought Content: Appropriate Incoherent Obsessive Delusional Paranoid Other
Memory: Appropriate Repressed Confused Other
Intelligence: Average Above Average Below Average
Judgment/Insight: Appropriate Impaired Suicidal Homicidal Other
Hallucinations: Auditory Visual Tactile Other
Comments:
DMH Initial Assessment and Crisis Contact Summary for Crisis Response Contacts form
Resolution
Condition of the Individual at Conclusion
of Contact
Referrals Made by Staff
Appointment with the Provider
Date:
Time:
Required Data
(Please mark as Unknown if Information is Unavailable)
Birth Date:
Age: Gender:
Race:
Education Level: Marital Status:
County of Residence:
Living Arrangement: Type of Residence:
Employment Status:
Legal Status: Primary Income Source:
Annual Income:
# in Household: SSI/SSDI Eligibility:
Veteran Status:
Physical Impairments: Service Code:
Staff Signature/Credentials:
DMH Clean 2016 Serious Incident Report guidance
Serious Incident Report
Date of Report: The date this report was written
Date of Incident: The date the incident occurred
Time of Incident: The time the incident occurred; make sure to check am or pm
Provider Name: The name of the Provider (example: Region X Mental Health)
Program Name: The Name of the specific program within the Provider agency (example:
Golden Rainbows PSR). In some instances the Provider Name may
actually be the Program; for instance with a smaller private Provider.
Service: The name of the specific Service for which the Program is certified.
(example: Psychosocial Rehabilitation Services)
Reported by: The name of the person completing the incident report. If the incident was
reported to the person completing the form, the names of the initial
reporter(s) will be included in the Description of Incident, Person(s)
Involved in Incident and Witnesses sections.
Event Codes:
SU Suicide attempt, or Completed Suicide
EMG Treatment received at an Emergency Room. Do not include trips to
Emergency Room that do not result in treatment
SR Any Seclusion or Restraints
ACL An unexpected absence from a community living program
ABN Any abuse or neglect of an individual receiving services, either suspected
or confirmed
WKV Any workplace violence occurring on the property of a certified Provider, or
at a Provider sponsored event
ELP Elopement of an individual receiving services
DIS Any Disaster that effects the normal functioning of a certified Provider. Do
not include reports of Disaster Drills.
MED Any confirmed Medication Errors
DMH Clean 2016 Serious Incident Report guidance
INJ Any serious injuries sustained by an individual receiving services. Minor
injuries need not be reported. Injuries resulting in fractures, stitches or
sutures (or preliminary x-rays to determine extent of injury) are considered
serious.
EVC Any event that requires evacuation of the premises. Do not include drills.
OTH Any incident that is deemed serious by the Provider, but is not listed above.
Details should be given in the Description of Incident section.
Description of Incident:
Give as detailed an account as possible of the incident in the space
provided.
Person(s) Involved In Incident:
List first and last names (if known) of all individuals involved in the incident.
This should include all alleged victims and alleged perpetrators (if
applicable). Use the provided check boxes to indicate whether or not the
individual(s) is on the ID/DD waiver.
Witnesses: List the names of any verified or potential witnesses to the incident.
Possible Contributing Factors:
List any identified possible contributing factors to the incident. (example: a
wet floor that resulted in a fall which caused a hip fracture)
Consequences/Follow Up Actions:
List any actions that the Provider has taken since the incident occurred to
lessen the chances of it happening again. Any disciplinary actions that
have been taken should also be included (example: Administrative Leave)
Any and all authoritative bodies to which this incident has been reported and the
dates of those reports. (example: Department of Health, 12/3/12; Attorney General’s
Office, 12/4/12)
Has A Report Been Made Within the Agency:
Mark “yes” here to acknowledge that a report of the incident has been
made to the proper authoritative body within the agency. For example, the
agency may have a Risk Management Department to which all incidents
should be reported internally. Or, if the agency does not have a formal Risk
Management Department, mark “yes” if a report has been made to the
Executive Director.
DMH Clean 2016 Serious Incident Report guidance
If yes, to whom has the Report of Incident been made?
Provide the names and positions of each person to whom the incident has
been reported.
At the time of this report, is the Agency conducting an Internal Investigation?
Mark “yes” if the agency is conducting its own internal investigation.
If yes, is the Agency’s Investigation Active or Closed?
If the investigation is ongoing, mark “Active.” If the investigation has been
completed, mark “closed.”
Is this a high visibility Incident?
Visibility refers to the likelihood that the incident will be reported by the
media. If there is a good possibility that the incident will be reported in the
media, check “yes.”
DMH Clean 2016 Serious Incident Report form
Serious Incident Reporting Form
Date of Report:
Date of Incident: Time of Incident: □ am □ pm
Provider Name:
Program Name:
Service:
Reported By:
Event Codes (Check All That Apply)
□ SU Suicide (Attempt or Completed)
□ EMG Emergency Room Treatment □ SR Seclusion/Restraint
□ ACL Absence from Community Living
□ ABN Abuse/Neglect □ WKV Workplace Violence
□ ELP Elopement
□ DIS Disaster □ MED Medication Error
□ INJ Injury
□ EVC Evacuation □ OTH Other (describe below in narrative)
Page 1 of 2
Description of Incident:
DMH Clean 2016 Serious Incident Report form
Page 2 of 2
Individual(s) Involved In Incident (include case # with name if known)
Is this individual on the
ID/DD Waiver?
□ Yes □ No
If yes, was Support Coordination notified?
□ Yes □ No
Witnesses:
Possible Contributing Factors:
Consequences/Follow Up Actions:
Any and all authoritative bodies to which this incident has been reported and the dates of those reports.
Has a Report of Incident been made within the agency? □ Yes □ No
If yes, to whom has the Report of Incident been made?
____________________________________________ ____________________________________________
Name Position
____________________________________________ ____________________________________________
Name Position
____________________________________________ ____________________________________________
Name Position
At the time of this report, is the Agency conducting an Internal Investigation? □ Yes □ No
If yes, is the Agency’s Investigation Active or Closed?
Is this a high visibility Incident? □ Yes □ No
DMH Clean 2016 Medical Examination Report guidance
Medical Examination
The DMH Operational Standards require that each individual served in any DMH certified
supervised living and residential treatment program must have a documented Medical
Examination in the individual’s record. The examination must take place within 72 hours of
admission or not more than 30 days prior to admission and be conducted by a licensed
physician, certified nurse practitioner or certified physician’s assistant. No individual may
remain in the program unless a medical examination is completed and documented.
Components of the medical examination and report include but are not limited to:
• Individual’s personal information
• Physician’s information (name, contact information, other)
• Examination information (blood pressure, pulse, height, weight, current diagnosis,
current medications, statement of freedom from communicable disease, physical and
dietary limitations, and allergies)
The medical examination report must be signed by a licensed physician/nurse practitioner/
certified physician’s assistant.
For ID/DD Waiver, the medical exam obtained as part of the admission process can be used
for up to one year from the date of the exam.
Medical Examination
Physician’s Name:
Date of
Evaluation
Physician’s Address:
Physician’s
Phone #
Person Receiving Examination: DOB
Age
Height: Temperature: Blood Pressure:
Weight Head
Circumference:
General Appearance:
Check Normal Abnormal Remarks
1. Head
2. Fontanelle
3. Skin
4. Lymph Nodes
5. Facies
6. Eyes a. Right
b. Left
7. Ears a. Right
b. Left
8. Nose
9. Mouth
10. Teeth and Gums
11. Tongue
12. Pharynx & Palate
13. Neck
14. Thorax
15. Heart
16. Lungs
17. Abdomen
18. Breasts
19. Genitals
20. Spine
21. Extremities
22. Neurological:
a. Cranial
b. Reflexes
c. Neuromuscular
d. Stand and Gait
e. Mood/ Behavior
23. Urine
24. CBC
Current Medications:
Special Dietary Requirements:
Based upon the results of this examination and the additional information provided, this person is
sufficiently free from disease and does not have any health conditions that would create a hazard
for other people.
_______________________________________ ___________________
Signature of Healthcare Provider Date
DMH Clean 2016 Documentation of Healthcare Provider Visits guidance
Documentation of Healthcare Provider Visits
Purpose
This form ensures that Supervised Living Services, Shared Supported Living Services,
Supported Living Services and Therapeutic Group Home Services providers are assisting
individuals in accessing routine healthcare services. This form is required for Supervised
Living Services and Therapeutic Group Home Services but can be used by any service
provider to document access to routine healthcare.
Timelines
This form must be completed each time the individual interacts with a healthcare provider of
any type.
Name/Type of Healthcare Provider
List the name and type of the healthcare provider. List the credential(s) of the provider.
Types of healthcare providers are physicians, nurses, pharmacists, optometrists, etc.
Reason for Visit
Provide a detailed description of why the individual is meeting with the healthcare provider.
Outcomes/Results
Provide a detailed description of the outcome of the meeting with the healthcare provider.
This includes any diagnosis(es), procedures conducted during the visit, and any
procedures/follow-up required. If a procedure of any type is scheduled, provide the date.
Medications
Medications ordered or changed must be documented on the Medication/ Emergency
Contact Information Form.
Change(s) in Existing Prescriptions
If the healthcare provider changes a currently prescribed medication(s), provide the same
information as required above and include the reason for the change(s). Update the
Medication/Emergency Contact Information form as needed.
DMH Clean 2016 Documentation of Health Care Provider Visits form
Documentation of Healthcare
Provider Visits
Name
ID Number
Date
Name of Health Care Provider:
Type of Health Care Provider:
Reason for Visit:
Outcomes/Results
Diagnosis(es) (if applicable):
Procedure(s) conducted:
Procedure(s) ordered: Date:
Describe any needed follow up, including dates:
Source of Information
Provider/ Staff participated in the visit
Family/ Guardian participated in the visit and provided results of the visit to the program
Provider assisted with access to healthcare but did not participate in the visit
Release of records completed
Records requested from healthcare provider
Staff Signature/Credential Date
DMH Clean 2016 Self Administration Medication Observation Log guidance
Self-Administered Medication Observation Log
Purpose
This form should be used to document all medications that are self-administered in day
programs and in all Supervised Living settings. This form is not intended for use by nurses
administering medication.
Forms can be prepared or generated by the pharmacy for up to one month for regularly
prescribed medication. Agencies must have policies and procedures to account for changes to
medications mid cycle. Signatures must be original at the time of observation.
Identifying Information
Enter the name and ID number of the individual.
Documentation
The provider must enter all required information.
Signature
The signature of the staff completing the log must be included. Two or more medications,
administered at the same time, can be signed with a single signature on a diagonal line across
rows. Signatures must be original and cannot be typed.
DMH Clean 2016 Self Administration Medication Observation Log form
Self-Administered
Medication
Observation Log
Name __________________________________
ID Number ______________________________
Program ________________________________
Time/ Date Medication Dosage Individual Signature
Staff Observation
Signature/
Credential
DMH Clean 2016 Telephone and Vistation Agreement guidance
Telephone/Visitation Agreement
Purpose
Individuals receiving services have the right to privacy as it pertains to the acknowledgement
of their presence in the program with regard to visitors as much as physically possible.
Individuals receiving services also have the right to determine from whom they will accept
phone calls and/or visitation. The fully executed Telephone/Visitation Agreement serves to
allow acknowledgement of the individual’s presence in the program to those listed in and
according to the terms detailed in the Agreement. This form is required for Substance
Use Residential Treatment programs, Supervised Living programs, Shared Supported Living
programs and Crisis Stabilization programs.
Timeline
The Telephone/Visitation Agreement must be completed upon admission/re-admission when
required. The Agreement must be reviewed or updated upon the request of the individual
receiving services.
Telephone Calls
Check only the box that applies. If the individual agrees to accept all telephone calls
regardless of source, the first box should be checked. If the individual agrees to only accept
calls from specific individuals, the second box should be checked and the name(s), phone
number, and relationship of those individuals must be documented.
Visits
Check only the box that applies. If the individual agrees to accept all visitors, the first box
should be checked. If the individual agrees to only accept visits from specific individuals, the
second box should be checked and the name(s), phone number, and relationship of those
individuals must be documented.
Staff and Facility-specific Visitors
By signing the Telephone/Visitation Agreement, the individual receiving services also
acknowledges their understanding that the program cannot be held responsible for
disclosures made by other individuals who may enter the premises.
DMH Clean 2016 Telephone and Visitation Agreement form
Telephone/Visitation
Agreement
Name
ID Number
While receiving
services from:
(Provider)
I give consent to receive phone calls and visits from those specific persons named in the sections below
and who are outside the program/facility for support and coordination of my treatment services.
C
I agree to have my participation in this program acknowledged and accept telephone calls from any
individuals.
C
I agree to have my participation in this program acknowledged and accept telephone calls only from
the following named individuals:
Name Telephone Number(s) Relationship
C
I agree to accept any individual as a visitors.
C
I agree to accept as visitors the following named individuals only:
Name Telephone Number(s) Relationship
I understand this consent will expire upon my discharge from the program. I may revoke this consent at
any time except to the extent that action has already taken place.
I understand that interns and delivery/maintenance people enter the premises on occasion and I will not
hold the service provider staff responsible for any visitors that may disclose my presence in this
program.
Individual Receiving Services Date Authorized Representative Date
Signature/Credential Date Relationship to Individual
DMH Clean 2016 Search and Seizure Report guidance
Search and Seizure Report
Purpose
The form serves as documentation that a search of an individual and/or his/her possessions
and/or space was conducted by a DMH certified provider. A separate form must be completed
for each individual receiving services who is included in the search.
Reason for the Search
Explain the specific reason the search was conducted.
Description of Search
Describe, in detail, all aspects of the search. Indicate the type of search conducted. Document
the specific location (room, building, program area, other), specific items searched, method of
search, and duration of search.
Items Seized
List all of the items seized as a result of the search. Specify source or location of items seized
if items were seized from more than one location or source.
Staff Involvement
The staff person who authorized the search is to sign the form and list his/her credentials and
position title. The same is true for any other staff involved in or witnessing the search.
DMH Clean 2016 Search and Seizure Report form
Search and Seizure
Report
Name
ID Number
Date
Time AM PM
Reason for Search
Description of Search
Type of Search
Person Room Locker Possessions Other
Location
List of Items Seized and Source(s) of Items
Staff Involvement
Authorized By
Signature/credentials/position title
Conducted By
Signature/credentials/position title
Other person(s) involved in or witnessing the search (signature/credential/position title):
DMH Clean 2016 Physical Escort Log guidance
Physical Escort Log
Purpose
When an individual is physically escorted away from a service or living area due to
inappropriate behavior, the intervention must be documented. A physical escort is the
temporary holding of the hand, wrist, arm, shoulder, or back for the purpose of inducing an
individual who is acting out to walk to a safe location.
Identifying Information
Enter the name and record number of the individual being escorted.
Presenting Need
The time, date and detailed description of the events necessitating an escort must be
documented. Describe in detail the individual’s behavior and the type of escort used. All staff
physically involved in the escort must be documented. Describe all other attempts to deescalate
the individual’s behavior. If less restrictive methods of de-escalation are bypassed, explain staff
reasoning. The supervisory staff person must document the face- to-face assessments provided
during the escort, including the time the assessments began and ended. List all dates the
individual was escorted within the last thirty (30) days. Indicate any treatment recommendations
and date Individual Service Plan was modified (if necessary.) The primary staff implementing
the escort must sign the documentation. Staff who witnessed but did not participate in the
escort must also sign the finalized log.
Requirements
Physical Escort cannot be utilized more than three (3) times in a thirty (30) day period unless a
Behavior Support Plan has been developed and approved by the program’s Clinical Director
and ordered by a physician or other licensed practitioner. Physical Escort cannot be used as
part of a standing order or on an as needed basis. If an individual is physically escorted, the
treating physician must be consulted within twenty-four (24) hours.
Timeline
Documentation of the physical assessments must take place when they occur. The form must
be completed in its entirety by the end of the working day in which the intervention took place.
DMH Clean 2016 Physical Escort Log form
Physical
Escort Log
Name
ID Number
Date
Page 1 of 2
Time intervention began: AM/PM ended: AM/PM
Describe the precipitating events necessitating escort:
Describe the behavior warranting escort:
Describe type of escort used:
List all staff members (regardless of position) that were involved in escort:
Describe ineffective/less restrictive alternatives attempted prior to escort:
Describe individual’s behavior during escort:
DMH Clean 2016 Physical Escort Log form
Page 2 of 2
Supervisory staff person’s face-to-face assessment of the individual’s mental and physical well
being during escort:
Time 1st assessment began: AM/PM Ended: AM/PM
Time 2nd assessment began: AM/PM Ended: AM/PM
Time 3rd assessment began: AM/PM Ended: AM/PM
Signature/credentials of
supervisor staff:
Date(s) individual restrained in
the last 30 days:
Is a Behavior Support Plan warranted? Yes No
Name of treating physician consulted: Date: Time:
Treatment Recommendations:
Date Individual Service Plan Modified:
Signature of Staff Implementing
Restraint/Escort ______________________________________________
Signature(s) of Other Staff Witness(es)
______________________________________________
______________________________________________
______________________________________________
DMH Clean 2016 Time Out Log guidance
Time Out Log
Purpose
When an individual is placed in time out due to inappropriate behavior, the intervention must be
documented.
Identifying Information
Enter the name and record number of the individual being placed in time out.
Presenting Need
The time, date and detailed description of the events necessitating the time out must be
documented. Describe in detail the individual’s behavior. All staff physically involved in the time
out must be documented. Describe all other attempts to de- escalate the individual’s behavior. If
less restrictive methods of de-escalation are bypassed, explain staff reasoning. Document the
visual assessments provided during the time out. Indicate any treatment recommendations and
date Individual Service Plan was modified (if necessary.) The primary staff implementing the
restraint/escort must sign the documentation. Staff who witnessed but did not participate in the
restraint/escort must also sign the finalized log.
Requirements
The use of time out must be justified and approved in the Individual Service Plan. Prior to the
use of time out, there must be a written Behavior Support Plan, which is developed in
accordance with the Individual Service Plan, and must be approved by the program’s clinical
director. An individual cannot be placed in timeout for more than one (1) hour. The individual
must be visually observed by staff during time out at least once every twenty (20) minutes.
Time out cannot be used for persons who have IDD.
Timeline
Documentation of visual assessments is made at the time of each observation. The form must
be completed in its entirety by the end of the working day in which the time out took place.
DMH Clean 2016 Time Out Log form
Time Out Log
Name
ID Number
Date
Time intervention began: AM/PM ended: AM/PM
Describe the precipitating events necessitating time out
Describe the behavior warranting time out
Describe ineffective/less restrictive alternatives attempted prior to time out
Describe individual’s behavior during time out, based on visual assessments
Does the Individual Service Plan require modification? Yes No
Signature of Staff Implementing Time Out Signature of Staff Observing Time Out
Signature/credentials of Supervisory Staff
DMH Clean 2016 Seclusion Behavior Management Log guidance
Seclusion Behavior Management Log
Purpose
The DMH only allows seclusion to be used in a Crisis Stabilization Unit (CSU) and only in
accordance with the order of a physician or other licensed independent practitioner, as
permitted by State licensure rules/regulations governing the scope of practice of the
independent practitioner. Programs utilizing Seclusion as part of an approved Individual
Service Plan (ISP) must document all aspects of the Seclusion intervention using the
Seclusion Behavior Management Log. There must be a written Behavior Support Plan
developed in accordance with the ISP and with signature approval by the Clinical Director.
Seclusion cannot be used for persons who have IDD.
Timeline
The Seclusion Behavior Management Log must be completed during the Seclusion
intervention in order to accurately record all aspects of the intervention. Each written order
for Seclusion must be limited to four (4) hours. After the original order expires, a physician or
licensed independent practitioner as provided above must see and assess the individual in
Seclusion before issuing a new order. Staff must observe the individual in seclusion every
15 minutes and record the observation.
Completion of the Log
The time the Seclusion intervention began and ended must be documented.
The precipitating event(s) and behavior(s) causing the Seclusion intervention to be
implemented must be documented in detail.
The less-restrictive interventions that were implemented prior to the use of Seclusion must be
documented in detail.
Visual observation by staff while the individual is in Seclusion and a description of the
individual’s behavior while in Seclusion must be documented in detail.
Staff Signatures
The Seclusion Behavior Management Log must be signed by both the staff person
implementing the Seclusion and the staff person observing the Seclusion.
DMH Clean 2016 Seclusion Behavior Management Log form
Seclusion
Behavior
Management Log
ID#
Name of Individual Being Placed in Seclusion
Time Intervention Began: Ended: Date:
Precipitating Events Necessitating Seclusion:
Behavior Warranting Intervention:
List all Staff (regardless of position) that were involved in seclusion:
Ineffective Less Restrictive Alternatives Attempted Prior to Intervention:
Description of Individual’s Behavior During Seclusion:
Signature of Staff Implementing Seclusion Signature of Other Staff Witness(es)
Physician or Other Licensed Practitioner’s Evaluation of the Need for Seclusion (within one hour
of onset):
Signature of Physician or other Licensed Practitioner
15 Minute Observations Indicated by Staff Signature
1. 7.
2. 8.
3. 9.
4. 10.
5. 11.
6. 12.
DMH Clean 2016 Service Termination Change Summary guidance
Service Termination/Change Summary
Purpose
Documentation must be provided and maintained when an individual receiving services
transfers between services. The Service Termination/Change Summary serves to document an
individual’s change(s) of service(s) with the current provider which may include transfers from
one program or service area to another.
For example: if an individual receives Service A and Service B and will no longer receive
Service A- a Service Termination/ Change Summary must be completed for Service A.
Service(s) initiated must be part of the Individual Service plan. If they are not on the ISP at the
time of change, a revision to the ISP must be completed and certified by those with signatory
authority and signed by the individual receiving services or legal representative.
Service Termination/Change Information
The staff member completing the Service Termination/Change Summary must provide as much
information as necessary to clearly describe the transfer that is taking place. It must be
documented if the transfer is expected to be temporary or permanent, with dates provided when
appropriate or available.
Date of Transfer
The date must indicate the point at which the transfer will become effective. One Service
Termination/Change Summary can be used for more than one service change that all become
effective the same date. Separate forms must be used for transfers that have different effective
dates.
Signatory Authority
The staff member authorizing the change must sign and date the for m.
DMH Clean 2016 Service Termination Change Summary form
Service
Termination/Change
Summary
Name
ID Number
Date
Service Termination
Service Change
Effective Date of Service Change/Termination:
___________________
Service Termination or Change is expected to be Temporary Permanent
Reasons for Service Termination/ Change (Check all that apply):
Change in Diagnosis Change in Symptoms Change in Service Activities
Change in Treatment Recommendations Appropriate for Less Intensive Service
Change in Service Staff
Other_________________________________________________
List Service(s) Discontinued
List Service(s) Initiated
Service Change Instructions or Information:
Signature/Credentials Date
DMH Clean 2016 Provider Discharge Summary guidance
Provider Discharge Summary
Purpose
When an individual is no longer receiving services from the agency, a Discharge Summary must
be completed and placed in the individual’s record. The Discharge Summary must be completed
to summarize the services provided, the reason for the discharge from the provider agency, and
any referrals made at the time of discharge.
Timeline
The effective date of the discharge must be documented.
Reason for Discharge
Indicate which category most appropriately describes the reason for discharge.
Referral Information
If the individual was referred to another provider or to other services, this should be indicated by
selecting one or more categories that most appropriately describes the service or provider
referral(s).
Instructions/Additional Information
If any instructions were provided to the individual or legal representative at the time of discharge,
these must be described and individual receiving information must sign to acknowledge.
Additional information specific to the discharge may be included.
If the individual participates in the ID/DD Waiver program, a copy of this form must be provided to
the Individual’s Support Coordinator within 5 days of discharge.
DMH Clean 2016 Provider Discharge Summary form
Provider Discharge
Summary
Name
ID Number
Date
Effective Date of Discharge
Reason For Discharge:
Evaluation Only Moved from service area
Treatment Completed Deceased
Provider Terminated Treatment No contact in 12 months
Individual Referred Elsewhere Individual requested discharge
Other _______________________
Referred To:
DMH Behavioral Health Program Family/Friend Private PRTF
Other MS CMHC School/Education Private ICF/IID
DMH IDD Program Employer/EAP Other_____________
Private Psychiatric Hospital Police / Sheriff
Other MH Provider Courts/Corrections
Other IDD Provider Probation/ Parole
Other A&D Provider Self Help Program
Gen/Hospital/Other Health Voc Rehab/Job Placement
Self Licensed Personal Care Home
Discharge Instructions provided to Individual Legal Representative
Discharge Instructions/Additional Information:
Individual/Legal Representative Date
Signature/Credentials Date
Section E
Day Service Programs
Acute Partial Hospitalization Services Summary Note
Individual Recovery Action Plan
DMH Clean 2016 Acute Partial Hospitalization Services Summary Note guidance
Acute Partial Hospitalization Services Summary Note
Purpose
Documentation must be maintained when an individual receives Acute Partial Hospitalization
Services. There must be documentation of medical supervision and follow along to include
on-going evaluation of the medical status of the individual. Support services for families and
significant others must be documented. Discharge criteria and follow-up planning must be
documented.
Identifying Information
Record the name, record number, date of service and total amount of time the individual
received the service.
Services
Indicate which services were provided during the day by checking the appropriate box,
specify the time the service began and ended and list the name of the staff providing the
service.
Therapeutic Activities Provided
List all activities the individual participated in during the day, specify the time the activity
began and ended and list the name of the staff providing the service.
Daily Summary Note
The Master’s level staff must summarize the progress of the individual receiving services in
SAP format as it relates to the Individual Service Plan.
Timeline
APH Services must be documented daily with a summary note that records services
provided.
DMH Clean 2016 Acute Partial Hospitalization Services Summary Note form
Acute Partial Hospitalization
Services
Summary Note
Name
ID Number
Date
Total Time
Services Check Time In Time Out Name of Service Provider
Medical Supervision
Nursing
Intensive Psychotherapy
Individual Therapy
Group Therapy
Family Therapy
Therapeutic Activities Provided
Activity Time In Time Out Name of Activity Coordinator
Daily Summary Note
S
A
P
Signature/Credential
DMH Individual Recovery Action Plan guidance
Purpose
Individuals attending the PSR program must have a Wellness Recovery Action Plan
(WRAP), Person-Centered Plan (PCP), or an IRAP (Individual Recovery Action Plan).
Individuals must participate in the development of his/her plan.
The IRAP mu st be reviewed and revised when the problems or goals change or as
needs of the individual change. At a minimum, the IRAP must be reviewed and
revised/rewritten annually.
Definition of Quality of Life
Individuals must define what he/she considers quality of life.
Barriers to Quality of Life
List barriers which prevent the individual from achieving the quality of life he/she
desires.
Goal
List the goals that are the focus of PSR services.
Action Step to Obtain Goal
List the action steps that ne ed to be accomplished in order to achieve the goal(s).
Address the identification and integration of natural supports to connect to the
community and the utilization of formal and informal resources to support goals and
desired outcomes.
Desired Outcome:
List the individual’s desired outcomes.
Date Goal Achieved
Document the date the goal was achieved.
Individual Recovery Action Plan
DMH Individual Recovery Action Plan form
Individual Recovery Action Plan
Name ___________________________________________________
ID Number _______________________________________________
Date ____________________________________________________
Definition
of Quality
of Life
Barriers
to Quality
of Life
Goals
Dates Achieved
Action
Steps
DMH Individual Recovery Action Plan form
Linked and
Followed
up to
Resources
In
Community
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
PSR
Staff: Date:
Individual
Receiving
Services: Date:
Section F
Mental Health Services
Adult Making A Plan (AMAP) Case Summary
Adult Making A Plan (AMAP) Monthly Reporting
Crisis Stabilization Services Daily Note
Adult Pre-Evaluation Screening
Youth Pre-Evaluation Screening
Violence Risk Assessment for Certified Holding Facility
Suicide Risk Assessment for Certified Holding Facility
DMH Adult Making A Plan Case Summary guidance
Adult Making A Plan (AMAP) Case Summary
Purpose
Adult Making a Plan (AMAP) Teams address the needs of adults with serious mental illness
who require services from multiple agencies and multiple program systems due to
multiple/frequent in-patient treatment admissions or commitments. The purpose of the AMAP
Team is to develop and implement new and different systems of wrap- around support in order
to treat individuals in the community rather than an institutional setting. All Community Mental
Health Centers must document participation in at least one AMAP Team in their region.
Documentation
If DMH funds are utilized to assist individuals referred to the AMAP Team, all questions in all
sections of the Case Summary form must be answered in as much detail as possible in order to
justify the need for AMAP Team intervention.
Timeline
The AMAP Case Summary form must be completed, attached to the Mobile Crisis Response
Team (M-CeRT) cash request, and submitted to the Department of Mental Health by the 15 th of
the following month.
DMH Adult Making A Plan AMAP Case Summary form
Signature of AMAP Team Coordinator _ __________ __________
AMAP Team
Case Summary Form
Name: ______________________
Date of Review ______________
Why was this individual referred to the AMAP Team? (How many inpatient tx/over what period of time)
Why was this individual considered to be at-risk?
Recommendations of the team (include how they differ from past interventions) :
If DMH funds will be used for this individual, indicate estimated amounts for each
recommended service/support agreed upon by the team.
If DMH funds will be used for this individual, how will the use of these funds maintain this
individual in his/her home and community? How will the service/support continue after the use
of DMH funds?
DMH Adult Making A Plan Monthly Report guidance
Adult Making A Plan (AMAP) Monthly Report
Purpose
Adult Making a Plan (AMAP) Teams address the needs of adults with serious mental illness
who require services from multiple agencies and multiple program systems due to
multiple/frequent in-patient treatment admissions or commitments. The purpose of the AMAP
Team is to develop and implement new and different systems of wrap- around support in order
to treat individuals in the community rather than an institutional setting.
Documentation
Document the county where the AMAP meeting was held and the month the meeting took
place. Document the number of each staff representing the agencies involved with the AMAP
Team. Have each team member sign the attendance log and write the name of their agency on
the same line.
Timeline
The AMAP Monthly Reporting form must be completed, attached the Mobile Crisis Response
Team (M-CeRT) cash request, and submitted to the Department of Mental Health by the 15
th of
the following month.
DMH Adult Making A Plan AMAP Monthly Report form
AMAP Team
Monthly Reporting
County _____________________
Month ______________________
Monthly Reporting Forms must be submitted to the Department of Mental Health by the
10th of each month. Case summary forms, for each adult reviewed, must be submitted
with the monthly reporting form. Cash requests will not be processed without this
information.
Referral Information
1. Number of cases reviewed _____
2. Number of follow-ups from previous month _____
3. Number of referrals from:
Mental Health Center in your county Mental Health Center Region-Wide
Mental Health Center (other Region) Chancery Court/Clerk
MDMH State Hospital Sheriff’s Department
Crisis Stabilization Unit Police Department
Behavioral/Mental Health Court Family Member(s)
Other
AMAP Team Member Participation
Please indicate, using a checkmark, which of the following agencies that were
represented at your AMAP Team Meeting(s) for the month.
Community Mental Health Center MDMH State Hospital
Chancery Court Crisis Stabilization Unit
Sheriff’s Department Police Department
______Families ______ Individual Receiving Services
______ NAMI ______ Other *please identify
DMH Adult Making A Plan AMAP Monthly Report form
AMAP Team Member Participation
Attendance Log
Team Member Agency Represented
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
DMH Crisis Stabilization Services Daily Activity/ Daily Progress Summary Note
Purpose
Documentation must be maintained with an individual receives Crisis Stabilization
Services. Each therapeutic activity must be documented along with a summary of
progress for each day the individual receives services. All psychiatric care, nursing
services and mental health therapy will be documented in the Individualized Progress
Note format.
Identifying Information
Record the name, record number, date of service and total amount of time the individual
received the service.
Therapeutic Activities Provided
Indicate the nature of the therapeutic activities being provided, specify the time the
activity began and ended and list the name of the staff leading the services.
Daily Summary Note
A Master’s level therapist must summarize the progress of the individual receiving
services as it relates to the Individual Service Plan.
Timeline
Crisis Stabilization Services must be documented daily with a summary note that
records services provided.
Crisis Stabilization Services (i.e. counseling, therapy, recreational, education, and
social/interpersonal activities) can be provided seven (7) days per week but must at a
minimum be;
a. Provided five (5) days per week.
b. Provided five (5) hours per day.
c. Provided two (2) hours per day for children/youth enrolled and attending
school full time.
Crisis Stabilization Services
Daily Activity/Daily Progress Summary Note
DMH Clean 2016 Crisis Stabilization Services Daily Activity Daily Progress Summary Note form
Crisis Stabilization Services
Daily Activity/Daily Summary
Note
Name
ID Number
Date
Total Time
Therapeutic Activities Provided
Activity Time In Time Out Name of Activity Coordinator
Daily Summary Note
Signature/Credential
DMH Youth and Adult Pre-Evaluation Screening guidance
Youth and Adult Pre-Evaluation Screening
Purpose
The Pre-Evaluation Screening is required under Mississippi Civil Commitment Statutes. The
Pre-Evaluation Screening must take place prior to the Civil Commitment Exam and can only
be completed by staff from a Community Mental Health Center. The Pre-Evaluation
Screening is used to gather information pertaining to an individual to be used by the
Chancery, Family and/or Youth Court in determining the need for civil commitment.
Timeline
The Pre-Evaluation Screening must take place within 48 hours after an affidavit has been
filed in Chancery, Family and/or Youth Court.
General
The Pre-Evaluation Screening must be filled out as completely as possible. Do not leave
any spaces blank. If you are unable to gather certain information then make a notation in
that space. Information can be gathered from informants, the individual and the individual’s
record.
The Adult Pre-Evaluation is to be used with individuals 18 years and older. The Youth Pre-
Evaluation is to be used with individuals 14 – 17 years of age.
Once the Pre-Evaluation Screening is completed, recommend to the court if a Civil
Commitment Exam should take place. If you recommend that the Civil Commitment Exam
does not need to take place, indicate on the form why and list appropriate referrals that
have been made or should be made. Include any additional comments that you think are
pertinent to the court.
A copy of the completed form must be kept in the individual’s record.
Signature
The staff person completing the Pre-Evaluation Screening must sign the report to include
credentials.
1
Adult Pre-Evaluation
Date: Time In: Time Out: Interview Location:
Individuals Present:
Interpretative Aids/Assisted Devices: Pending Felony Charges: ☐ Yes ☐ No
Case Number: CMHC Region:
In the court of County Voluntary CSU Admission Sought : ☐ Yes ☐ No
Mobile Crisis Involvement : ☐ Yes ☐ No
Information from this interview will be reported on a standardized form and submitted to the chancery court and civil commitment
examiners. You have the right to refuse to participate. Other sources of information including a review of your legal medical
records and interviews with family member and the affiant requesting commitment will be included in this report.
Respondent Demographics
Name: DOB: select dob Age: Gender: Race:
Social Sec #: Medicaid #: Medicare#:
Home Address: Phone Number:
Respondent resides with minor children: ☐ Yes ☐ No Name & Ages of Children:
Respondent has visitation rights to minor children: ☐ Yes ☐ No
Respondent has legal guardian/conservator: ☐ Yes ☐ No
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Affiant Demographics
Affiant Name: Relation of Respondent:
Phone Number: Home Address:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Respondent Psychosocial Information
Current Living: ☐Alone ☐Family/Friends ☐Assisted Living ☐Homeless ☐Other/Describe:
Housing: Dwelling: Home Address:
Employed: ☐ Yes ☐ No Employer/Position: Length of Job:
If unemployed (most recent job?): Highest Level of Education Completed:
Religious Preference or Practice:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Psychiatric History
Current Psychotropic Medications:
Dosage & Date/Time Last Taken:
Is the medication helpful or problematic:
Psychiatric Hospitalizations:
Locations/Dates:
Outpatient Treatments: Locations/Dates:
Psychological Testing: Provider/Dates:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
2
Medical Status & Treatment History
Current Medications (not listed above):
Dosage & Date/Time Last Taken:
Is the medication helpful or problematic:
Known Medication Allergies:
Currently Under Physician Care For: Physician’s Name:
Conditions Treated In The Past: Provider/Dates:
Medical Hospitalization History: Physical Disabilities:
Current Communicable Diseases:
☐HIV/AIDS ☐Hepatitis A ☐Hepatitis B ☐Hepatitis C ☐TB(Tuberculosis)
☐MRSA ☐Influenza ☐Head Lice ☐Scabies ☐Body Lice ☐STIs ☐Other
Currently Pregnant: ☐ Yes ☐ No
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Developmental Disability
History of Special Education Ruling: ☐ Yes ☐ No If yes, describe:
Documented IQ below 70: ☐ Yes ☐ No If yes, describe:
Documented sub-average intellectual functioning before age 18: ☐
Yes ☐ No If yes, describe:
Documented Adaptive Functioning Deficits: ☐ Yes ☐ No If yes, describe:
Specific Observed Adaptive Functioning Deficits:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Mental State Exam
Oriented to Date: Time: Place:
*Cue for three words (provide words)
President:
Counting Response:
Word Recall:
Completed Written Command: ☐ Yes ☐ No If no, describe:
What do you understand the reason for our meeting today to be?
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Psychiatric Symptoms Past Month
Respondent( R ) Informant(I)
Depressive Symptoms R I Anxiety Symptoms R I Somatic Symptoms R I
☐ Depressed mood most of the day ☐ ☐ ☐ Worry ☐ ☐ ☐Headaches ☐ ☐
☐ Lack of Interest/Pleasure ☐ ☐ ☐ Restlessness ☐ ☐ ☐Chest Discomfort/Pain ☐ ☐
☐ Appetite Change or Sig Weight
Change ☐ ☐ ☐ Easily Fatigued ☐ ☐ ☐Faintness ☐ ☐
☐ Insomnia (Difficulty Falling Asleep) ☐ ☐ ☐ Irritability ☐ ☐ ☐ Hot or Cold Flashes ☐ ☐
☐ Feelings of Worthlessness ☐ ☐ ☐ Muscle Tension ☐ ☐ ☐Stomach Aches/Pains ☐ ☐
☐ Fatigue or Loss of Energy ☐ ☐ ☐ Difficulty Concentrating ☐ ☐ ☐ Heart Palpitations ☐ ☐
☐ Diminished Concentration ☐ ☐ ☐ Sleep Disturbance ☐ ☐ ☐ Dizziness or Vertigo ☐ ☐
3
Depressive Symptoms R I Anxiety Symptoms R I Somatic Symptoms R I
☐ Indecisiveness ☐ ☐ ☐ Other ☐ ☐ ☐Shaking/Trembling ☐ ☐
☐ Hypersomnia (Sleeping Excessively) ☐ ☐ ☐Tingling in hands or feet ☐ ☐
☐ Recurrent Thoughts of Death ☐ ☐ ☐Excessive Sweating ☐ ☐
☐ Motor Retardation ☐ ☐ ☐ Other ☐ ☐
☐ Motor Agitation ☐ ☐
☐ Feelings of Hopelessness ☐ ☐
☐ Other ☐ ☐
Psychiatric Symptoms Past Month
Respondent( R ) Informant(I)
Mania & Hypomania Symptoms R I R I
☐ At least 1 week ☐ ☐ ☐More talkative than usual ☐ ☐
☐ 4 consecutive days < weeks ☐ ☐ ☐Excessive involvement in activities with high potential for
painful consequences ☐ ☐
☐ Flight of ideas/racing thoughts ☐ ☐ ☐Distractibility ☐ ☐
☐ Decreased need for sleep ☐ ☐ Persistent elevated, or irritable mood and significant increases in
goal directed activity ☐Yes ☐No ☐ ☐
☐ Increased self-esteem of Grandiosity ☐ ☐
Thought Disorder Symptoms R I
☐ Hallucinations ☐ ☐ ☐ Absence of emotions ☐ ☐
☐ Auditory ☐Visual ☐Olfactory ☐ ☐ ☐Absence of speech ☐ ☐
☐ Tactile ☐Gustatory ☐ ☐ ☐Absence of movement ☐ ☐
Specific Hallucinations:
☐ ☐ ☐ Lack of Hygiene ☐ ☐
☐ Delusions ☐ ☐ ☐Lack of eating/feeding ☐ ☐
☐Persecutory ☐Grandiose ☐Paranoid ☐
Other ☐ ☐
Specific Delusions:
Obsessive Compulsive Symptoms
Obsessive Thoughts ☐Yes ☐No ☐ ☐ Obsessive Thoughts ☐Yes ☐No ☐ ☐
Severity: ☐Mild ☐Moderate ☐Severe ☐ ☐ Severity: ☐Mild ☐Moderate ☐Severe ☐ ☐
Specific Obsessions: ☐ ☐ Specific Obsessions: ☐ ☐
TRAUMA HISTORY
Trauma Exposure ☐Yes ☐No (type/approx. Date)
Trauma Triggers:
Environmental ☐ Crowding ☐Room checks ☐Confusing signs ☐ Slamming doors
☐ Leaving bedroom door open ☐ Dark room ☐ Too hot or too cold ☐ Noise
Interpersonal ☐ Lack of privacy
☐ Being approached by
men or women ☐Arguments ☐People Yelling
☐ Confined spaces ☐Being touched ☐ People too close ☐Contact with Family
☐ Being stared at ☐ Being ignored ☐Feeling pressured
☐ Being ordered to do
something
☐ Being approached by women ☐ Being Teased/picked on
☐ People focusing on my
symptoms ☐ Smells
☐ Tall or large people
Other Triggers ☐ Taste ☐ Time of Day ☐ Sounds ☐ Sights ☐ Sensations/textures ☐ Wringing hands
Warning Signs of
Emotional
escalations
☐ Heart Pounding
☐ Clenching teeth
☐Bouncing legs
☐ Shortness of Breath
☐ Flushed/red face
☐Singing
☐ Breathing Hard
☐ Crying
☐Can’t sit still
☐Wringing hands
☐Clenching fists
☐Cursing/swearing
☐ Sweating ☐ Rocking ☐Pacing ☐Giggling
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
4
Suicide Assessment
Prior Attempts: Friend or Family Member Completed Suicide:
Approximate Date: Approximate Date:
Method of attempt: Method of suicide:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Behaviors Exhibited by Respondent
History or Present Danger to Others ☐ Yes ☐ No (If Yes, mark appropriate statement(s) below)
☐ Thoughts of suicide ☐ Threats of suicide ☐ Plan for Suicide ☐Pre-occupation with death
☐ Suicide gesture ☐ Suicide attempts ☐ Family history of suicide ☐ Self-mutilation
☐ Inability to care for self ☐ High risk behavior ☐ Provoking harm to self from others
☐ Other
Describe:
Violence Risk Assessment
Current thoughts about harming another person ☐ Yes ☐ No
If Yes, whom:
If yes, how long have you had these thoughts
If yes, specific plan:
Access to means to carry out plan:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Violence Risk Factors Present
Present Unknown Present Unknown
☐ ☐ Male Gender ☐ ☐ Substance Abuse
☐ ☐ Suspiciousness/Perception of hidden threat ☐ ☐ Comorbid MI & Substance Use Dx
☐ ☐ Early offense history ☐ ☐ Anger
☐ ☐ Psychopathy ☐ ☐ Antisocial Personality Diagnosis
☐ ☐ Violent Fantasies Frequency, type, recency
☐ ☐ Previous violence against other people Frequency, severity, type
☐ ☐ Childhood physical abuse Frequency, severity
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Substance Use
Do you currently use?
Past Use Amount Frequency Age of Initiation
Alcohol
Marijuana
Opioids
Amphetamines
Hallucinogenic
Prescription Medication
Over the counter medication
History of legal charges related to substance use? ☐ Yes ☐ No Describe:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
5
Physical Appearance
Attire Hair Nails Skin
☐ Glasses ☐ Appropriate for occasion ☐ Clean ☐ Clean ☐ Clean ☐ Bruised
☐ Contacts ☐ Appropriate for weather ☐ Dirty ☐ Dirty ☐ Dirty ☐ Cuts/Scrapes
☐ Hearing Aids ☐ Clean ☐ Disheveled ☐ ☐ Tattoos
Describe: ☐ Dirty ☐ Styled
☐ Torn/worn through ☐ ☐ Sores
☐ Other ☐
Teeth Unusual alterations or distinguishing features:
☐ Clean
☐ Dirty
☐ Decay
☐ Missing
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Behavioral Observations
Motor Activity
Diminished Normal Excessive Unusual
☐ Frozen ☐ Purposeful ☐ Restless ☐ Other
☐ Catatonic ☐ Coordinated ☐ Squirming
☐ Almost motionless ☐ Other ☐ Fidgety ☐ Little animation ☐ Constant movement
☐ Psychomotor
retardation ☐ Hyperactive
☐ Slowed reaction
time ☐ Other
☐ Other
Speech
Slowed Normal Pressured Verbose Unusual
☐ Minimal response ☐ Initiates ☐ Excessively wordy ☐ Over productive ☐
☐ Unspontaneous ☐ Alert/responsive ☐ Expansive ☐Long winded
☐ Sluggish ☐ Productive ☐ Rapid ☐Non stop
☐ Paucity ☐ Animated ☐ Fast ☐ Frequent run ons
☐ Impoverished ☐ Spontaneous ☐ Rushed ☐Flight of ideas
☐ Single word
answers ☐Smooth ☐ Other ☐Hyper verbal
☐ Other ☐ Other ☐Other
Thought Process
Attention Insight Preoccupations
☐ Normal ☐ Good ☐ Somatics ☐ Self
☐ Unengaged ☐ Fair ☐ Children ☐ Finances
☐ Distractible ☐ Poor ☐ Spouse/Sig Other ☐ Other
☐ Hyper vigilant ☐ No insight ☐ Job
☐ Hyper focused
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Affect
☐Flat ☐ Blunted ☐ Constricted ☐ Normal ☐Broad
6
Facial Expression
☐ Vacant ☐ Blank ☐ Strained ☐Pained ☐ Grimacing
☐ Smiling ☐ Other
Summary & Recommendations
Based on the data gathered for the current Pre Evaluation Screening:
☐ It is NOT recommended that this respondent receive a civil commitment exam.
1) Current available information indicates that present symptomatology is due to
☐Dementia ☐Intellectual/Developmental Disability ☐ Epilepsy ☐Chemical Dependency ☐Mental Illness
2) The following referrals for appropriate evaluation or treatment have been provided:
a.
b.
c.
☐ It IS recommended that this respondent receive a civil commitment exam. Based on the data available for the current Pre Screening Evaluation the
following symptomatology cannot be managed/treated in a less restrictive environment:
1)
2)
3)
4)
Comments:
___________________________________________
Signature-Credentials
1
Youth Pre-Evaluation
Date: Click for date Time In: Enter Time Time Out: Enter Time Interview Location: Click here to enter text.
Individuals Present: Click here to enter text.
Interpretative Aids/Assisted Devices:Click here to enter text. Pending Felony Charges: ☐ Yes ☐ No
Case Number: CMHC Region: Click here to enter text.
In the Court court of Choose a county. County Voluntary CSU Admission Sought: ☐ Yes ☐ No
Mobile Crisis Involvement: ☐ Yes ☐ No
Information from this interview will be reported on a standardized form and submitted to the chancery court and civil commitment
examiners. You have the right to refuse to participate. Other sources of information including a review of your legal medical
records and interviews with family member and the affiant requesting commitment will be included in this report.
Respondent Demographics
Name: Click here to enter text. DOB: select dob Age: Gender: Select Race: Choose an item.
Social Sec #: e.g. 123-12-1234 Medicaid #: Medicare#:
Home Address: City, State, and Zip Code Phone Number: e.g. 555-555-5555
Does the respondent have a legal guardian or conservator: ☐ Yes ☐ No
Guardian/Conservator Contact Information Click here to enter text.
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Affiant Demographics
Affiant Name: Click here to enter text. Relation of Respondent: Choose an item.
Phone Number: e.g. 555-555-5555 Home Address: City, State, and Zip Code
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Respondent Psychosocial Information
Current Living: Click here to enter text.
Current Grade in School: Name of School: City, State, and Zip Code
History of IEP or 504C: ☐ Yes ☐ No Date of most recent IEP or 504C: Click here to enter text.
Juvenile Justice Involvement: ☐ Yes ☐ No Describe: City, State, and Zip Code
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Psychiatric History
Current Psychotropic Medications:
Click here to enter text.
Dosage & Date/Time Last Taken:
Click here to enter text.
Is the medication helpful or problematic:
Click here to enter text.
Psychiatric Hospitalizations:
Click here to enter text.
Locations/Dates:
Enter Location and Date
Outpatient Treatments: Click here to enter text. Locations/Dates: Enter length of job
Psychological Testing: Click here to enter text. Provider/Dates:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
2
Medical Status & Treatment History
Current Medications (not listed above):
Click here to enter text.
Dosage & Date/Time Last Taken:
Click here to enter text.
Is the medication helpful or problematic:
Click here to enter text.
Known Medication Allergies:Click here to enter text.
Currently Under Physician Care For: Click here to enter text. Physician’s Name: Enter length of job
Conditions Treated In The Past: Click here to enter text. Provider/Dates:
Medical Hospitalization History: Physical Disabilities:
Current Communicable Diseases:
☐HIV/AIDS ☐Hepatitis A ☐Hepatitis B ☐Hepatitis C ☐TB(Tuberculosis)
☐MRSA ☐Influenza ☐Head Lice ☐Scabies ☐Body Lice ☐STIs ☐Other
Currently Pregnant: ☐ Yes ☐ No
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Developmental Disability
Pregnancy/Delivery Complications: ☐ Yes ☐ No Describe:
Met Developmental Milestones On Time:
Walked ☐ Talked ☐ Crawled ☐ Toilet Trained ☐ Feeding ☐ If no, describe: escribe
History of Special Education Ruling: ☐ Yes ☐ No If yes, describe: Describe
Documented IQ below 70: ☐ Yes ☐ No If yes, describe: Describe
Documented sub-average intellectual functioning before age
18: ☐ Yes ☐ No If yes, describe: Describe
Documented Adaptive Functioning Deficits: ☐ Yes ☐ No If yes, describe: Describe
Specific Observed Adaptive Functioning Deficits: Click here to enter text.
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Mental State Exam
Oriented to Date: select date Time: Enter Time Place:Enter place.
*Cue for three words (provide words)
President: Enter Response
Counting Response: Click here to enter text.
Word Recall: Click here to enter text. Click here to enter text. Click here to enter text.
Completed Written Command: ☐ Yes ☐ No If no, describe: Click here to enter text.
What do you understand the reason for our meeting today to be? Click here to enter text.
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Psychiatric Symptoms Past Month
Respondent( R ) Informant(I)
Mood Symptoms R I Mood Symptoms R I Behavioral Symptoms R I
☐ Depressed mood/Appears Sad ☐ ☐ ☐ Dizzy ☐ ☐ ☐Attempts to “ Annoy” Others ☐ ☐
☐ Enjoys Very Little ☐ ☐ ☐ Shaking/Trembling ☐ ☐ ☐ Defies Requests ☐ ☐
☐ Cries Frequently ☐ ☐ ☐Excessive Sweating ☐ ☐ ☐ Angry & Resentful ☐ ☐
☐ Decrease in Appetite ☐ ☐ ☐ Shortness of Breath ☐ ☐ ☐ Sullen ☐ ☐
☐ Increase in Appetite ☐ ☐ ☐ Tingling in Hands or Feet ☐ ☐ ☐ Irritable ☐ ☐
3
Mood Symptoms continues R I Mood Symptoms
continues R I Behavioral Symptoms
continues R I
☐ Fatigued or Underactive (without
reason) ☐ ☐ ☐ Headache ☐ ☐ ☐ Tantrums ☐ ☐
☐ Difficulty Sleeping ☐ ☐ Behavioral Symptoms R I ☐ Lying ☐ ☐
☐ Nightmares/Nigh Terrors ☐ ☐ ☐Impulsive ☐ ☐ ☐ Cheating ☐ ☐
☐ Withdrawn From Peers ☐ ☐ ☐ Fails to Finish Tasks ☐ ☐ ☐ Steals ☐ ☐
☐ Bullied or Rejected by Peers ☐ ☐ ☐ Talks Excessively ☐ ☐ ☐ Physically Harms People ☐ ☐
☐ Engages in Self Harm ☐ ☐ ☐ Loud ☐ ☐ ☐ Physically Harms Animals ☐ ☐
☐ Talks About Killing Self Wishes to die ☐ ☐ ☐ Blurts Words/Interrupts ☐ ☐ ☐ Destroys Property ☐ ☐
☐ Clings to Adults/Dependent ☐ ☐ ☐ Difficulty Sitting Still,
Restless ☐ ☐ ☐ Sets Fires ☐ ☐
☐ Fears Specific Situations or Objects
Describe: ☐ ☐ ☐ Fidgets ☐ ☐ ☐ Threatens Others ☐ ☐
☐ Reports Fearing School ☐ ☐ ☐ Easily Distracted ☐ ☐ ☐ Physical Fights With Peers ☐ ☐
☐ Worries ☐ ☐ ☐ Disorganized ☐ ☐ ☐ Skips School ☐ ☐
☐ Tense ☐ ☐ ☐ Forgetful/Misplaces
Belongings ☐ ☐ ☐ Used a Weapon ☐ ☐
☐ Stomach Aches or Pains ☐ ☐ ☐ Loses Temper Frequently ☐ ☐ ☐ Delinquent Peers ☐ ☐
☐ Heart Palpitations ☐ ☐ ☐ Argues with Adults
☐ Home ☐ School ☐ ☐
Psychiatric Symptoms Past Month
Respondent( R ) Informant(I)
Thought Disorder Symptoms R I R I
☐ Hallucinations ☐ ☐ ☐ Absence of emotions ☐ ☐
☐ Auditory ☐ Visual ☐ Olfactory ☐ ☐ ☐ Absence of speech ☐ ☐
☐ Tactile ☐Gustatory ☐ ☐ ☐ Absence of movement ☐ ☐
Specific Hallucinations:
Click here to enter text. ☐ ☐ ☐ Lack of Hygiene ☐ ☐
☐ Delusions ☐ ☐ ☐ Lack of eating/feeding ☐ ☐
☐Persecutory ☐Grandiose ☐ Paranoid
☐Other ☐ ☐
Specific Delusions:
Click here to enter text.
Obsessive Compulsive Symptoms
Obsessive Thoughts ☐Yes ☐ No ☐ ☐ Obsessive Thoughts ☐Yes ☐ No ☐ ☐
Severity: ☐Mild ☐Moderate ☐Severe ☐ ☐ Severity: ☐Mild ☐Moderate ☐Severe ☐ ☐
Specific Obsessions:Click here to enter text. ☐ ☐ Specific Obsessions:Click here to enter
text. ☐ ☐
TRAUMA HISTORY
Trauma Exposure ☐Yes ☐No (type/approx. Date) Click here to enter text.
Trauma Triggers:
Environmental ☐ Crowding ☐ Room checks ☐ Confusing signs ☐ Slamming doors
☐ Leaving bedroom door open ☐ Dark room ☐ Too hot or too cold ☐ Noise
4
Suicide Assessment
Prior Attempts: Click here to enter text.
Friend or Family Member Completed Suicide: Click here to
enter text.
Approximate Date: Click here to enter text. Approximate Date: Click here to enter text.
Method of attempt: Click here to enter text. Method of suicide: Click here to enter text.
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Behaviors Exhibited by Respondent
History or Present Danger to Others ☐ Yes ☐ No (If Yes, mark appropriate statement(s) below)
☐ Thoughts of suicide ☐ Threats of suicide ☐ Plan for Suicide ☐Pre-occupation with death
☐ Suicide gesture ☐ Suicide attempts ☐ Family history of suicide ☐ Self-mutilation
☐ Inability to care for self ☐ High risk behavior ☐ Provoking harm to self from others
☐ Other
Describe:
Violence Risk Assessment
Current thoughts about harming another person ☐ Yes ☐ No
If Yes, whom: Click here to enter text.
If yes, how long have you had these thoughts Click here to enter text.
If yes, specific plan: Click here to enter text.
Access to means to carry out plan: Click here to enter text.
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Violence Risk Factors Present
Present Unknown Present Unknown
☐ ☐ Male Gender ☐ ☐ Substance Abuse
☐ ☐ Suspiciousness/Perception of hidden threat ☐ ☐ Comorbid MI & Substance Use Dx
☐ ☐ Early offense history ☐ ☐ Anger
☐ ☐ Psychopathy (PCL:SV>12) ☐ ☐ Antisocial Personality Diagnosis
☐ ☐ Violent Fantasies Frequency, type, recency Click here to enter text.
☐ ☐ Previous violence against other people Frequency, severity, type Click here to enter text.
☐ ☐ Childhood physical abuse Frequency, severity Click here to enter text.
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Interpersonal Lack of privacy
☐ Being approached by
men or women ☐ Arguments ☐People Yelling
☐ Confined spaces ☐ Being touched ☐ People too close ☒Contact with Family
☐ Being stared at ☐ Being ignored ☐ Feeling pressured ☐ Being ordered to do something
☐ Being approached by women ☐ Being Teased/picked on ☐ Tall or large people ☐ Smells
☐People focusing on my symptoms
Other Triggers ☐ Taste ☐ Time of Day ☐Sounds ☐ Sights ☐ Sensations/textures ☐ Wringing hands
Warning Signs
of Emotional
escalations
☐ Heart Pounding
☐ Clenching teeth
☐ Bouncing legs
☐ Shortness of Breath
☐ Flushed/red face
☐Singing
☐ Breathing Hard
☐ Crying
☐Can’t sit still
☐Wringing hands
☐Clenching fists
☐Cursing/swearing
☐ Sweating ☐ Rocking ☐Pacing ☐Giggling
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
5
Substance Use
Do you currently use?
Past Use Amount Frequency Age of Initiation
Caffeine Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.
Nicotine Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.
Alcohol Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.
Marijuana Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.
Opioids Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.
Amphetamines Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.
Hallucinogenic Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.
Prescription Medication Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.
Over the counter medication Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.
History of legal charges related to substance use? ☐ Yes ☐ No Describe: Click here to enter text.
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Physical Appearance
Attire Hair Nails Skin
☐ Glasses ☐ Appropriate for occasion ☐ Clean ☐ Clean ☐ Clean ☐ Bruised
☐ Contacts ☐ Appropriate for weather ☐ Dirty ☐ Dirty ☐ Dirty ☐ Cuts/Scrapes
☐ Hearing Aids ☐ Clean ☐ Disheveled ☐ ☐ Tattoos
Describe: Click here to enter text. ☐ Dirty ☐ Styled
☐ Torn/worn through ☐ ☐ Sores
☐ Other ☐
Teeth Unusual alterations or distinguishing features:
Click here to enter text. ☐ Clean
☐ Dirty
☐ Decay
☐ Missing
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Behavioral Observations
Motor Activity
Diminished Normal Excessive Unusual
☐ Frozen ☐ Purposeful ☐ Restless ☐ Other Click here
to enter text.
☐ Catatonic ☐ Coordinated ☐ Squirming
☐ Almost motionless ☐ Other Click here to
enter text. ☐ Fidgety
☐ Little animation ☐ Constant movement
☐ Psychomotor
retardation ☐ Hyperactive
☐ Slowed reaction
time ☐ Other Click here to enter
text.
☐ Other Click here
to enter text.
Speech
Slowed Normal Pressured Verbose Unusual
☐ Minimal response ☐ Initiates ☐ Excessively wordy ☐ Over productive ☐ Click here to enter text.
☐ Unspontaneous ☐ Alert/responsive ☐ Expansive ☐Long winded
☐ Sluggish ☐ Productive ☐ Rapid ☐Non stop
☐ Paucity ☐ Animated ☐ Fast ☐ Frequent run ons
☐ Impoverished ☐ Spontaneous ☐ Rushed ☐Flight of ideas
☐ Single word
answers ☐Smooth ☐ Other Click here to enter text. ☐Hyper verbal
☐ Other Click here
to enter text.
☐ Other Click here to enter
text. ☐Other Click here to
enter text.
6
Thought Process
Attention Insight Preoccupations
☐ Normal ☐ IGood ☐ Somatics ☐ Self
☐ Unengaged ☐ Fair ☐ Children ☐ Finances
☐ Distractible ☐ Poor ☐ Spouse/Sig Other ☐ Other Click here to
enter text.
☐ Hyper vigilant ☐ No insight ☐ Job
☐ Hyper focused
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Affect
☐Flat ☐ Blunted ☐ Constricted ☐ Normal ☐Broad
Facial Expression
☐ Vacant
☐ Blank
☐ Strained
☐Pained
☐ Grimacing
☐ Smiling
☐ Other Click here
to enter text.
Summary & Recommendations
Based on the data gathered for the current Pre Evaluation Screening:
☐ It is NOT recommended that this respondent receive a civil commitment exam.
1) Current available information indicates that present symptomatology is due to
☐Dementia ☐Intellectual/Developmental Disability ☐ Epilepsy ☐Chemical Dependency ☐Mental Illness
2) The following referrals for appropriate evaluation or treatment have been provided:
a.
b.
c.
☐ It IS recommended that this respondent receive a civil commitment exam. Based on the data available for the current Pre Screening Evaluation the
following symptomatology cannot be managed/treated in a less restrictive environment:
1) Click here to enter text.
2) Click here to enter text.
3) Click here to enter text.
4) Click here to enter text.
Comments:
___________________________________________
Signature-Credentials
DMH Clean 2016 Violence Risk Assessment for Certified Holding Facility guidance
Violence Risk Assessment for Certified Holding Facility
Purpose
A DMH approved Violence Risk Assessment must be conducted on each individual who is
being housed in a DMH Certified Holding Facility. The results of the Violence Risk
Assessment will determine if a follow-up assessment by a nurse or physician is needed or if
immediate violence prevention protocols must be initiated.
Timeline
The Violence Risk Assessment must be conducted immediately upon arrival of an individual
at the Holding Facility.
Signature/Credentials
The Violence Risk Assessment must be conducted by the designated Screening Officer of
the Holding Facility.
DMH Clean 2016 Violence Risk Assessment for Certified Holding Facility form
Violence Risk
Assessment for
Certified Holding
Facility
Detainee’s Name
Date of Birth
Date
Name of Facility
Screening Officer
FEMALE MALE Most serious charge:
Scoring Instructions: Collect information about each of the 10 risk factor items on the checklist using
examples given. Place a check in the box to indicate the degree of likelihood that the risk factor applies to this
individual. Use the following indicator scale:
No: Does not apply to this person Yes: Definitely applies to a severe degree
Maybe: Applies/present to a moderately severe degree Do not know: Too little information to answer
Results: If 5 or more questions are checked YES or MAYBE, notify supervisor and other Holding Facility staff.
Initiate proper safety protocols.
1. Previous and/or current violence
Physical attack, including with various weapons, towards another individual
with intent to inflict severe physical harm. “Yes” means individual has
committed at least 3 moderately violent aggressive acts or 1 severe violent act.
“Maybe/moderate” means less severe aggressive acts such as kicks, blows
and shoving not resulting in severe harm to the victim.
No Maybe
Yes Do not know
2. Previous and/or current threats (verbal/physical)
Verbal: Statements, yelling, other that involve threat of inflicting physical harm
Physical: Movements and gestures that warn of physical attack
No Maybe
Yes Do not know
3. Previous and/or current substance abuse
History of abusing alcohol, medication and/or other substances including
abuse of solvents, glue, similar. “Yes” means extensive abuse/dependence
with reduced occupational/educational functioning, reduced health and/or
reduced participation in leisure activities.
No Maybe
Yes Do not know
4. Previous and/or current major mental illness
Individual has or has had a psychotic disorder (schizophrenia, delusional
disorder, psychotic affective disorder, other)
No Maybe
Yes Do not know
5. Personality Disorder
Eccentric (schizoid, paranoid), impulsive, uninhibited (emotionally unstable,
antisocial) types
No Maybe
Yes Do not know
6. Shows lack of insight into illness and/or behavior
Degree to which individual lacks insight into his/her mental illness regarding
medication, social consequences of behavior related to illness or personality
disorder
No Maybe
Yes Do not know
7. Expresses suspicion
Expresses verbal or nonverbal suspicion towards others; appears to be “on
guard” toward environment/surroundings
No Maybe
Yes Do not know
8. Shows lack of empathy
Appears emotionally cold, without sensitivity towards others’ thoughts or
emotional situations
No Maybe
Yes Do not know
9. Unrealistic planning
Unrealistic plans for future. Unrealistic expectation of support from family and
professional/social network. Assess ability to cooperate with/follow plans.
No Maybe
Yes Do not know
10. Future stress situations
Ability to cope with future stress; ability to tolerate boundaries, physical
proximity to possible victims of violence, substance use, homelessness, violent
environment, easy access to weapons, other.
No Maybe
Yes Do not know
DMH Clean 2016 Suicide Risk Assessment for Certified Holding Facility guidance
Suicide Risk Assessment for Certified Holding Facility
Purpose
A DMH approved Suicide Risk Assessment must be conducted on each individual who is
being housed in a DMH Certified Holding Facility. The results of the Suicide Risk
Assessment will determine if a follow-up assessment by a nurse or physician is needed or if
immediate suicide prevention actions must be instituted.
Timeline
The Suicide Risk Assessment must be conducted immediately upon arrival of an individual
at the Holding Facility.
Signature/Credentials
The Suicide Risk Assessment must be conducted by the designated Screening Officer of
the Holding Facility.
DMH Clean 2016 Suicide Risk Assessment for Certified Holding Facility form
Suicide Risk
Assessment for
Certified Holding
Facility
Detainee’s Name
Date of Birth
Date and Time
Name of Facility
Screening Officer
FEMALE MALE Most serious charge:
Check YES or NO for each numbered item below. Each YES response requires support documentation
Personal Data Questions YES NO Support Documentation
1. Individual lacks support of family of friends
2. Individual has a history of drug or alcohol
abuse
3. Individual is very worried about problems
other than legal issues (financial, family,
medical condition, other)
4. Individual has experienced a significant
loss within the last 6 months (loss of job or
relationship, death of a close family
member)
5. Individual is expressing feelings of
hopelessness
6. Individual is thinking about killing
himself/herself
7. Individual has previous suicide attempt(s)
8. Attempt occurred within last month
Total number of YES checks
Officer’s/Staff’s Comments/Impressions:
Action: If total number of YES checks is 4 or more or if item # 6 is checked or if screener believes it is
necessary, notify the supervisor and initiate Constant Watch for the individual.
Supervisor Notified Yes No
Constant Watch Initiated Yes No
Signature of Screening Officer Badge Number
Medical/Mental Health Personnel Actions
(to be completed by medical/MH staff):
Section G
Alzheimer’s and Other
Dementia Services
Life Story Narrative
DMH Clean 2016 Life Story Narrative guidance
Life Story Narrative
Purpose
As Alzheimer’s disease progresses, individuals lose developmental skills and abilities and
appears to “move backward in time.” A Life Story gives those around them the ability to assist
and be with them as they remember the past and work through the stages of the disease. The
Life Story Narrative should include specific details about pertinent events and the lifestyle of the
individual. Traumatic events that occurred in the individual’s life or family should also be
included in the narrative.
Timeline
The Life Story Narrative must be completed as part of the initial assessment process and must
be included in the individual’s record. Program staff must review the individual’s narrative prior
to initial contact with the individual. The Life Story Narrative must also be reviewed whenever
the Individual Service Plan is reviewed.
Narrative Completion
The Program Supervisor is responsible for completing the narrative and should ask the family
and/or responsible party for assistance in completing the narrative. All those individuals who
participate in developing the Life Story Narrative must sign where indicated.
List any significant traumatic events in the “Other” section of the narrative that coincides with
the time of life that the trauma occurred. For example, if the individual had a sibling to die in
early childhood, list that in the “Other” section of the “Childhood” narrative. If the individual had
a stillborn baby or suffered miscarriages, include that information in the “Other” section of the
“Young Adulthood” narrative.
DMH Clean 2016 Life Story form
Life Story Narrative
Name
ID Number
Date
Page 1 of 6
Childhood (Birth - 12 years)
Birth date and birth place:
Parents and grandparents:
Brothers and Sisters:
Birth Order:
Friends:
Significant relatives:
House (s) lived in:
Towns lived in:
Church (s) attended and activities:
Schools attended:
Early education events:
Interest/activities/sports/games/ etc:
Pets:
Other:
DMH Clean 2016 Life Story form
Life Story Narrative
Name
ID Number
Date
Page 2 of 6
Adolescence (13-21 years)
Name and location of school (s):
Favorite/least favorite classes:
Friends/relationships:
Interests/hobbies/activities/sports/etc:
Behavior problems:
First Job:
Church (s) attended and activities:
School(s) attended:
House(s) lived in:
Town (s) lived in:
Pets:
Specific happy/sad events:
Other:
DMH Clean 2016 Life Story form
Life Story Narrative
Name
ID Number
Date
Page 3 of 6
Young Adulthood (21-39 years)
College and work:
Military Service:
Marriage(s)/Relationship(s):
Family:
Clubs/community involvement:
Church (s) attended and activities:
First home:
Other Homes:
Interests/hobbies/sports:
Town(s) lived in:
Pets:
Specific happy/sad events:
Other:
DMH Clean 2016 Life Story form
Life Story Narrative
Name
ID Number
Date
Page 4 of 6
Middle Age (40-65 years)
Work Role:
Family Role:
Marriage(s)/Relationship(s):
Family:
Grandchildren:
Clubs/community involvement:
Church (s) attended and activities:
Homes lived in:
Interests/hobbies/sports:
Town(s) lived in:
Pets:
Specific happy/sad events:
Other:
DMH Clean 2016 Life Story form
Life Story Narrative
Name
ID Number
Date
Page 5 of 6
Later Years (66+ years)
Work Role:
Family Role:
Marriage(s)/Relationship(s):
Family:
Grandchildren:
Clubs/community involvement:
Life achievements and accomplishments:
Church (s) attended and activities:
Homes lived in:
Interests/hobbies/sports:
Town(s) lived in:
Pets:
Specific happy/sad events:
Other:
DMH Clean 2016 Life Story form
Life Story Narrative
Name
ID Number
Date
Page 6 of 6
Questions to Enrich the Story
1. How would the individual have enjoyed spending holidays? (New Year’s Eve, Christmas, Fourth of July,
Memorial Day, etc.)?
2. What are their favorite books/music/artists/athletes/movies stars, etc?
3. If the individual was stuck on a desert island, what three (3) things would they wish to have with them?
(Assume there is food, drink, and shelter.)
4. How would the person’s desk, kitchen shelves/drawers, tool box, etc., be organized?
5. Would he/she have looked at life thinking the glass is half -full (optimist) or half-empty (pessimist)?
6. Where did he/she travel?
7. What special skills did he/she have?
8. What special awards did he/she acquire?
Other
Section H
Children and Youth
Services
Therapeutic Foster Care Contact Log
MAP Team Report
MAP Team Case Summary
Wraparound Facilitation Individual Support Plan
DMH Clean 2016 Therapeutic Foster Care Contact Log guidance
Therapeutic Foster Care Contact Log
Purpose
The Therapeutic Foster Care (TFC) Specialist must document face-to-face contact with TFC
parents including home visits. Documentation must be maintained that each TFC home has no
more than one child/youth with serious emotional disturbance (SED) placed in the home at one
time.
Timeline
Documentation of at least one family session per month with the foster parent(s) must be
maintained.
DMH Clean 2016 Therapeutic Foster Care Contact Log form form
Therapeutic Foster
Care Contact Log
Foster Parent’s
Name
Foster Parent’s
Case Number
Date
Type of Contact
(in-home, monthly group,
meeting, other)
Total # of
children/youth
in the home
Total # of
children/youth
with SED in the
home
Staff Signature/
Credential
DMH Clean 2016 MAP Team Report guidance
MAP Team Report
Purpose
Making a Plan (MAP) Teams address the needs of children/youth with Serious Emotional
Disorder (SED) who require services from multiple agencies and multiple program systems and
who can be diverted from inappropriate institutional placement. MAP Teams are a significant
piece of the statewide System of Care for children/youth with serious emotional/behavioral
disorders. Quarterly reports are required for data collection purposes.
Timelines
The MAP Team Reporting form must be completed and submitted to the DMH, Division of
Children & Youth Services by the 10th of each quarter; January 10th for October – December,
April 10th for January – March, July 10th for April – June, and October 10th for July – September.
Case Summaries
If MAP Team grant funds are used, Case Summary forms for each child/youth reviewed must be
submitted with the MAP Team Report. Cash requests will not be processed without this
information.
Clean 2016 MAP Team Report form
MAP Team
Report
MAP Team
Months/Quarter
Referral Information
1. Number of new cases reviewed
2. Number of children/youth in DHS
custody (of the new cases only)
3. Number of follow-ups from previous
quarter
4. Number of children/youth not
Medicaid eligible
5. Number of referrals from new cases only:
Mental Health Center in your
county
Mental Health Center Region-Wide
DHS - Family & Children’s
Services
Youth Court
Therapeutic Group Home Therapeutic Foster Care
Acute Psychiatric Hospital Psychiatric Residential Tx Facility
Local School District Parent(s)
Faith-Based Agency/Church A.O.P
MYPAC College/University
Substance Abuse Residential
Facility
Other (specify)
MAP Team Member Participation
Check the following agencies that were represented at your MAP Team Meeting(s) for the
quarter
Families/Parents (Local Family Partners – must be parent(s) or primary caregiver(s) of a
child/youth with SED. Use Families As Allies Partners when available.)
Community Mental Health
Center
DHS – Family & Children Services
Youth Court Local School District
Vocational Rehabilitation Health Department
Boys & Girls Club Law Enforcement
Substance Abuse Residential
Facility
A. O. P.
Youth Villages MYPAC
Faith-based Agency/Church Other (specify)
DMH Clean 2016 MAP Team Case Summary guidance
MAP Team Case Summary
Purpose
Making a Plan (MAP) Teams address the needs of children/youth with Serious Emotional
Disturbance (SED) who require services from multiple agencies and multiple program
systems and who can be diverted from inappropriate institutional placement. All Community
Mental Health Centers must document participation in at least two MAP Teams in their
region.
Timeline
If DMH flexible funds are utilized, a MAP Team Case Summary form must be completed for
each child/youth and submitted to the DMH, Division of Children & Youth Services by the 10th
of each quarter; January 10th for October – December, April 10th for January – March, July
10th for April – June and October 10th for July – September along with the MAP Team
Monthly Reporting form.
Identifying Information
To ensure confidentiality, the child/youth’s ID number (CMHC or other provider) is entered on
the MAP Team Case Summary in place of the child/youth’s name.
Referral Information
All questions in all sections must be answered with as much detail as possible in order to
justify the need for MAP Team intervention. Space is provided for the specific
recommendations of the MAP Team after all aspects of the case have been considered by
the team.
DMH Clean 2016 MAP Team Case Summary form
MAP Team
Case
Summary
MAP Team Name
ID Number
SED Dx
ID/DD Dx
Age Race Sex
Transitional Needs? □ Yes □ No
Why was this
child/youth’s case
referred to the MAP
Team?
Why is this child/youth
considered to be at-risk
for an institutional mental
health placement?
Recommendations of the
MAP Team
If MAP Team flexible funds will be used for this child/youth,
indicate the estimated amount agreed upon by the Team.
If MAP Team flexible funds will be
used for this child/youth, how will
the use of these funds keep the
child/youth in the community in a
manner that makes it possible for
the child/youth to be diverted
from an inappropriate 24-hour
institutional mental health
placement?
Signature of MAP Team Coordinator/Credentials Date
DMH Wraparound Facilitation Individualized Support Plan guidance
Wraparound Facilitation
Overview of Wraparound
Wraparound is an approach to individualized care planning encompassing the concept of wrapping
services and supports around children, youth and families, utilizing both clinical treatment services
and natural supports. Wraparound is built on the collective action of a committed group of family,
friends, community, professionals, and cross-system supports mobilizing resources and talents from
a variety of sources. This results in the creation of an Individualized Support Plan that is the best fit
between the family vision and story, strengths, needs, team mission, and strategies.
Target Population
Wraparound facilitation is for children/youth with serious emotional disturbances (SED) who have
highly complex needs and/or have multiple agency involvement and are at risk of out -of-home
placement. With ratios of 1 Wraparound Facilitator to 10 families and youth, youth can be diverted
from residential placements and served in their communities and homes.
Key Elements of the Wraparound Process
Grounded in a Strengths Perspective
Strengths are defined as interests, talents, and unique contributions that make things better for the
family and youth. Within an entire process that is grounded in a strengths perspective, the family
story is framed in a balanced way that incorporates family strengths rather than a focus solely on
problems and challenges. A strengths perspective should be overt and easily recognized, promoting
strengths that focus on the family, team, and community, while empowering and challenging the team
to use strengths in a meaningful way.
Driven by Underlying Needs
Needs typically define the underlying reasons why behaviors happen in a situation. In a needs-driven
process, the set of underlying conditions (needs) that cause a behavior and/or situation to exist are
both identified and explored in order to understand why a behavior and/or situation happened. These
needs would be identified across family members in a range of life areas beyond the areas defined by
the system. These underlying conditions would be articulated with overt agreement with the family
and all team members about which to select for action or attention first. The process involves
flexibility of services and supports that will be tailored to meet the needs of the family and youth.
Supported by an Effective Team Process
Wraparound is a process that requires active investment by a team, comprised of both formal and
informal supports willing to be accountable for the results. Measurable target outcomes are derived
from multiple team member perspectives. The team’s overall success is demonstrated by how much
closer the family is to their vision and how well the family needs have been addressed.
Determined by Families
A family-determined process includes both youth and caregivers with the family having the authority
to determine decisions and resources. Families are supported to live a life in a community rather than
in a program. The critical process elements of this area inc lude access, inclusion, voice, and
DMH Wraparound Facilitation Individualized Support Plan guidance
ownership. Family access is defined as inclusion of people and processes in which decisions are
made. Inclusion in decision making implies that families should have influence, choice and authority
over services and supports identified in the planning process. This means that they should be able to
gain more of what is working and less of what they perceive as not working. Family voice is defined
as feeling heard and listened to, and team recognition that the families are important stakeholders in
the planning process. Therefore, families are critical partners in setting the team agenda and making
decisions. Families have ownership of the planning process in partnership with the team when they
can make a commitment to any plans concerning them. In Wraparound, the important role of families
is confirmed throughout the duration of care.
Wraparound Facilitation
Wraparound Facilitation is the creation and facilitation of a child and family team for the purpose of
developing a single plan of care to address the needs of youth with complex mental health challenges
and their families. The child and family team will meet regularly to monitor and adjust the plan of care
if necessary or if progress is not being made. Wraparound facilitation is intended to serve individuals
with serious mental health challenges that exceed the resources of a single agency or service
provider, experience multiple acute hospitals stays, are at risk of out -of-home placement or have
been recommended f or residential care. Individuals who have had interruptions in the delivery of
services across a variety of agencies due to frequent moves, failure to show improvement, lack of
previous coordination by agencies providing care, or reasons unknown can also be served through
wraparound facilitation.
Wraparound facilitation must be provided in accordance with high fidelity (as outlined below) and
quality wraparound practice.
1. Services comprised of a variety of specific tasks and activities designed to carry out the
wraparound process, including:
a. Engaging the family;
b. Assembling the child and family team;
c. Facilitating a child and family team meeting at a minimum every thirty (30) days;
d. Facilitating the creation of a plan of care, which includes a plan for anticipating, preventing
and managing crisis, within the child and family team meeting;
e. Working with the team in identifying providers of services and other community resources
to meet family and youth needs;
f. Making necessary referrals for youth;
g. Documenting and maintaining all information regarding the plan of care, including revisions
and child and family team meetings;
h. Presenting plan of care for approval by the family and team;
i. Providing copies of the plan of care to the entire team including the youth and
family/guardian;
j. Monitoring the implementation of the plan of care and revising if necessary to achieve
outcomes;
k. Maintaining communication between all child and family team members;
l. Monitoring the progress toward needs met and whether or not the referral behaviors are
decreasing;
m. Leading the team to discuss and ensure the supports and services the youth and family
are receiving continue to meet the caregiver and youth’s needs;
DMH Wraparound Facilitation Individualized Support Plan guidance
n. Educating new team members about the wraparound process; and
o. Maintaining team cohesiveness.
2. Child and family team membership must include:
a. The wraparound facilitator;
b. The child’s service providers, any involved child serving agency representatives and other
formal supports, as appropriate;
c. The caregiver/guardian;
d. Other family or community members serving as informal supports, as appropriate; and
e. Identified youth, if age nine (9) or above, unless there are clear clinical indications this
would be detrimental. Such reasons must be documented clearly throughout the record.
3. Wraparound facilitation is limited to one hundred (100) units (15 minute unit) per state fiscal year
and eight (8) units per day.
4. Provider requirements
a. Wraparound facilitators and supervisors of the process must have completed and show
evidence of completion of the Introduction to Wraparound 3-day training.
b. Wraparound facilitators and supervisors must participate in ongoing coaching and training
as defined by the Division of Medicaid and the Department of Mental Health.
c. The provider organization providing Wraparound f acilitation must be participating in the
wraparound certification process through the Division of Medicaid or its designee.
d. Providers must ensure case load size for each wraparound facilitator of no more than ten
(10) cases.
Wraparound Facilitation Additional Documentation Requirements
All contacts, specific tasks and activities must be documented in Progress Note and filed in the
child/youth’s record.
DMH Wraparound Facilitation Individualized Support Plan form
Wraparound Facilitation
Individualized Support Plan
Youth Name (First, MI, Last):
Client #:
TAN #:
Date:
Guardian Name:
DOB:
Phone:
Address:
Initial
Review
Discharge
Start Date:
Target Completion Date:
Vision/Mission/Strengths
Family Vision/Preference Statement:
Team Mission:
Strengths/Abilities:
Youth, Family
Members, & Team
DMH Wraparound Facilitation Individualized Support Plan form
Client Name Case #
Crisis Plan
Diagnosis:
Medications:
Brief History:
Triggers:
Potential Crisis:
Action Steps for home and school to meet Identified Needs re: Potential Crisis:
Persons Responsible and phone numbers:
Crisis Debriefing after Resolution:
DMH Wraparound Facilitation Individualized Support Plan form
Client Name Case #
Needs Statements/Strategies
Needs
Statement
1
Start Date:
End Date/Duration:
Outcome:
Life Domain Area of need:
Family Residence Social Education/Vocation
Medical/Physical Health Community Psychological/Emotional/Behavioral
Safety Basic Physical Needs Financial Leisure/Recreation
Youth
Strategies
Parent/Guardian/Community Strategies:
Strategy Completion
Date:
Strategy Discontinue Date:
Reason for Discontinuation:
DMH Wraparound Facilitation Individualized Support Plan form
Client Name Client #
Needs
Statement
2
Start Date:
End Date/Duration:
Outcome:
Life Domain Area of need:
Family Residence Social Education/Vocation
Medical/Physical Health Community Psychological/Emotional/Behavioral
Safety Basic Physical Needs Financial Leisure/Recreation
Youth
Strategies
Parent/Guardian/Community Strategies:
Strategy Completion
Date:
Strategy Discontinue Date:
Reason for Discontinuation:
DMH Wraparound Facilitation Individualized Support Plan form
Client Name Client #
Needs
Statement
3
Start Date:
End Date/Duration:
Outcome:
Life Domain Area of need:
Family Residence Social Education/Vocation
Medical/Physical Health Community Psychological/Emotional/Behavioral
Safety Basic Physical Needs Financial Leisure/Recreation
Youth
Strategies
Parent/Guardian/Community Strategies:
Strategy
Completi
on Date:
Strategy Discontinue Date:
Reason for Discontinuation:
DMH Wraparound Facilitation Individualized Support Plan form
Client Name Client #
Needs
Statement
4
Start Date:
End Date/Duration:
Outcome:
Life Domain Area of need:
Family Residence Social Education/Vocation
Medical/Physical Health Community Psychological/Emotional/Behavioral
Safety Basic Physical Needs Financial Leisure/Recreation
Youth
Strategies
Parent/Guardian/Community Strategies:
Strategy Completion
Date:
Strategy Discontinue Date:
Reason for Discontinuation:
DMH Wraparound Facilitation Individualized Support Plan form
Client Name Client #
Team Contacts/Resources
Support
Name/Signature
Contact and Organization Role
Discharge
Support Summary:
Further Recommendations:
Youth Signature: Date:
Parent/Guardian Signature: Date:
Wraparound Facilitator Signature: Date:
Supervisor Signature: Date:
Other Signature (Name/Relationship): Date:
Other Signature (Name/Relationship): Date:
DMH Wraparound Facilitation Individualized Support Plan form
Case # __________________
Wraparound Team Meeting
Wraparound team for __________________________ and Family
Date: ______________________ Start – End Time: ___________________
* I am aware that everything said in this meeting is confidential. Confidentiality means that what we discuss is
private and should not be discussed outside of this meeting or with others not involved in this family’s
Wraparound process. By signing, I agree to preserve the confidentiality of all information discussed. I agree
that this information will be used for the purposes outlined in the Wraparound planning process only. I
understand that if any abuse or neglect is disclosed in this process, mandated reports will be made.
Name of Family Team
Member*
Role, Agency, or Relationship
to Youth
Phone Number(s) To be filled out by
Wrap Facilitator:
Release authorized?
Wrap Facilitator
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
“Wraparound is a family centered, community-oriented, strengths-based, highly individualized planning
process aimed at helping people achieve important outcomes by helping them meet their unmet needs both
within and outside of formal human services systems, while the y remain in their neighborhoods and homes,
whenever possible” (wraparoundsolutions.com).
Section I
Intellectual/ Developmental
Disabilities Services
IDD Plan of Services and Supports
IDD Activity Support Plan
IDD Service Note
IDD Weekly Service Note
ID/DD Waiver/IDD CSP Service Authorization
ID/DD Waiver Home and Community Supports Service Agreement
ID/DD Waiver In-Home Respite Service Agreement
ID/DD Waiver In-Home Nursing Service Agreement
ID/DD Waiver In-Home Nursing Respite Service Note
IDD Employment Profile
ID/DD Waiver Job Discovery Profile
IDD Request for Behavior Support and/or Crisis Support Services
ID/DD Waiver Medical Verification for Behavior Support/Crisis Intervention Services
ID/DD Waiver Functional Behavior Assessment
ID/DD Waiver Behavior Support Plan
ID/DD Waiver Justification for Behavior Support Services
ID/DD Waiver Behavior Support Quarterly Review Report
ID/DD Waiver Request for Additional Behavior Support Services
ID/DD Waiver Request for Additional Crisis Support Services
ID/DD Waiver Request for Crisis Intervention Services
ID/DD Waiver Crisis Intervention Plan
ID/DD Waiver Crisis Intervention Daily Service Note
ID/DD Waiver Crisis Intervention Log- Episodic
ID/DD Waiver Request for Additional Crisis Intervention Services
DMH IDD Plan of Services and Supports guidance
Plan of Services and Supports
General
The Plan of Services and Supports is to be used by Support Coordinators, Targeted Case
Managers, Transition Coordinators and providers of non-Waiver/IDD Community Support
Program (CSP) services.
If a person receives non-Waiver Supervised Living and Work Activity Services and/or
Supported Employment Services, the Supervised Living provider is responsible for arranging
the PSS meeting and having all providers present. If a person receives only Work Activity or
non-Waiver/IDD CSP Supported Employment services, that provider is responsible for
arranging for the PSS meeting.
Timelines
Support Coordinators: The PSS must be revised and submitted to BIDD within 45 days of a
person’s recertification date.
Targeted Case Managers: The PSS must be revised and submitted to BIDD within 45 days of
a person’s recertification date.
Non-Waiver/IDD CSP Providers: The PSS is to be completed annually or within 30 days of
admission to a service. It is to be kept in the file for BIDD review. The Activity Support Plan
is to be developed within 30 days of the date the PSS was developed.
PLAN OF SERVICES AND SUPPORTS INSTRUCTIONS
Plan of Services and Supports Overview
The Plan of Services and Supports (PSS) document reflects a person’s vision of their desired life. It
includes a description of the person’s strengths, what is important to and for them, and supports
necessary to live their best life. The PSS contains the outcomes that lead to the development of a
person’s supports and services. The outcomes indicate what a person wants their life to look like. The
PSS is developed by the person with the involvement of others identified by the person, such as
family, friends, and service providers, and is facilitated by the person’s ID/DD Waiver Support
Coordinator (SC), IDD Community Support Program Targeted Case Manager (TCM), or a Regional
Program’s Transition Coordinator (TC). The planning team uses the PSS as a guide to developing
needed paid supports and services as well as natural and unpaid supports from the community. It is
the fundamental document used to assist the person in achieving their desired outcomes and thus
their best life. The PSS meeting and the 4th Quarterly meeting can be combined.
Plan of Services and Supports Format
The PSS document is divided into six (6) parts:
I. Essential Information
II. Personal Profile
III. Person Centeredness
IV. Signatures
V. Shared Planning
VI. Activity Support Plans
DMH IDD Plan of Services and Supports guidance
Part I
Essential Information (EI)
This part is completed prior to the Plan of Services and Supports meeting. For the person’s first PSS,
the Essential Information should be gathered during a conversation with the person/legal
representative/family member either via phone or in person. The SC/TCM will keep the Essential
Information current throughout the year. Address each section for which information is available,
regardless of whether or not it is a required section to be completed through the LTSS system. For
example, the Employment Section is not required for submission of the PSS to BIDD. However, it
must be completed if the person is eighteen (18) years old or above.
Parts II – IV
Personal Profile, Person-Centeredness, and Signatures
These parts contain information that will be gathered during the PSS meeting. Each member of the
person’s planning team must contribute information that will best help others learn about the person
and how to support them.
Part V
Shared Planning – Outcomes
Ideas for outcomes must be developed during the PSS meeting.
Part VI
Activity Support Plans (ASP)
Activity Support Plans are developed by providers, based on the outcomes developed in Part V-
Shared Planning, after they receive the BIDD approved PSS from the SC/TCM.
Information Gathering
The Plan of Services and Supports should paint a picture of the focus person’s life. The person is the
expert on his/her life and should contribute as much information as possible. Other team members
should consist of the supports in the person’s life that are closest and know him/her the best. All
providers that work closely with the person are required to contribute to the PSS. The PSS should
help the team understand the person, what the person wants and needs, and how best to support
him/her to live the life he/she desires.
With the focus person’s permi ssion, information is also obtained from others with whom the person
interacts. These supports may not be able to attend the PSS meeting but can contribute information
prior to the meeting via the SC/TCM/TC. This information is gathered over the phone and documented
in planning notes along with the date the conversation took place. The SC/TCM /TC is responsible for
sharing this information at the planning meeting.
Person Centered Thinking Skills© (PCT) developed by The Learning Community will be used during
the planning meeting to gather information. The Person Centered Thinking skills provide a structure
for gathering information during a conversation rather than simply having a question/answer session.
With the SC/TCM/TC acting as the facilitator and the person acting as co-facilitator of the planning
meeting, the team must work together to obtain all the information that goes in the PSS.
*******Always remember to ask “why,” especially when people give yes/no answers. “Why”
provides an important avenue of exploring topics further. *******
Person Centered Thinking Skills© (PCT) are used as a way to gather information during the PSS
meeting. The skills can also be useful throughout a person’s certification year to gather and organize
information. The PCT Skills include:
DMH IDD Plan of Services and Supports guidance
• The Relationship Map©
• Important To and For©
• Working and Not working©
• 4+1 Questions©
• Communication Chart©
• Good Day/Bad Day©
• Routines and Rituals©
• 2 Minute Drill©
• The Donut©
• Matching Profile©
• Learning Log©
The SC/TCM/TC and all providers are responsible for taking notes during the planning meeting. Notes
can be written on flip chart paper, the PCT Skills© forms or regular paper depending on what is
comfortable for the person and team. SCs/TCMs/TCs are not required to provide copies of their notes/
PCT Skills© forms to providers. Providers must have their own notes/ PCT Skills© forms to be able to
develop Activity Support Plans for the outcomes they are responsible for implementing. Notes/ PCT
Skills© forms will be used by the BIDD to monitor PSSs and Activity Support Plans.
Completing the PSS
The following instructions and examples should be used as a guide to completing a PSS. The
examples do not encompass all items required in each section. These examples must not be
used in writing a future PSS. Instructions are organized in the sequence in which they appear in the
PSS document. Once the PSS is approved by BIDD, everyone on the team will receive a complete
copy of the plan – including the Essential Information.
Part I: Essential Information
This part of the PSS should be completed by the Support Coordinator/Targeted Case
Manager/Transition Coordinator prior to the PSS meeting. The information should be obtained
through a conversation(s) with the person/legal representative/family either via phone or in person.
The Essential Information can also be completed with staff if they are the ones most likely to have any
of the current information. Certain items can be completed prior to the planning meeting but must be
reviewed with the person’s team at the beginning of the meeting. At the beginning of the PSS
meeting, the following items must be reviewed:
• Medications
• Back-up and Emergency Plans
• Risk assessment
• Employment
• Behavior Supports (If a person has a Behavior Support Plan, it must be reviewed
and documented in the notes/ PCT Skills forms and be attached to the PSS.)
• Contact Information - Complete the identification information for the person and
his/her family members. The person’s address must be entered in the Personal Profile
section of LTSS.
• In the Family Contact Information, include any family members that will not be listed in
the “Natural Supports” section. The Emergency Contact is to be entered in the
Personal Profile section of LTSS.
• ID/DD Waiver/IDD Community Support Program Supports
Depending upon the program, this section includes ID/DD Waiver Supports or IDD
Community Support Program Supports as well as those not funded by either program.
Write the person’s name at the
top of each Skill or note page.
SCs/TCM/TCs must submit
their notes/ PCT Skills© forms
to BIDD as attachments to the
PSS. Providers must maintain
theirs in the person’s record for
BIDD review.
DMH IDD Plan of Services and Supports guidance
This section should not be generic definitions of services or include
medical/institutional terminology. It must be specific to the person and contain
enough information and justification to support the services a person is
approved to receive – the why, when and how. The information listed below must be
included in the PSS.
ID/DD Waiver Supports IDD Community Support Program Supports
• List the services/supports provided through
the ID/DD Waiver along with all the
necessary contact information for each
agency (email address is required) Use the
email address of the staff member who is
most likely the appropriate staff to receive
alerts from LTSS
• Indicate the frequency of the
service/support (hours per day, month or
year)
• Describe in detail: WHEN the person uses
the service; HOW the person utilizes the
service; and WHY the person needs the
service/support.
• Include a set schedule if there is one or the
times services are usually provided
• If the service is Home and Community
Supports, indicate if a family member is
providing the service, their relationship to
the focus person, and how many hours per
month they provide
• All direct support professionals (DSPs)
must be reflected on the Relationship Map
• List the services/supports provided
through the IDD CSP along with all the
necessary contact information for each
agency (email address is required)
• Indicate the frequency of the
service/support (hours per day, month or
year)
• Describe in detail: WHEN the person
uses the service; HOW the person
utilizes the service; and WHY the person
needs the service/support.
• Include a set schedule if there is one or
the times services are usually provided
• All direct support professionals (DSPs)
must be reflected on the Relationship
Map
Non-Waiver Agency Supports Non-IDD CSP Program Supports
• List the agencies that provide
services/supports to the person through
avenues other than the ID/DD Waiver
along with all the necessary contact
information for each agency
• Provide a brief summary of how, when and
why the support is used
• Examples of non-Waiver agency supports
are Vocational Rehabilitation, Physical
Therapy, Community Support Services,
Counseling, etc. All supports listed here
must also be reflected on the Relationship
Map.
• List the agencies that provide
services/supports to the person through
avenues other than the IDD CSP along
with all the necessary contact information
for each agency
• Provide a brief summary of how, when
and why the support is used
• Examples of IDD CSP agency supports
are Vocational Rehabilitation, Physical
Therapy, Counseling, etc. All supports
listed here must be reflected on the
Relationship Map.
DMH IDD Plan of Services and Supports guidance
• Natural Supports
List the people who provide unpaid supports to the focus person.
Include family, friends, neighbors, people who support the person in the
community and anyone else the person wishes to include. This could include
those that provide support through a church, job or a volunteer program.
Include names (first and last) of the natural support rather than “family” or
“friends” since this section will pre-populate the Shared Planning section in
LTSS.
Indicate the natural support’s relationship to the person, their phone number
and how and when they provide support to the person. (This must include how
often the natural support sees or speaks with the person and what they do
together. If the phone number is unavailable, enter 000-000-0000. **
All natural supports listed here must be reflected on the Relationship Map.
People listed in the center section of the Relationship Map should be reflected
in the PSS. If they do not support the person regularly or never but the person
wants them on the map, document this information somewhere on the
Relationship Map page.
• Medical Information
List the physician(s) who provide services/supports to the focus person and
their specialty area such as general practitioner, dentist, neurologist,
ophthalmologist, etc.
Provide the physician’s contact information.
All medical agency services/supports listed here must be reflected on the
Relationship Map.
Medications
List all of the current medications the person is taking including over-the-
counter medicines.
For each medication, indicate the dosage and frequency the person is
taking, the physician who prescribed the medication and the reason for
taking it. (www.rxlist.com
is a good resource for understanding
medications and their usage)
If it is an over-the-counter medication, indicate why they need it or the
condition for which it is taken.
Indicate if the medicine is used as a psychotropic medication
List any chronic health or physical conditions the person has. Chronic health
or physical conditions are ongoing conditions that the person has lived
with and will continue to live with for the foreseeable future. (Ex: diabetes,
cerebral palsy, hypertension, epilepsy, etc.) Also indicate any diagnoses that
are not listed in the evaluation section.
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The history of health problems/issues addresses any illnesses the person
experienced in the past but that are not affecting their health and welfare
presently. Include any surgeries or procedures the person has undergone that
may affect his/her current situation. (Ex: stroke, heart attack, cancer, removal of
organs, no seizures experienced in 5 years, etc.) Also indicate any historical
diagnoses that are not listed in the evaluation section.
Current limitations on physical activities are usually supported by a doctor’s
note. The SC/TCM/TC is to upload the note into the attachments section of the
PSS module under “Other.” It may be that a person can only lift a certain
amount of weight due to a hurt back or are temporarily restricted from certain
activities due to medical issues. (This section does not include Cerebral Palsy,
wheelchair, walker or crutches, etc.)
If the person was ever admitted to a facility (Ex: ICF/IID, Nursing Facility,
Rehabilitation Facility, Behavioral Health Facility, etc.) indicate when, where
and why they were admitted and the circumstances surrounding discharge.
List the dates of the most recent physical and dental exams.
List anything the person may be allergic to and indicate how he/she reacts to
the allergen.
• Medical and Mental Health Support Needs
If the person has experienced any physical complaints or other medical issues
during the past year, provide a summary of the issue(s) and the outcome. This
is where the SC/TCM/TC can list anything that may have come about as a
result of a physical exam during the past year.
List any special medical items necessary for the person to live comfortably.
Indicate the equipment or treatment and when, why and how it is used and who
is responsible. (Examples: Baclofen pump, G-tube, Peg-tube, oxygen,
disposable adult briefs, ventilator, blue pads, Epi-pen, etc.) (Example: Mary is
allergic to bees. She keeps an Epi-pen with her at all times.)
If the person is receiving Mental Health support services, provide a description
of the services/support, when and why the support is needed and how it
benefits the person.
• Communication and Equipment/Technology
Indicate the person’s method of communication. (Do they use words or
gestures to speak?)
Describe supports needed for communication (what communication devices,
sign language, etc.)
Describe any adaptive equipment or assistive technology supports the person
uses and why. (Examples: wheel chair, lifts, hospital bed, hearing aids, walker,
bath chair, adaptive forks or knives)
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Indicate how is the equipment maintained and who is responsible.
Describe is the back-up plan for power outages if medical equipment is used.
• Risk Assessment
The Support Coordinator /Targeted Case Manager/Transition Coordinator completes
the Risk Assessment Tool with the focus person, his/her family or legal representative,
and providers before the meeting. It will be reviewed at the meeting and all pertinent
information will be included in the PSS. List the date(s) the Risk Assessment Tool was
completed, any identified risks and the strategies for avoiding identified risks
(Resolution) for each. If the person has no identified risks, write “none” in this section
and on the Risk Assessment Tool and upload it to LTSS.
• Back-Up and Emergency Plans
Indicate what will happen if the provider does not show up – this includes all
services that go to the person’s home, not just in-home services.
Indicate the actions to take if the day program, work or other activity is canceled
or closed.
Indicate the actions to take when disasters occur – this refers not only to natural
disasters but also to emergencies, issues with housing, staff not being
available, issues with evacuation, etc.
These plans must include the name and phone number of who the person is to
call.
Plan for future living arrangements – where will a person live in the future or
where will they go if something happens to their home or people they live with.
• Family and Current Living Arrangements
Indicate the current living arrangement for the focus person (at home with
parents, at home with siblings, in a supervised living setting, in an apartment
with/without a roommate, etc.).
State with whom the person lives, and the age, occupation and health condition
of everyone living in the home. Provide information about the level of support
each individual living in the home provides to the person.
Include ALL family listed on the Relationship Map and the amount of support
they provide to the person (Example: Aunt Mary lives in Chicago and sees Sue
twice a year.)
If the person resides in a group home, indicate the roommates’ first names.
If the person resides alone or in a group home, indicate the extent of the
support/interaction he/she has with family as well as the information above.
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• Education
Indicate the current school, if applicable. List the name of the last school
attended (if known). Indicate if he/she received a certificate of completion or a
diploma and the date (an estimate of May 31st and the year of graduation is
appropriate). If a person is under the age of 21 and not in school, indicate in
the notes the reason(s) why.
Employment and Volunteer Activities
If the person currently has a job, indicate where he/she is employed, when
he/she began, the days and hours he/she works, and provide a summary of the
work duties. If the person’s schedule varies, the SC/TCM/TC can choose the
days and times the person generally works. ** Estimate the begin date if
necessary. Indicate such in the notes.
If the person was previously employed, indicate where he/she worked as well
as the end date and the reason he/she is no longer employed at that location.
Estimate dates and days, if not known, and indicate such in the notes.
If a person is not employed, indicate why in the “Duties” column. Employment
MUST be addressed at all meetings for people ages eighteen (18) and older
and be documented in the PCT Skills/Notes.
If the person volunteers somewhere in the community, indicate where, the
begin date, the days and hours he/she volunteers and what duties are
performed while volunteering. List as many places as applicable. If exact begin
dates are not known or if the schedule varies, estimate in this section and
indicate such in the notes.
If the person volunteered in the past, provide the necessary information, if
available. Estimate dates and days, if not known, and indicate such in the
notes.
If the person has never volunteered, please indicate such in the notes.
• Previous and Current Behavior Supports
This section includes any and all information regarding current or past actions that
providers would need to know to support the person.
If the person is currently or has previously received services to assist in
correcting inappropriate actions, indicate what the actions are/were, when they
occur or occurred and what was done or is being done to eliminate or change
the actions, if necessary.
If the person has a Behavior Support Plan in place, indicate there is a plan
being implemented and upload a copy of the plan with the PSS.
If the person currently does things out of the ordinary but they do not need a
Behavior Support Plan, list those actions and specifics, if known.
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• Serious Incidents During the Past Year
Write a summary of any serious incidents that occurred during the past certification
year. Include information regarding the incident(s) that occurred and how the
incident(s) was resolved or the outcome(s) of the incident(s). Indicate if the PSS was
changed as a result of the incident.
• Evaluation Information
Record the person’s current ICAP score and level, the date the assessment
was conducted, and who conducted it.
Indicate the date of the most recent Psychological Evaluation and who
conducted the evaluation.
List the diagnoses given as a result of the evaluation.
If there are any diagnoses on Axis I or III, ask which, if any, are still relevant
and list them in the Chronic Medical Conditions section, History of Health
Problems/Issues section, or Medical Needs section, depending on the nature of
the diagnosis.
• Essential Information Completed By
The SC/TCM/TC completes this section by indicating the person/legal
representative/family that provided the information, his/her name, and the date
completed. The SC/TCM/TC can indicate in the Notes who else may have provided
information for completion of the Essential Information. This person should be listed in
the section “Contributors Not at Meeting” if they are not at the actual meeting.
The Planning Meeting
The Support Coordinator/Targeted Case Manager /Transition Coordinator is responsible for
facilitating the planning meeting. Good facilitation is crucial to complete the Personal Profile. The
Personal Profile must be reflective of the person and the supports needed to make sure he/she lives
the best life possible. The more information that is elicited during the planning meeting, the stronger
the plan will be to support the person. This will entail asking questions to draw information out of the
person/team rather than asking yes/no questions. In some cases subjects or ideas may need to be
challenged or teased out to determine a way to change something or make something new and
different happen that is important to or for the focus person. If optimistic discontent is not created,
change will not occur.
The key to a good person centered plan is asking “why” when gathering information and
understanding the “why” when reviewing the PSS.
Remember the plan belongs to the person and is about what they want for their life rather than
what the family and providers think is best for them. Plan WITH the person rather than FOR
the person.
The plan must always be current and reflect what is happening in the person’s life. The person
must be aware of the process for requesting changes and updates to their PSS throughout the
year and not just at the annual planning meeting in order for the document to always be
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current. Requests for change should be made to the Support Coordinator/Targeted Case
Manager. The person/legal representative must make the request. Providers can inform the
Support Coordinator/Targeted Case Manager of issues that may be occurring, but the request
for additional services must come from the person/legal representative. The process must be
explained during the planning meeting so all team members are aware of the process.
The Personal Profile is written in the present tense rather than describing what has happened
in the past or what may happen in the future.
Using people’s first names in a PSS makes the plan more person centered. It is their plan and
they know the people supporting them and their relationship to the support person.
The PSS must be written in plain language so that it is easily understood by the person and
everyone else on their team. Medical or institutional terminology must be avoided.
Pay attention to behaviors as well as words. People often speak louder with actions than with
words. Sometimes people tell us what they think we want to hear rather than how they really
feel or what they really think. By reading a person’s behaviors, these things can be figured out.
The Person Centered Thinking Skills© provide a guide for gathering information through a
regular conversation rather than a question/answer session. People are more likely to
contribute information if they feel comfortable and are not being pressured with answering
questions. Make sure everyone at the meeting is included in all aspects of the conversation.
All information included in the Personal Profile section must come directly from the notes or
Person Centered Thinking Skills forms written during the meeting; however not all information
gathered will always go into the Personal Profile. Some information may not be appropriate to
include in the person’s PSS.
Examples: negative things about the person stated at the meeting;
discussions at the meeting that may have not been positive or were hot
topics; information gathered/offered that may not be important to know or do,
etc. However, these things should be reflected in your notes so that you
know they were discussed and can follow up on them at a more appropriate
time.
Information should be recorded as it is expressed during the meeting. When the SC/TCM/TC
writes the Personal Profile, he/she organizes the information and determines where it belongs
in the PSS. If information is expressed in a negative manner, the SC/TCM/TC should use the
“Reframing Reputations” Skill© when writing the information in the PSS. Negatives must be re-
worded in the PSS to make them factual, yet not stereotypical or clinical. (Example: “Amy is
attention seeking.” Could be “Amy wants alone time with staff.”)
The SC/TCM/TC is responsible for organizing the information discussed during the planning
process and developing the PSS. The PSS should not be a copy of the PCT Skills©/notes
taken during the meeting. Information is gathered using the skills but it does not necessarily
belong under that section of the PSS. It may be more appropriate in another section of the
PSS.
Example: Bad Day Skill© – a person says “last minute changes” can cause
them to have a bad day. If something has an effect on a person and how
they act, that is information that could go under the Important TO or
Important FOR section of the PSS. Same with Dislikes – if a person dislikes
something, why and what happens? Is this something that is Important To or
For them?
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Information in the Personal Profile must be in the form of a sentence. (Example: “Spot is
important to Mary because he is her constant companion:” not just “Spot.”)
For people who do not use words to speak, write what a support person may think the focus
person would say or do. (Example: “Suzy says she thinks Mary would say playing with Spot is
working for her.”)
Once a PSS is developed and implemented, the SC/TCM (not the Transition Coordinator) is
responsible for keeping the PSS document current and ensuring all team members have the
most recent information.
If/when changes or revisions are made to the PSS during the certification year, all team
members must agree and will then receive an updated copy of the PSS from the SC/TCM.
Throughout the planning process, it is recognized that sometimes difficult choices may
have to be made. Teams are encouraged to be creative in overcoming obstacles such
as limited funding, isolated geographical locations and limited community resources in
order to support the person in meeting their desired outcomes.
All information included in the PSS must be written in complete sentences and include
“WHY” – For example, someone says attending the day program is important to
him/her. WHY is it important to him/her? Is it because they see their friends there?
Part II: Personal Profile
The Personal Profile is the core of the person’s plan and contains the most vital information – an
image of the person and the supports needed to make sure he/she lives his/her best life possible.
Good facilitation and participation of all team members is crucial to completing the Personal
Profile.
A. Introduction: Great Things about ______
The Introduction is written with positive, person-first language to introduce the focus person. It
emphasizes the positive qualities identified by the person and others that know him/her best. Written
correctly, the Introduction should capture the person’s spirit and provide a clear impression of the
person’s admirable qualities and present his/her “positive reputation.” It should be worded as if you
were introducing the person to someone new.
Example: Mary has a dynamic personality. She has a great sense of humor
and loves to make people laugh. Mary is very passionate about things that
are important to her such as her dog Spot. She is a loyal friend. Mary loves
a challenge and will not give up until she has done what she set out to do.
B. Hopes and Dreams
This section describes the hopes and dreams of the focus person at this time in their life. The PSS
must reflect the true hopes and dreams of the person and not just what the team believes is
obtainable. No hope or dream should go unacknowledged or be dismissed just because team
members believe it is unattainable. These must be the person’s hopes and dreams. Hopes and
dreams should not be tied to health or welfare.
Ask the questions:
What would he/she like to accomplish?
Where does he/she want to go?
What does he/she hope to have one day?
What would he/she like to learn to do?
Example: Mary wants to live in an apartment with her best friends,
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Kimberly and Susan. Mary hopes that one day she will get the
chance to go to Washington and meet the president.
C. Important TO and Important FOR
Recognizing what is important TO and important FOR a person is the fundamental Person Centered
Thinking Skill©. When planning with a person, focus on what is important to the person as well as
what is important for them (health and safety). The goal is to balance what is important to/for the
person so that they can live a good life.
IMPORTANT TO:
These are things in life that are special to the person. This section must include things, when present
(or if applicable), that are likely to contribute to a good day, or when absent, are likely to contribute to
a bad day. The following areas MUST be addressed:
Relationships
Things to do and have
Community Integration (places to go)
Rhythm and pace of life
Rituals and Routines
Status or control over one’s life (choices, decisions, options)
Anything else the person wishes to include
Tips:
• Do not include items the team thinks are or should be important to the
person. This is just what the person thinks.
• Remember there is a difference between what someone “likes” and what is
“important to” the person. “Likes” can be included in the section “Things
People Need to Know and Do to Support the Person and Keep Them
Healthy and Safe” or “Strengths.”
IMPORTANT FOR:
These are things that are necessary in a person’s life to ensure their health and welfare. The following
areas MUST be addressed but not limited to:
Things pertaining to issues of health (prevention, treatment, diet, exercise,
physical health, mental health, etc.)
Issues of safety
Support needs
Medical conditions
What is necessary to help the person be a valued and contributing member
of their community
Examples:
Important to Mary Important for Mary
It’s important to spend time with best
friends, Kimberly and Susan, to laugh and
have fun.
Spending time with Abby, Sam, and her
friends is important for Mary so she has
good relationships and supports
Spot (puppy) is important to Mary because
he is her constant companion.
It is important for Mary not to be rushed so
she doesn’t forget things and become
upset.
It’s important to Mary to choose where she
and Suzy (HCS provider) eat lunch and
Being with Suzy is important for Mary.
With Suzy, she gets to go do things
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Important to Mary Important for Mary
shop so she has some say in what she
does.
without her parents.
It’s important to Mary to not be rushed; she
will forget things and become upset.
Taking care of Spot is important for Mary.
It gives her a sense of responsibility and
she takes it very seriously
D. Working/Not Working
This section provides a snapshot of what is currently working and not working in a person’s life from
multiple perspectives. Things that may occur in the future or that need to be prevented are not
recorded here. All team members must look through the lenses of the focus person and not just their
own. Each service must have its own section and the information working and not working must be
relevant to that service/support being provided. Topics addressed MUST include but are not limited to:
Living arrangement (where and with whom)
Relationships (family, friends, providers, anyone else)
What the person does for fun
Where they like to go and what they like to do in the community
How the person spends his/her days (include school, day program, job,
volunteering, retirement activities, etc.)
The amount of control the person has over life choices (Example: churches,
activities, clothes, time they go to bed at night, etc.)
Any plans developed to support the person in addition to the PSS, when applicable.
(Example: a Behavior Support Plan, doctor ordered diet, any plans written for
restrictions/limitations.)
Addressing ALL of the items indicated above from each team member’s perspective allows the team
to think through how to support the person rather than jumping straight to the “fix” for the person.
The “Not Working” section shows different perspectives which leads to questions as to why something
is occurring. In these cases, the information may show up here and in the “Questions/Things to Figure
Out” section.
Examples: The examples listed below do not encompass all items required to be addressed.
• Perspectives:
Person’s perspective – list things the person says are working and not working
in his or her life as related to ALL areas listed above. If the person cannot use
words to speak, the team may all contribute. Indicate who says what they think
Mary would say is working/not working from her perspective.
Mary’s perspective
Working Not Working
Mary thinks taking care of Spot is working.
She likes playing with him and feeding
him.
Not being able to decide what she
wants to eat for lunch at the day
program is not working for Mary. She
doesn’t like some of the food they
serve.
Spending time doing fun things with Suzy
like getting nails done, going to eat
Mexican food, and walking at the park is
working for Mary.
Having to sit next to Steve at the day
program is not working. He gets on her
nerves with his loud mouth.
Mary is happy learning to play games on Suzy not being around enough isn’t
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Mary’s perspective
Working Not Working
the computer. She thinks this is working
well.
working for Mary. She misses Suzy
when she is gone and thinks they don’t
get to spend enough time together.
Family’s perspective - list things family members see as working and not
working for the person regarding the topics listed above. Family members must
look through the lenses of the person as well as their own. Ideas/subjects
should not be listed in a negative fashion, nor should they violate the person’s
rights.
Abby (mom) and Sam’s (dad) perspective
Working Not Working
Suzy spending time with Mary and taking
her places she wants to go is working.
Not having enough HCS hours to do
more things with Suzy on the weekends
is not working.
It is working that Mary gets to do new
activities and experience new things at the
day program.
The weight Mary has gained from
eating too many sweets is not working.
It is not good for her health and
wellbeing.
Mary being able to do things for herself
like getting ready to go to the day program
is working out well.
Mary not having a job in the community
so she can be around more people and
make money isn’t working.
Provider’s perspective - list things the provider(s) see as working and not
working for the person regarding the support(s) they are providing. Providers
must look through the lenses of the person as well as their own. Each
service/support should have a separate working/not working perspective.
Ideas/subjects should not be listed in a negative fashion, nor should they violate
the rights of the person. The provider should say “why” something is not
working.
XYZ Agency; HCS; Suzy’s perspective
Working Not Working
It is working that Mary takes good care of
Spot. She loves him so much.
Not enough HCS hours to do more
things with Mary isn’t working.
Mary and I having fun together laughing
and singing in the car is working well for
her and me.
It’s not working that Mary doesn’t have
more opportunities to make new friends.
The schedule Abby and I have worked out
for me to support Mary works well for
everyone.
Mary always asking to go get ice cream
isn’t working. Her mother says she has
gained a lot of weight. I don’t like telling
her no though.
XYZ Agency; DSA; Dan’s perspective
Working Not Working
Mary learning to use the computer to play
games is working well. She is very good
on the computer.
Mary wanting to do everything in the
kitchen and not allowing others to have
a chance isn’t really working.
It is working that Mary keeps the day It’s not working that Mary doesn’t want
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XYZ Agency; DSA; Dan’s perspective
Working Not Working
program calendar up to date. She always
knows what is going on.
to get off the van when returning from
community activities.
Mary eating lunch with her best friends
Kimberly and Susan works well for her.
Sitting next to Steve during certain
activities doesn’t seem to be working for
Mary. He gets on her nerves.
E. Things People Need to Know (and do) to Support the Person and Keep Them Healthy
and Safe
This section includes information/instructions others need to know and do to support the
person. The information should not focus on services but rather on a description of the person
and supports necessary for them to have a good life. It should be detailed and specific and be
written so it is easy to understand and clearly explains how to provide supports. Any
information can be recorded in this section including, but not limited to, inappropriate actions,
means of communication, routines, likes, dislikes, coping strategies, relationships, fears or
concerns and what to do about them, movement and mobility, seizures, medications, feeding
rituals or instructions, treatments and interventions, special considerations, etc. Think about it
from a provider’s perspective and what they would need to know and do to support someone
they just met. A provider should be able to know what to do for or with someone and
when, how and WHY. This may be the only part of the PSS a DSP reads.
Examples:
Actions that are not appropriate or may cause problems:
Example: John will hit staff or other people in the program when he doesn’t
get his way.
Special considerations that relate directly to the person
Example: Remind Ryan not get in other people’s faces when talking to
them.
Person's fears or concerns
Example: Sam is afraid of the dark. Always make sure the nightlight is on
before turning out his light at bedtime.
Movement and mobility - include any approaches, supplies or devices that are
used to accomplish movement and mobility; movement patterns and/or habits
Example: Lizzie uses a power wheelchair to get around. The chair needs to
be charged every night. When she goes to the mall, Walmart or out to eat,
Lizzie takes her manual wheelchair and needs to be pushed.
Routines - include routines for the morning, bathing, evening, etc.
Example: Dottie has a bed bath every other morning and a shower the other
days. Dottie does not like having her face wet so staff use a special shower
chair that reclines to keep the water out of her face.
F. Strengths
This section focuses on what the person can do for him/herself or can do with assistance.
Indicate the person’s abilities to perform specific activities. This should be a description of the
person rather than a list of their positive qualities. The description reflects the person’s abilities
and likes. Use complete sentences.
Example: Mary has the ability to control her emotions. She likes to make her
own decisions. Mary manages her money with the assistance of Sam. She
will let you know when she doesn’t like something or isn’t excited about
doing something. Mary uses the microwave to cook popcorn when she
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watches movies. She gets herself ready for the day program in the morning
and does her nighttime routine on her own. She loves to ride her bike
around the neighborhood.
G. Referrals
Describe any referrals necessary for the person. Indicate who will make the referral and by
when. (Examples: VR, MH, therapy, etc.)
H. Questions/Things to figure out
This section is a place to record things the team does not know about the person and/or
questions left unanswered at the end of the planning meeting. More times than not, the team
will not know all the necessary information or the answers to all questions.
Where are we missing information?
What do we need to know more about?
What do we need to figure out to make something happen or how to better support
the person?
Always include who will be responsible for following through with getting more
information regarding the issue or what they will do. Also include the timeline. If a
staff person is responsible, then this information will also go in the person’s Activity
Support Plan for that specific service.
Example: Mary wants to swim more often. Where is a place that has a pool
that can accommodate a person who uses a wheelchair? – Shelly from DSA
will look into this
Part III - Person-Centeredness
All services and supports provided must be person centered. People with disabilities have rights that
cannot be violated and must be protected. Each person must be given choices regarding the services
and supports they need to live a good life. Each of the following must be addressed in the PSS and
there must be a statement associated with each answer:
Information on what services are available must be presented to the person/legal
representative/family in an understandable manner in order for them to make an informed
decision on which service(s) they wish to utilize. Explain each applicable service and how it is
used.
Information on all certified providers must be presented to the person/legal
representative/family in an understandable manner in order for them to make an informed
decision on which provider(s) to utilize.
Information regarding different living environments/arrangements must be presented to the
person/legal representative/family in an understandable manner in order to choose the best
living environment/arrangement for the person. Some people living at home with families may
not know there are other options. People already living in the community need to know there
are other places to live if they are not happy where they are.
If the person chooses to live in a group setting, there must be documentation that they were
given a choice of roommates.
Unless the person is a minor (under the age of 18) or has a legal guardian/representative (with
legal documentation), they should be given control over their personal resources.
Example: access to money, access to health and wellness, emotional support,
spirituality, social supports, etc. If a person’s family assists them with making
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choices or budgeting their money, please indicate this information.
Documentation must be maintained indicating the person is given a choice of activities in
their day program and home settings. Examples must be provided of what the person
chooses to do.
Example: arts and crafts, where to go eat, where to go look for a job; where to
shop, etc.
Any limitations or restrictions must be addressed. Limitations and/or restrictions limit a person’s
movement, daily activities, choices, access, or functions. Placing limitations and/or restrictions on
a person often results in the person losing an object or not getting to do something they enjoy.
Positive reinforcement is not present when restrictions are in place. If a person has a limit or
restriction, there must be a plan in place supporting the necessity of the restriction/limitation and
how it is to be used. A copy of the plan must be attached to the PSS. The plan must include the
specific circumstances it will be used in, the fading techniques of the plan and the consent of the
person/legal representative to implement the plan. If there is a doctor’s note supporting a special
diet or other health items, a copy of the medical or a doctor’s note must be attached to the PSS.
Examples of limitations/restrictions: visitors not allowed; having items taken
away for certain reasons; food choices not allowed; being limited to a special
diet; being told when to eat or sleep.
Part IV – Signatures
Everyone at the PSS planning meeting must sign the Signature Page to indicate they participated in
developing the PSS. Each team member’s signature indicates a promise being made to the
focus person to work on making their life better by supporting their outcomes. The signature
page also serves to hold those team members accountable for implementing their part of the PSS. If
someone did not attend the planning meeting but still contributed information via the SC/TCM/TC,
their name and relationship to the person must be indicated in the appropriate section along with the
date the information was provided to the SC/TCM/TC. The SC/TCM/TC signs the document last
indicating they are responsible for monitoring the implementation of the PSS. The signature page
must be uploaded into the LTSS system along with the Skills/Notes from the planning meeting in the
attachments section of the PSS module.
The Support Coordinator/Targeted Case Manager sends a copy of the signature page to providers
who attended the meeting.
Part V - Shared Planning
The Shared Planning section of the Plan of Services and Supports indicates specific outcomes a
person wishes to achieve in order to lead the life they desire. Outcomes are developed by the
person and his/her team based on what is important TO them according to the information
collected and written in the Personal Profile section of the PSS. The person may want to change
an aspect of his/her life, learn to do something new, or continue doing something that is currently
working in their life.
Outcomes are not directed by the services/supports a person receives but rather by the life
they wish to live. Outcomes direct the services and supports to be provided. Outcomes are not
services a person receives or specific details written on how to support them. They are
general statements about living life.
• Outcomes must be measurable:
Can you see it?
Can you count it?
DMH IDD Plan of Services and Supports guidance
• The Support Coordinator/Targeted Case Manager/Transition Coordinator may choose to
use the “Person Centered PSS Outcome Worksheet” to record ideas or recommendations
for outcomes as agreed upon at the meeting. The form is optional.
• All outcomes must be written using the following formula:
Name + action verb + what/where + so that/in order to = expected results
The “Desired Outcomes” is where each outcome idea developed during the meeting is recorded.
The SC/TCM/TC writes the outcomes after the meeting based on the ideas discussed
during the meeting.
The “Provider Services” column indicates who is responsible for completing activities related to
each outcome. This may include more than one provider and/or service. Natural supports can
also be responsible for supporting outcomes. If a natural support is going to support an
outcome their name will be pre-populated from the Natural Supports section of the PSS in the
LTSS system.
The "How Often" column indicates how often activities will be completed while working towards
the outcome. The timeframe must indicate if the activity will be completed daily, weekly or
monthly. If activities are to be completed weekly or monthly, the number of times of
participation/support must be included. The start and end dates will be pre-populated by the LTSS
system to reflect the dates of the person’s current certification year.
Examples:
Outcome Desired Outcomes Provider
Services
How
Often
Start
Date
End
Date
1
Mary participates in arts and crafts
in order to make things to give to
her family and friends.
XYZ Agency/HCS,
DSA
3 x
per
week
10/1/15 9/30/16
2
Mary attends church so that she can
worship God and see her friends in
Sunday School.
XYZ Agency, HCS
XYZ Agency, DSA
Abby and Sam
2 x
per
week
10/1/15 9/30/16
3
Mary feeds and walks Spot in order
to ensure he is healthy and well
cared for.
XYZ Agency, HCS
Abby and Sam
Daily 10/1/15 9/30/16
4
Mary eats out, shops, gets her nails
done and does other things in order
to enjoy herself and be a part of her
community.
XYZ Agency, HCS
XYZ Agency, DSA
Abby
4 x
per
week
10/1/15 9/30/16
The Plan of Services and Supports should always be a complete, current snapshot of a person’s life.
Everyone’s life changes all the time. The people who receive supports are no different. Health
changes, friends come and go, jobs change, life changing events happen. The plan should always be
updated to reflect those changes in order to know the person and what is currently happening in
his/her life.
Planning with a person using Person Centered Thinking Skills© and practices allows you to dig
deeper, ask more questions, and find out more about a person than ever before. Always ask
“WHY”?? Plans and outcomes are truly individualized. People we support will begin communicating
with us and letting us help he/she live the life they want. Only when people see change do they
believe it.
DMH IDD Plan of Services and Supports guidance
Revisions to the Plan of Services and Supports
The PSS is a fluid document that is meant to be revised throughout the year as a person’s situation
changes. Revisions can be made to any section of the PSS. Providers can also ask for changes to a
PSS regarding the Shared Planning Section. An outcome may be accomplished or a new outcome
may need to be added. Additionally, they may have information regarding an item in the Essential
Information Section that may need to be updated. The person/legal representative must agree to all
changes either in writing, or via a witness hearing the request. Everyone who attended the most
recent in-person PSS meeting must get a copy of the revised PSS.
Due to changing needs, there could be instances when all members of the team must come together
during the person’s certification year to review/revise the PSS. For example, a person could have a
change in medical condition and new services must be requested, the Personal Profile must be
updated and the Shared Planning must be revised. Other examples could include someone moving
from their family home to Supervised Living. A new PSS meeting would need to be held to involve the
new provider and new outcomes may need to be developed. The revised PSS and signature page
would be sent to everyone who attended the meeting.
Recertification Plans of Services and Supports
For recertification Plans of Services and Supports, the SC/TCM may take a copy of the current PSS to
the PSS meeting. It can be used as the basis of the conversation. All elements of the Essential
Information should be kept current throughout the year. Before the PSS meeting, the Support
Coordinator/TCM can review the elements with the person/legal representative/service providers to
ensure they are up-to-date. However, the following elements of the Essential Information must be
reviewed at the PSS meeting to ensure they are, indeed, current:
Medical Information
Medications
Back-up and Emergency Plans
The Risk Assessment
Employment
Behavior Supports (if applicable)
Any restrictions
The Skills to be used at each meeting will vary from person to person. The SC/TCM must use their
judgement to determine which Skills may be necessary to gather additional information. Any new
Skills and all notes taken at the PSS meeting must be submitted to BIDD with the recertification PSS.
The Relationship Map is the only required Skill to be used. It is to be updated, as needed, and be
submitted with the PSS.
All sections of the Part II: The Personal Profile should be reviewed to ensure all sections are accurate
and current. All questions in the Person Centeredness Section must be addressed. The Shared
Planning Section is to be updated/changed according to information gathered during the PSS
meeting. Everyone who attends the recertification PSS meeting must get a copy of the revised PSS
and the signature page.
Providers should bring copies of their Activity Support Plans to the meeting to review, also. The
provider has 30 days from receipt of the PSS to complete revisions the Activity Support Plan. It must
be submitted to the SC/TCM by the 15
th of the month following the month it is developed.
The Plan of Services and Supports Instructions include person centered concepts, principles and materials used
with permission from The Learning Community for Person Centered Practices. Find out more at
www.learningcommunity.us. Support Development Associates, Inc. also contributed to development of the PCT
Skills©.
DMH Plan of Services and Supports form
Plan of Services and Supports Status: Program Type: ID/DD
Overview
Active: Created Date:
PSS Type: Initial/Recertification/Change Effective Date:
Service Type End Date:
Comments:
Part I - Essential Information
Contact Information
Legal First Name: Medicaid #
Legal Last Name: Initial Certification Date:
Legal Middle Name: Home Phone:
Preferred Name: Cell Phone:
Date of Birth: Email:
Address: Support Coordinator/TCM
Family Contact
First Name: Phone:
Last Name: Fax:
Middle Name: Email:
Contact Type: Address:
First Name: Phone:
Last Name: Fax:
Middle Name: Email:
Contact Type: Address:
First Name: Phone:
Last Name: Fax:
Middle Name: Email:
Contact Type: Address:
DMH Plan of Services and Supports form Page 2 of 9
Name: Medicaid #: Certification Date:
ID/DD Waiver Supports
Service Information
Service Type: PSS Service:
Frequency Type: Units per month:
Hours per Month: Rate:
Minutes: Costs:
How/When Support is Used:
Provider Information
Provider Name: Provider Number:
Contact Name: Phone:
Address: Email address
Service Information
Service Type: PSS Service:
Frequency Type: Units per month:
Hours per Month: Rate:
Minutes: Costs:
How/When Support is Used:
Provider Information
Provider Name: Provider Number:
Contact Name: Phone:
Address: Email address
PSS Costs
Annual Waiver Plan Services Total:
Annual 1915(i) Services Total:
Total PSS Budget:
Non – Waiver Agency Supports
Agency Contact Name Phone Number: Non-Waiver Agency
Support
How/When Support Provided
DMH Plan of Services and Supports form Page 3 of 9
Name: Medicaid #: Certification Date:
Natural Supports
Are there natural supports? Yes/No
Support Person Relationship Support Role Phone Number
Medical Information
Physician Specialty Address Phone
Medications
Medications required?
Medication: Physician: Dosage Frequency Reason(s)
Prescribed
Psychotropic
Y/N
Recent Physical and Health Conditions
Recent Physical Complaints and/or Health Conditions
Chronic health conditions? Yes
No
Description:
History of health problems/issues? Yes
No Description:
Current limitations or restrictions
on physical activities?
Yes
No
Description:
Any serious illnesses and/or
hospitalizations in the past year
including ER visits?
Yes No
Description:
Admissions to ICF/IID, Mental
Health Facilities, Rehabilitation
Facilities or other inpatient care?
Yes No
Description:
(when,
where, why)
Latest Exam Dates
Date of my last physical exam:
Date of my last dental exam:
Estimated/approximate date? Estimated/Approximate date?
Examination Results
Examination Results
DMH Plan of Services and Supports form Page 4 of 9
Name: Medicaid #: Certification Date:
Allergies:
Reactions:
Medical Support Needs and Mental Health Support Needs
Medical Support Needs Mental Health Support Needs
.
Communication, Adaptive Equipment, Assistive Technology and/or Modifications
Method(s) of communication:
Describe supports needed for communication (if any):
Describe any adaptive equipment or assistive
technology supports used:
How is equipment maintained? Who is responsible?
What is the back-up plan for power outages if medical
equipment is used?
Describe any environmental modifications necessary:
Risk Assessment
Date Created:
Risk:
Resolution
Back-up and Emergency Plans
Steps to take if the provider does not show up:
Steps to take if the day program/work or other activity
is canceled, closes or you have to
leave for some other reason:
Steps to take when a natural disaster occurs:
Plan for future living arrangements if something were
to happen to the primary caregiver:
DMH Plan of Services and Supports form Page 5 of 9
Name: Medicaid #: Certification Date:
Family and Current Living Arrangements
Education
Current School Year
Last School
Attended:
Year
Type of
Diploma/Certificate:
Year:
Employment History
Was {name} ever
employed? Yes No
Reason why
{name} isn’t
working:
Volunteer Activities
Did {name} ever
volunteer? Yes No
Behavior Supports
Previous and Current Behavior Supports:
Serious Incidents During the Past Year
Evaluation Information
Current ICAP Date: Current ICAP Score
Who Completed the ICAP Current ICAP Service Level
Previous ICAP Date Previous ICAP Score
Who Completed the ICAP? Previous ICAP Service Level
Psychological
Date:
Examiner Name: Examiner Agency:
Primary DSM Code
Secondary DSM Code(s)
Essential Information completed by:
Person: Legal Guardian:
Support Coordinator/Credentials: Additional
Contributors:
Date Reviewed:
DMH Plan of Services and Supports form Page 6 of 9
Name: Medicaid #: Certification Date:
Part II – Personal Profile
Great Things About {name}
Hopes and Dreams
Important To/For
Important TO Important FOR
Working/Not Working
Perspectives
Things that work Things That Do Not work
__________’s Perspective:
___________’s Perspective:
Family’s Perspective
Family’s Perspective
Family’s Perspective
Family’s Perspective
Provider’s Perspective
Provider’s Perspective
Provider’s Perspective
Provider’s Perspective
DMH Plan of Services and Supports form Page 7 of 9
Name: Medicaid #: Certification Date:
Need to Know & Strengths
Things People Need to Know to Support {name} and Keep Him/Her Healthy and
Safe
{Name} ‘s Strengths
Questions/Things to Figure Out
Question Person Responsible
Are any referrals needed?
Yes No Explain:
DMH Plan of Services and Supports form Page 8 of 9
Name: Medicaid #: Certification Date:
Part III – Person Centeredness
Choice, Control, Restrictions/Limitations
Were you given a choice of
service(s)?
Yes
No Please describe:
Were you given a choice of
provider(s)?
Yes
No Please describe:
Were you given a choice of
living setting(s)?
Yes
No Please describe:
Were you given a choice of
roommate(s)?
Yes No
Please describe:
Do you have control of your
personal resources?
Yes
No Please describe:
Are you given a choice of
activities in your living
setting? (including where you want
to go in the community)
Yes
No Please describe:
Are you given a choice of
activities in your day program
setting?
(including where you want
to go in the community)
Yes
No Please describe:
Do you have any restrictions
or limitations set by staff?
(including visitors and food)
Yes No
Please describe:
DMH Plan of Services and Supports form Page 9 of 9
Name: Medicaid #: Certification Date:
Contributors Not at Meeting
Support Person Relationship Date contributed
Signatures
Type Name Services Signature Name Signature Date
Part IV - Shared Planning
Desired Outcome Supports How Often Start Date End Date
DMH IDD Activity Support Plan
IDD Activity Support Plan
Purpose
The purpose of the Activity Support Plan (ASP) is to document activities and strategies/support
instructions to be completed in order for a person to work towards reaching their desired
outcomes as documented in the Plan of Services and Supports. Staff should be able to read a
person’s ASP and know exactly how to provide services and supports to that person.
General
An ASP is required for each service a person receives. Providers are responsible for developing
the ASP with the person and legal/representative after the development of the Plan of Services
and Supports (PSS). The ASP is tailored to the outcomes developed during a person’s PSS
meeting. Each service will have a separate ASP regardless of whether or not the same provider is
providing more than one service.
The Support Coordinator/Targeted Case Manager must ensure all ASPs are consistent and
include activities that were identified to meet the outcomes developed during the PSS meeting. If
the Support Coordinator/Targeted Case Manager finds the ASP does not reflect what was
discussed at the PSS meeting, he/she can return it to the provider for revision.
Outcome Statement
Providers write the outcome statements from the Shared Planning section of the PSS that pertain
to the service/support they provide. Outcomes may be on more than one ASP if both services can
provide support in reaching the outcome.
Person’s Support Activities
List the support activities a person will participate in to assist him/her in meeting his/her stated
outcomes. Activities are things that can be seen and counted. They include some sort of action
word, relate to the desired outcome being addressed and are appropriate to the service/support
being provided. There may be multiple support activities for each outcome.
Strategies/Support Instructions
The Strategies/Support Instructions describe how supports will be provided based on the person’s
choices and preferences. The strategies/support instructions will provide detailed directions for
staff to follow when completing support activities with the person. The strategies/support
instructions may include what the person likes to do, the type of support needed, specific
directions for staff to follow, teaching steps, what is needed for success. The information must be
very detailed and specific to each person and each outcome.
The ASP includes how often activities will be conducted/completed as decided upon during the
PSS Development meeting. In order to track progress and collect data, each outcome must be
completed/done a certain number of days per week or days per month. If an outcome is
addressed daily, the number of times per day does not need to be indicated.
Once the provider receives the approved PSS, they develop the Activity Support Plan with the
DMH IDD Activity Support Plan
person/legal representative within 30 days of certification date.
Timelines
For ID/DD Waiver and IDD CSP providers, Activity Support Plans must be developed with the
person/legal guardian (if applicable) within thirty (30) days of receipt of the person’s PSS. The
ASP is to be submitted to the appropriate Support Coordinator/Targeted Case Manager by the
15
th of the month following development. It must be reviewed and/or revised at least annually, as
changes are needed or whenever the person wishes to revise it.
Other IDD services – The Activity Support Plan is to be developed with the person/legal guardian
(if applicable) within 30 days of the date of the PSS and be in the person’s record no later than the
10th of the month following development. It must be reviewed and/or revised at least annually, as
changes are needed or whenever the person wishes to revise it.
The Support Coordinator must ensure all ASPs are consistent and include activities that were
identified to meet the outcomes developed during the PSS meeting. If the Support Coordinator
does not feel the ASP reflects what was discussed in the PSS meeting, he/she can send it back
and request clarification. The ASP must be reviewed and/or revised at least annually, as changes
are needed or whenever the person wishes to revise it.
Copies of ASPs must be available to staff at all times.
Questions/Things to Figure Out
List questions/ideas/things discussed in the PSS meeting that need to be addressed but cannot
be decided upon at the meeting or that require research or additional information to figure out.
There must be a person responsible assigned to address each item. There must also be
timelines for accomplishing the activity.
Signatures
The ASP is developed with the person/legal representative and signed at the time of
development/review. Staff developing the plan with the person/legal representative sign (including
credentials) and date the plan.
IDD Activity Support Plan
Name: Medicaid #: Agency: Service:
DMH IDD Activity Support Plan
(Use as much space as necessary)
Outcome Statement List the support activities for each
desired outcome
Support Instructions
Describe how supports need to be tailored
to the person’s preferences and profile
How often or
by when?
IDD Activity Support Plan
Name: Medicaid #: Agency: Service:
DMH IDD Activity Support Plan
Questions/Things to Figure Out
(use as many lines as necessary)
1.
Person
Responsible: By when:
2.
Person
Responsible: By when:
Signatures
Person: Date:
Legal
Representative: Date:
Provider
Signature/Credentials: Date:
DMH IDD Service Note
IDD Service Notes
Purpose
IDD Service Notes are used to document activities that take place during the provision of services.
Documentation must be detailed and specific to each person’s Activity Support Plan. Staff
activities toward the provision of services must also be documented. A single form can be used
for one (1) or two (2) days, depending on the amount of information; use as many pages as
necessary to adequately document the information each day/time services are provided. For
example, if a person goes out to participate in a community activity, two (2) notes may be
necessary for that day: one (1) for program site activities and one (1) for community activities.
General
Indicate the person’s name, Medicaid number (or other ID number if the person does not receive
Medicaid), the name of the service and the name of the agency providing the service. Document
the date of service, the time it begins (using a.m./p.m.), the time it ends (using a.m./p.m.), and the
total time spent providing services. Staff providing the service must sign indicating his/her
credentials and date the form.
IDD Service Notes replace Activity Notes. IDD Service Notes are required for the following IDD
services:
• Behavior Support (Each time services are provided. A separate form for detailed observation may be
used if desired.)
• Early Intervention (Each time services are provided.)
• Home and Community Supports (Each time services are provided.)
• In Home Respite (Each time services are provided)
• Host Homes (Daily)
• Job Discovery (Each time services are provided.)
• Supervised Living (Daily - There must be a Service Note for each shift.)
• Supported Employment (Each time services are provided.)
• Shared Supported Living (Daily)
• Supported Living (Each time services are provided.)
IDD Service Notes must reflect who, what, when, where, how and why for activities each day/ time
services are provided. The following must be specifically addressed:
• Activities in which the person chose to participate
• Where all activities occurred (at the program site, in the community[list the specific location of the
activity], in the home)
• How and why activities were completed (this relates activities back to the person’s Activity Support
Plan)
• What worked well about the activity(ies) and what the person liked
• What did not work well about the activity(ies) and what the person did not like
• Staff followed during the provision of services
• Progress toward meeting stated outcomes
IDD Service Notes must also be used to document the following:
• When supports are not provided according to the Activity Support Plan
• Why a person chose not to participate in an activity
DMH IDD Service Note
• Unusual events/circumstances
• Why a person is absent on any given day
• Phone calls or interaction with family or other providers/entities on behalf of the person
Service notes can be written or typed. Use as much space as necessary to completely document
all activities.
Timelines
IDD Service Notes must be completed the day services are provided and be in the person’s
record no later than the 10th day of the month following the month service are provided.
IDD Service Note
Name: Medicaid #:
Service: Agency:
DMH IDD Service Note form
Date: Begin Time: End Time: Total Time: Location(s):
Person’s Activities Staff’s Activities
(Who, What, When, Where, How, Why)
Staff Signature/
Credentials
Date: Begin Time: End Time: Total Time: Location(s):
Person’s Activities Staff’s Activities
(Who, What, When, Where, How, Why)
Staff Signature/
Credentials
DMH IDD Clean 2016 IDD Weekly Service Note guidance
IDD Weekly Service Note
Purpose
IDD Service Notes are used to document activities that take place during the provision of
services. Documentation must be detailed and specific to each person’s Activity Support
Plan. Staff activities toward the provision of services must also be documented.
General
Indicate the person’s name, Medicaid number (or other ID number if the person does not
receive Medicaid), the name of the service and the name of the agency providing the service.
Document the date of service, the time it begins (using a.m./p.m.), the time it ends (using
a.m./p.m.), and the total time spent providing services. Staff providing the service must sign
indicating his/her credentials and date the form.
IDD Weekly Service Notes are required for the following IDD services:
• Community Respite
(Each time services are provided.)
• Day Habilitation (Daily)
• Day Services Adult (Daily)
• Prevocational Services (Daily)
• Work Activity (Daily)
IDD Weekly Service Notes must reflect who, what, when, where, how and why for activities
each week services are provided. The following must be specifically addressed:
• Activities in which the person chose to participate
• Where all activities occurred (at the program site, in the community[list the specific location of the
activity], in the home)
• How and why activities were completed (this relates activities back to the person’s Activity
Support Plan)
• What worked well about the activity(ies) and what the person liked
• What did not work well about the activity(ies) and what the person did not like
• Staff followed during the provision of services
• Progress toward meeting stated outcomes
IDD Weekly Service Notes must also be used to document the following:
• When supports are not provided according to the Activity Support Plan
• Why a person chose not to participate in an activity
• Unusual events/circumstances
• Why a person is absent on any given day
• Phone calls or interaction with family or other providers/entities on behalf of the person
Service notes can be written or typed. Use as much space as necessary to completely
document all activities.
Timelines
IDD Weekly Service Notes must be completed the week services are provided and be in the
DMH IDD Clean 2016 IDD Weekly Service Note guidance
person’s record no later than the 10th day of the month following the month service are
provided.
Monthly Summary
At the end of the month, a summary of progress or lack of progress toward outcomes must
be documented.
Staff completing the Weekly Progress Note must sign and date the form at the end of the
month.
DMH IDD Clean 2016 IDD Weekly Service Note form
IDD Weekly Service Note
Name ___________________________________________
ID Number _______________________________________
Service __________________________________________
Attendance during month of in the year of
Days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Time
In
Time
Out
Total
Time
Weekly
Dates Summary of Activity
1st Week
Outcomes:
Date: Signature/Credential:
2nd Week
Outcomes:
Date: Signature/Credential:
DMH IDD Clean 2016 IDD Weekly Service Note form
3rd Week Outcomes:
Date: Signature/Credential:
4th Week Outcomes:
Date: Signature/Credential:
5th Week
Outcomes:
Date: Signature/Credential:
Monthly
Summary
Date:
Staff Signature/Credential:
Date: Supervisor Signature/Credential:
DMH Clean 2016 ID-DD Waiver IDD CSP Service Authorization guidance
ID/DD Waiver/IDD CSP Service Authorization
Purpose
To inform a provider what type and amount of ID/DD Waiver and IDD CSP service(s) they are
authorized to provide to an individual and the begin and end dates for the authorization.
The provider receives this form from the Support Coordinator/ Targeted Case Manager.
General
Initially and when updated, the Support Coordinator/ Targeted Case Manager sends the most
current Social and Psychological Reports from the Diagnostic and Evaluation Team with the
Service Authorization. The Support Coordinator also sends the most current Medical
Evaluation.
Timelines
No service can begin before the start date on the Service Authorization. Before any services
can begin, the provider must review the Social, Medical and Psychological Reports from the
Diagnostic and Evaluation Team and document the review in the Service Notes in the
individual’s record.
The Support Coordinator/ Targeted Case Manager must issue the Service Authorization(s) to
the providers chosen by the individual and listed on the Plan of Services and Support within five
(5) days of receipt of the approved certification/change(s) from the BIDD.
1. Initial Certification/Readmission – The Support Coordinator/ Targeted Case Manager will
issue Service Authorization(s) within five (5) days of receipt of the approved initial
certification/readmission request.
2. Changes – If, during the individual’s certification year, there is a change in the
type/amount of service a person receives, the Support Coordinator/ Targeted Case
Manager will send the provider an updated Service Authorization indicating there are
changes within five (5) days of receipt of the Plan of Services and Supports from the
BIDD. The Service Authorization will have the new type(s) and/or amount(s) of services
being authorized along with the end date of the previously authorized types(s) and/or
amount(s) of service.
3. Recertification – Annually, within five (5) days of receiving an individual’s approved
recertification, the Support Coordinator/ Targeted Case Manager issues a new Service
Authorization to the provider(s) reflecting the services and the amount(s) of service(s) the
agency is authorized to provide. The effective date of the Service Authorization will be
the individual’s certification begin date and the end date will be the certification lock-in
end date.
If the Support Coordinator / Targeted Case Manager does not receive a signed copy of the
DMH Clean 2016 ID-DD Waiver IDD CSP Service Authorization guidance
Service Authorization from an agency within ten (10) days, the Support Coordinator/ Targeted
Case Manager will ask the individual if he/she would like to be referred to another provider. At
that time, the Support Coordinator / Targeted Case Manager sends the agency a Service
Authorization with an end date for the service(s).
Another Service Authorization is issued for the next agency chosen. The start date for that
agency must be no sooner than the end date of the previous Service Authorization.
Start and End Dates
All service amounts/frequencies will have an authorized start and end date. Service
Authorizations are valid only for the dates listed on the form. The end date cannot exceed the
person’s current certification lock-in end date, regardless of the authorized start date.
1. Authorized Start Date
a. The date of the individual’s certification, regardless of type
b. Date changes to the Plan of Services and Supports are approved by BIDD
2. End Date
a. Initial/readmission/recertification – The certification lock-in end date
b. Changes – The day the BIDD approves changes to the Plan of Services and
Supports
c. When a service is terminated
If at any time a person chooses to change providers of in home services, the Service
Authorization will be effective on the 1st day of the month following the request unless the
Support Coordinator can obtain documentation of the amount of services provided thus far in
the month.
Exceptions:
a. Suspected abuse or neglect or other situations in which the individual’s health and
welfare are at risk
b. The individual is not receiving/has not received the particular service during the
month in which the change in provider is requested.
Signature of Authorized Agency Representative
An authorized agency representative must sign and date the form to verify the information is
accurate and return a copy to the appropriate Support Coordinator/ Targeted Case Manager
BEFORE services can begin.
The Support Coordinator/ Targeted Case Manager must sign and date the form when received
from the agency.
DMH Clean 2016 ID-DD Waiver CSP Waiver Service Authorization form
ID/DD Waiver
Service Authorization
To: From:
Name of Agency Support Coordination Department
Re:
Individual’s Name IDD Waiver Support Coordinator
Medicaid Number IDD Waiver Support Coordinator Phone/e-mail
Individual’s Address and Phone Number
Change in type(s)/amount(s) of service
Procedure
Code
Service
Amount Frequency Authorized
Start Date End Date
--- ---
--- ---
--- ---
--- ---
--- ---
--- ---
--- ---
ID/DD Waiver Support Coordinator Comments/Information
Can the agency provide the service(s) requested? Yes No
Agency Comments
Signature of Authorized Agency Representative Date
To Be Completed by Support Coordinator
Date Received from Agency Support Coordinator Signature
DMH ID/DD Waiver HCS Service Agreement
ID/DD Waiver Home and Community Supports
Service Agreement
Purpose
The Home and Community Supports (HCS) Service Agreement outlines the allowable activities,
rules and procedures regarding the provision of the service. The agreement indicates supports
and/or activities that can and cannot be provided by staff when services are rendered.
General
The provider is responsible for reviewing the form with the person/legal representative. Both the
staff person and person/legal representative must sign form to indicate agreement to adhere to
the requirements in order to receive services.
Timelines
The provider reviews the Home and Community Supports Service Agreement with the
person/legal representative prior to or at the time the provider begins providing services and at
least annually thereafter, at the same time the Activity Support Plan is completed. A signed
document must be maintained in the person’s record and the person/legal representative must
be given a copy to keep.
ID/DD Waiver HCS Service Agreement
ID/DD Waiver Home and Community Supports
Service Agreement
Name: Medicaid Number:
1. Home and Community Supports (HCS) will meet the support needs identified in the Plan of Services
and Supports and Activity Support Plan. Only the amount of Home and Community Supports authorized
in the Plan of Services and Supports will be provided. If a change in the amount is needed, the Support
Coordinator must be contacted.
2. HCS can be provided in the home and/or in the community and either with or without a parent/legal
representative present, depending upon identified support needs.
3. HCS staff cannot be responsible for caring for others who may be in the home. HCS staff is only
responsible for the person who is enrolled in the ID/DD Waiver. Also, the HCS staff person is not
responsible for caring for pets.
4. HCS cannot be provided at a staff person’s home.
5. If a scheduled HCS visit must be canceled (e.g. because of a doctor’s appointment, illness, going out of
town, etc.), the provider must be notified as soon in advance of the cancellation as possible. Three (3)
cancellations for which no notice is given will result in a review of the Plan of Services and Supports to
determine if Home and Community Supports are still necessary and appropriate.
6. HCS may be terminated according to the provisions in the ID/DD Waiver Enrollment Agreement.
7. If a decision is made to terminate HCS, notification will be sent as soon as possible. The Support
Coordinator will assist in locating other service options, if available. There are established procedures
for filing an appeal of the decision. The services will not change until the outcome of the appeal is
determined. If termination of services is due to the environment or persons in the environment posing a
risk to the HCS staff person, services might continue pending the outcome of the appeal.
8. Should any problems arise regarding the provision of HCS, the Support Coordinator is to be notified
immediately.
9. HCS cannot be provided on an overnight basis outside of the legal residence.
10. HCS staff cannot provide medical treatment of any sort, as defined in the Mississippi Nurse Practice Act
Rules and Regulations.
11. Home and Community Supports staff cannot accompany a minor child on a medical visit without the
parent/legal representative.
HCS staff cannot provide services to someone who is in a hospital or any other facility being reimbursed
by Medicaid, Medicare or private insurance.
12. Home and Community Supports cannot be provided in a school setting.
13. Home and Community Supports providers cannot do personal errands or have interactions with their
family and friends during the provision of services.
The above information has been reviewed and the circumstances under which Home and Community
Supports can be provided are understood.
Person/Legal Representative Signature Agency Representative Signature/ Credentials
Date Date
DMH ID/DD Waiver IHR Service Agreement
ID/DD Waiver In-Home Respite
Service Agreement
Purpose
The In-Home Respite Service Agreement outlines the allowable activities, rules and procedures
regarding the provision of the service. The agreement indicates supports and/or activities that
can and cannot be provided by staff when services are rendered.
General
The provider is responsible for reviewing the form with the person/legal representative. Both the
staff person and person/legal representative must sign form to indicate agreement to adhere to
the requirements in order to receive services.
Timelines
The provider reviews the In-Home Respite Service Agreement with the person/legal
representative prior to or at the time the provider begins providing services and at least annually
thereafter, at the same time the Activity Support Plan is completed. A signed document must be
maintained in the person’s record and the person/legal representative must be given a copy to
keep.
ID/DD Waiver In-Home Respite Service Agreement
ID/DD Waiver In-Home Respite Service Agreement
Name: Medicaid Number:
1. In-Home Respite will meet the support needs identified in the Plan of Services and Supports and
Activity Support Plan. Only the amount of In-Home Respite authorized in the Plan of Services and
Supports will be provided. If a change in the amount is needed, the Support Coordinator must be
contacted.
2. In-Home Respite is to be provided in the home. The provider can take the person on short (1-2 hour)
community outings to get out of the house for a short period, but community participation cannot be the
purpose of the service.
3. In-Home Respite staff cannot be responsible for caring for others who may be in the home. In-Home
Respite staff is only responsible for the person who is enrolled in the ID/DD Waiver. Also, the In-Home
Nursing Respite staff person is not responsible for caring for pets.
4. If a scheduled In-Home Respite visit must be canceled (e.g. because of a doctor’s appointment, illness,
going out of town, etc.), the provider must be notified as soon in advance of the cancellation as
possible. Three (3) cancellations for which no notice is given will result in a review of the Plan of
Services and Supports to determine if In-Home Respite is still necessary and appropriate.
5. In-Home Respite may be terminated according to the provisions in the ID/DD Waiver Enrollment
Agreement.
6. If a decision is made to terminate In-Home Respite, notification will be sent as soon as possible. The
Support Coordinator will assist in locating other service options, if available. There are established
procedures for filing an appeal of the decision. The services will not change until the outcome of the
appeal is determined. If termination of services is due to the environment or persons in the environment
posing a risk to the In-Home Respite staff person, services might continue pending the outcome of the
appeal.
7. Should any problems arise regarding the provision of In-Home Respite, the Support Coordinator is to be
notified immediately.
8. In-Home Respite staff cannot provide medical treatment of any sort, as defined in the Mississippi Nurse
Practice Act Rules and Regulations.
9. In-Home Respite staff cannot accompany anyone on a medical visit.
10. A relative may only provide up to 172 hours of In-Home Respite per month.
11. In-Home Respite providers cannot do personal errands or have interactions with their family and friends
during the provision of services.
The above information has been reviewed and the circumstances under which In-Home Respite can
be provided are understood.
Person/Legal Representative Signature Agency Representative
Signature/Credentials
Date Date
DMH Clean 2016 ID-DD Waiver IHNR Service Agreement guidance
ID/DD Waiver In-Home Nursing Respite Service Agreement
Purpose
The In-Home Nursing Respite Service Agreement outlines the allowable activities, rules and
procedures regarding the provision of the service. The agreement indicates supports and/or
activities that can and cannot be provided by staff when services are rendered.
General
The provider is responsible for reviewing the form with the person/legal representative. Both
the staff person and person/legal representative must sign form to indicate agreement to
adhere to the requirements in order to receive services.
Timelines
The provider reviews the In-Home Nursing Respite Service Agreement with the person/legal
representative prior to or at the time the provider begins providing services and at least annually
thereafter, at the same time the Activity Support Plan is completed. A signed document must
be maintained in the person’s record and the person/legal representative must be given a copy
to keep.
DMH ID/DD Waiver IHNR Service Agreement form
ID/DD Waiver In-Home Nursing Respite
Service Agreement
Name: Medicaid Number:
Agency:
1. In-Home Nursing Respite (IHNR) services will meet the support needs identified in the Plan of Services and
Supports and Activity Support Plan. Only the amount of In-Home Nursing Respite authorized in the Plan of
Services and Supports will be provided. The Support Coordinator must be contacted if a change in the amount is
needed.
2. IHNR is provided by either a Licensed Practical Nurse (LPN) or Registered Nurse (RN). The service is intended to
be temporary (short-term) and provide periodic relief to the primary caregiver.
3. IHNR is provided in the family home either with or without a parent/legal guardian present, depending upon
identified support needs.
4. IHNR services cannot be provided in the nurse’s or any of his/her relatives’ homes.
5. Nurses are NOT responsible for caring for others who may be in the home. The nurse is only responsible for the
person who is enrolled in the ID/DD Waiver. Also, the nurse is not responsible for caring for pets.
6. If a scheduled time for IHNR must be canceled (e.g. because of a doctor’s appointment, illness, going out of town,
etc.) the nurse must be notified as soon in advance of the cancellation as possible. Three (3) cancellations for
which no notice is given will result in a review of the Plan of Services and Supports to determine if IHNR services
are still necessary and appropriate.
7. It is understood that the IHNR staff person will complete all forms necessary to document the provision of IHNR. I
or my parent/legal representative will be asked to initial the Service Note each time IHNR services are provided to
verify that the provider provided the amount of service indicated. It is understood that signing false or fraudulent
documentation is against the law.
8. If a decision is made to terminate IHNR services because of failure to adhere to the ID/DD Waiver Enrollment
Agreement or the IHNR Service Agreement, notification will be sent as soon as possible. The Support
Coordinator will assist in locating other service options, if available. There are established procedures for filing an
appeal and those will be provided. The services will not change until the outcome of any appeal is determined. If
the environment or persons in the environment pose a risk to the IHNR staff person, the he/she/the agency does
not have to continue providing services.
9. Should any problems arise regarding the provision of IHNR, notify the Support Coordinator immediately to avoid
possible interruption of services.
10. Medical treatment provided by nurses must be completed according to the Mississippi Nurse Practice Act Rules
and Regulations. Any questions regarding nurses and their scope of practice must be addressed directly to the
Mississippi Board of Nursing.
The above information has been reviewed and the circumstances under which In-Home Nursing Respite
Services can be provided are understood.
Person/Legal Representative Signature Agency Representative Signature/Credentials
Date Date
DMH IDD Waiver IHNR Service Note guidance
IDD Waiver In-Home Nursing Respite Service Note
Purpose
The provider must document on the In-Home Nursing Respite Service Note time spent in
service provision with the person receiving supports. In-Home Nursing Respite Service
Notes must reflect activities and strategies written in the Activity Support Plan.
General
Nurses are governed by the Mississippi Board of Nursing and the Mississippi Nurse
Practice Act and Rules and Regulations. For purposes of the ID/DD Waiver, the In-Home
Nursing Respite Service Note must have information sufficient enough to justify the time
spent providing the service. The In-Home Nursing Respite Service Note must identify the
time services began, the time they ended (indicating a.m./p.m.) and the total amount of
time spent providing services. The person/legal representative must sign the note
verifying the services documented were provided during the times indicated.
In-Home Nursing Respite Service Notes must be completed during service provision. The
nurse completing the In-Home Nursing Respite Service Note signs and dates it at the
completion of the shift.
Timelines
In-Home Nursing Respite Service Notes must be in the person’s record no later than the 10th
day of the month following the month they were completed.
DMH IDD Waiver IHNR Service Note form
IDD Waiver In-Home
Nursing Respite
Service Note
Name
Agency
ID Number
Page of
Provider’s Signature/Credentials Date
(m/d/yr)
Time In
(am/pm)
Time
Out
(am/pm)
Total Time Person/Legal
Representative’s
Signature
Notes
DMH Clean 2016 IDD Employment Profile guidance
IDD Employment Profile
Purpose
The IDD Employment Profile is used for people who have not had or who do not wish to
participate in Job Discovery. The IDD Employment Profile is used to determine a person’s skills,
interests and preferences as they relate to a career path or field of employment. This
information serves as the basis of job searching for the person.
General
Information gathered is used to determine the best job fit for someone. The Employment
Specialist/Job Coach is to use this information when assisting a person in locating a job.
The information can be relayed to potential employers in order to help facilitate obtaining
a job in which the person can be satisfied and successful.
If a person is referred to a Supported Employment provider already has a job, this form
would not need to be completed. It would be completed at such time as when the person
desires a new job or is terminated from his/her current job.
Information to Be Gathered
Address each area with the person and/or someone who knows him/her best if he/she does not
speak using words. This information can be gathered by the Program Supervisor or a Direct
Support Staff person.
Timelines
The IDD Employment Profile is to be completed within thirty (30) days of enrollment in a
Supported Employment program and is to be updated if a person loses/changes jobs. The
purpose of the update is to ensure any changes in the information are reflected. For instance, a
person may find after working for several months that he/she likes a more interactive work
environment than when he/she first started or he/she may gain skills that would need to be
reflected when looking for another job. The IDD Employment Profile must be in the person’s
record by the 10
th of the month following the month in which it is completed.
ID/DD Waiver/IDD Community Support Program
The IDD Employment Profile must be submitted to the person’s ID/DD Waiver Support
Coordinator or IDD Community Support Program Targeted Case Manager by the 15th of the
month following the month it is completed. The information gathered from the IDD Employment
Profile may be used to update the Plan of Services and Supports and generate new outcome(s)
for the person. A Team Meeting may be necessary and provider staff will be required to attend.
DMH IDD Employment Profile form
IDD
Employment Profile
Name:
ID Number:
Date:
Provider Agency:
Availability:
☐ Weekdays ☐ Evenings ☐ Full time (40 hours/week)
☐ Weekends ☐ Part-time (at least 20 hrs/week) ☐ Less than part-time (less than 20 hrs/week)
Transportation:
☐ Needs transportation ☐ Needs assistance/training to access public transportation
☐
Can access public
transportation ☐ Family/neighbor/friend/co-worker will transport
Financial Situation:
☐ Income must not affect benefits ☐ Financial ramifications not an obstacle
☐ Is concerned/would like more information about increased income effect on SSI/SSDI
Time awareness:
☐ Cannot tell time ☐ Understands break and lunch
☐ Can tell exact time ☐ Can tell time to the hour
☐ Must have digital clock/watch to tell time ☐ Can tell time with analog clock/watch
Lifting ability:
☐ 0-5 lbs. ☐ 10-20 lbs.
☐ 20+ lbs. ☐ Cannot lift
Endurance (hours per day):
☐ 2-4 hrs, many breaks ☐ 2-4 hrs, few breaks
☐ 5-8 hrs, many breaks ☐ 5-8 hrs, few breaks
Preferred work area (check all that apply):
☐ Small area/one room ☐ Several rooms
☐ Building-wide ☐ Building and grounds
Mobility:
☐ Walks without assistance ☐ Requires adaptations/assistance to walk/stand
☐ Uses a wheelchair/must be pushed ☐ Uses a wheelchair/can self-navigate
Supervision (check all that apply):
☐ Requires one-on-one supervision/all times ☐ Can be unsupervised for 30 minutes
☐ Can be unsupervised for 60 minutes ☐ Does not require immediate supervision
☐ Prefers to work alone ☐ Likes to be a part of a team of 3 or less
☐ Likes to work in larger groups
Adapt to change/ability to follow rules:
☐ Accepts change ☐ Does not adapt to change ☐ Does not like change
☐ Prefers routine tasks ☐ Prefers variety of tasks ☐ Flexible
☐ Follows variety of rules ☐ Must have assistance to follow rules
Multitask (check all that apply):
☐ Can complete 1-3 tasks in sequence
independently ☐ Can complete 1-3 tasks in sequence with assistance
☐ Can complete 4-6 tasks in sequence
independently ☐ Can complete 4-6 tasks in sequence with assistance
☐ Can complete more than 7 tasks independently ☐ Can complete more than 7 tasks with assistance
Self-initiation:
☐ Always requires prompting to move to next step ☐ Will ask for next step 25% of the time
☐ Will ask for next step 25%-50% of the time ☐ Will ask for next step more than 50% of the time
Benefits desired (check all that apply):
☐ None ☐ Vacation ☐ Vision
☐ Medical ☐ Dental
DMH IDD Employment Profile form
IDD
Employment Profile
Name:
ID Number:
Date:
Provider Agency:
Interactions/Preferred Work Environment (check all that apply):
☐ Friendly, talkative co-workers ☐ Prefers few interactions with co-workers
☐ Helps others (co-workers, customers) ☐ Prefers busy, high demand work site
☐ Receives satisfaction from completing tasks ☐ Prefers very quiet work site
☐ Prefers a relaxed work site ☐ Requires recognition for a job well done
☐ Would like to advance in the company
Person has expressed interest in:
Things done to earn money in the past:
Short term jobs(less than 90 days):
Describe any interactions/services from MDRS (include dates and activities)
Volunteer or internship experiences:
Describe favorite employment experience (if applicable):
Describe work skills the person already has:
How does the person get around in the community:
DMH IDD Employment Profile form
IDD
Employment Profile
Name:
ID Number:
Date:
Provider Agency:
What are the person’s hobbies and interests:
What are the person’s preferred conditions (non- negotiations) for employment at this time:
What are the person’s potential contributions to offer to employers:
Staff signature/credentials
DMH ID/DD Waiver Job Discovery Profile guidance
ID/DD Waiver Job Discovery Profile
Purpose
The Job Discovery Profile is developed as a result of the Job Discovery Process and contains
information that provides a full and accurate picture of the person.
General
The Job Discovery Profile should be written in positive, person-first language that portrays the
person in the best light possible. While a specific form is not required, all elements listed below
must be addressed.
Part I
Identification information (birthdate, gender, address, phone number(s), Medicaid Number, Social Security
Number, place of residence, name of parent/legal representative, address and phone number, if different than the
person’s, marital status, additional agencies involved with the person and what they provide and/or agencies
involved with the family and what they provide. The PSS can be used to gather some of this information.)
Living Arrangements
a. Family members involved in the person’s life, including extended family in the local area
b. Names, ages and employment (if applicable) of the people living in the home/residence (if
applicable)
c. Residential history
d. Description of neighborhood
e. Location of neighborhood in the community
f. Transportation used by person, family, staff
g. General commercial areas (shopping , industry, services) near the home
Education and Specialized Training History
a. School, dates of attendance, degree/Certificate of Completion/Occupational Diploma,
reason if not completed
b. Vocational training, internships, special trainings, sheltered workshops, other day
programs, dates, locations, name of entity, special skills developed, level of interest in
these activities
Part II
Person and Family
a. Brief summary
b. Typical routine
c. Family (or staff, as appropriate) supports
d. Family (staff) and person’s needs for daily routine support
e. Physical and health related issues
Employment and Related Activities
a. Informal work performed at home for others
b. Formal chores and responsibilities
c. Entrepreneurial activities
d. Internships, structured work experiences, sheltered work, other day programs,
DMH ID/DD Waiver Job Discovery Profile guidance
volunteering
e. Wage employment
f. General areas of previous work interest
Life Activities and Experiences
a. Friends and social groups
b. Personal activities including hobbies, done at home
c. Family/friend activities, including hobbies, done at home
d. Personal activities, including hobbies, done in the community
e. Family/friend activities, including hobbies, done in the community
f. Specific events and activities that are of crucial importance
Skills, Interests and Conditions in Life Activities
a. Domestic/home skills
b. Community participation skills
c. Recreation/leisure skills
d. Academic skills
e. Physical fitness skills
f. Arts and Talents
g. Communication skills
h. Social skills
i. Mobility skills
j. Sensory skills (sight, hearing, smell, touch)
k. Vocational skills
l. Personal care needs
Connections for Employment
a. Potential connectors in family (or staff, as appropriate)
b. Potential connectors among friends, neighbors, and work colleagues
c. Potential connection sites in community relationships
d. Potential connections through clubs, organizations, or groups (such as church or school)
e. List of local employers (determined by proximity, relationships, interest areas, etc.)
Part III
Conditions for Success
a. General conditions for participant
b. General conditions for family (or staff, as appropriate)
c. Conditions for task performance
d. Instructional strategies
e. Environmental conditions
f. Supervisory strategies
g. Supports needed for successful task performance
h. Conditions to be avoided
Interests Toward an Aspect of the Job Market
a. General personal interest
b. General family interests (or staff, as appropriate)
c. Activities participant engages in without being expected to do so
DMH ID/DD Waiver Job Discovery Profile guidance
d. General areas of current work interest
e. Specific areas of past work experience
Contributions
a. Strongest positive personality characteristics
b. Most reliable strengths regarding performance
c. Best current and potential skills to offer to potential employers
d. Credential training, certifications, and recognized skills
e. Possible sources for recommendations
f. Resources/financial assets
Challenges
a. Areas potentially needing matching to employment sites
b. Areas potentially needing negotiation with local employers
c. Physical/health restrictions
d. Habits and routines
e. Challenges related to disability – need for accommodation and disclosure
f. Financial issues
g. Transportation issues
Potential Employer List
List businesses, addresses and types of each business.
Signatures
The Job Discovery Profile must be signed and dated by the person/legal representative, Job
Discovery staff, and his/her program director.
Timelines
The Job Discovery Profile is to be completed no more than three (3) months from the date of the
person’s referral to the Job Discovery agency. It is to be in the record by the 10
th of the month
following the month it is completed. Submit to the Support Coordinator by the 15th of the month
following the month it is developed.
DMH ID/DD Waiver Request for BS/CS Services guidance
Request for ID/DD Waiver Behavior Support
and/or Crisis Support Services
Purpose
The form must be completed when a person requests a Behavior Support Evaluation or Crisis
Support. The form is submitted by the ID/DD Waiver Support Coordinator with input from the
person, family, providers, and the chosen Behavior Support or Crisis Support provider.
General
Indicate the service being requested, the person’s diagnoses, medications, targeted behaviors,
the frequency of behaviors and the last occurrence and the environment(s) where the behavior(s)
occurred. The form must reflect whether or not the person has received the service in the past. If
the answer is yes, the previous provider and dates services were provided must be indicated.
The request for each service must be tailored to the service and the justification must support the
definition of the service as indicated in the DMH Operational Standards.
Timelines
If a person is admitted to Crisis Support services prior to the service being approved on his/her
Plan of Services and Supports, the Support Coordinator has five (5) days to submit a request to
BIDD for approval. Behavior Support services cannot be provided prior to BIDD approval.
DMH IDD Waiver Request for BS/CS form
ID/DD Waiver Request for Behavior Support
and/or Crisis Support
Name:
Date:
Medicaid #: Regional Program:
Support
Coordinator: SC Phone Number:
Service(s)
Requested:
Provider Requested:
Diagnoses:
Current
Medications:
Target
Behavior(s):
Frequency of
behavior(s):
Date of last
occurrence of
behavior(s):
Environment(s)
where behavior(s)
occur:
Desired
goal/outcome of
service:
Has the person received the service(s) before? Yes No
If so, list dates and provider(s)
and reason(s) services are
provided:
Source(s) of Information:
Support Coordinator Signature/Credentials Date
BIDD Staff Approval
DMH ID/DD Waiver Medical Verification for BS and CS Services guidance
Medical Verification for ID/DD Waiver
Behavior Support and Crisis Intervention Services
Purpose
A physical evaluation must be conducted by a licensed physician or nurse practitioner to rule out
any underlying medical conditions that may be causing the behavior(s) to occur (for example, an
abscessed tooth, ulcer, ear ache etc.).
General
ID/DD Waiver Behavior Support
This form is to be completed during the Behavior Support evaluation process. During the
Behavior Support Consultant’s initial meeting with the person/legal representative and service
provider(s), if applicable, the rationale for the form is explained. The person/legal
representative/service provider is responsible for ensuring the form is completed by a physician
or nurse practitioner. The physical evaluation cannot be more than ninety (90) days old at the
time Behavior Support Services begin.
ID/DD Waiver Crisis Intervention
A person must see a physician/nurse practitioner as soon as feasible after the initiation of ID/DD
Waiver Crisis Intervention Services to determine if there are any physical/medication factors that
may be contributing to the crisis behaviors. The ID/DD Waiver Crisis Intervention Services
provider is responsible for working with the person/legal representative and/or other service
providers to have the form completed as soon as possible, but not to exceed ten (10) days after
the initiation of ID/DD Waiver Crisis Intervention Services.
Timelines
The ID/DD Waiver Behavior Support/ID/DD Waiver Crisis Intervention provider must maintain a
copy of this form in the person’s record. It must be placed in there no later than the 10th of the
month following the month it is signed by the physician/nurse practitioner. A copy must be
forwarded to the Support Coordinator no later than the 15th of the month following the month it is
completed.
DMH ID/DD Waiver Medical Verification for BS/CI Services form
Medical Verification for ID/DD Waiver
Behavior Support and Crisis Intervention Services
Person’s Name:
Healthcare
Provider’s Name: Office Phone:
Healthcare
Provider’s Address:
Proposed Behavior Support/Crisis Intervention Service:
Healthcare Provider: Please initial to indicate your agreement or disagreement with each of
the items listed below. If you are in disagreement with any of the statements, please
summarize on the reverse side of this form your reasons for disagreeing, as well as your
recommendations and/or treatment plans.
Agree Disagree
There is no medical reason that this person cannot participate in the
proposed Behavior Support/Crisis Intervention Services.
This person presents no symptoms of physical illness that should
receive medical treatment prior to starting/continuing Behavior
Support/Crisis Intervention services.
This person presents no symptoms of mental illness that should receive
medical treatment prior to starting Behavior Support/Crisis Intervention
services.
There are no special medical precautions to follow during the
implementation of Behavior Support/Crisis Intervention services.
Based Upon My Knowledge of This Person:
He/she can participate in the proposed Behavior Support/Crisis Intervention services.
He/she requires medical treatment that must be successfully completed prior to
starting Behavior Support/Crisis Intervention services.
He/she cannot participate in the proposed Behavior Support/Crisis Intervention
services for medical reasons.
Signature of Healthcare Provider/Credentials Date
DMH ID/DD Waiver Functional Behavior Assessment guidance
ID/DD Waiver Functional Behavior Assessment
Purpose
To assess where the behavior(s) occurs, any antecedent(s) of the behavior(s), consequences(s)
of the behavior(s), factor(s) that may be maintaining the behavior(s), frequency of the
behavior(s), and how the behavior(s) impacts the person’s environment and life.
General
This assessment is completed by the Behavior Support Consultant using interviews with the
person, family, others, and direct observation. Observation of youth can occur in the school
setting, but actual Behavior Support Services cannot be provided in the school and be billed to
Medicaid.
All components must be addressed.
The Recommendations sections contains information indicating if the Behavior Support
Consultant recommends a Behavior Support Plan is warranted, staff training only is warranted, or
no Behavior Support Services are needed. It also indicates information regarding any referrals
that may need to be made or other recommendations that can assist the person/family.
Timelines
The Functional Behavior Assessment must be completed within ninety (90) days of BIDD
approval for Behavior Support Services.
Submission of Documentation
The ID/DD Waiver Functional Behavior Assessment must be submitted to the Support
Coordinator along with the Behavior Support Plan and Justification for Behavior Support Services
within ten (10) days of completion of the Behavior Support Plan. The Support Coordinator then
submits all documentation to BIDD for review.
If the ID/DD Waiver Functional Behavior Assessment indicates a Behavior Support Plan is not
warranted, but training of staff and other individuals who interact with the person is, indicate such
on the Justification for Behavior Support Services.
If the ID/DD Waiver Functional Behavior Assessment indicates neither a Behavior Support Plan
nor training is necessary, submit the completed ID/DD Waiver Functional Behavior Assessment
to the appropriate Support Coordinator within ten (10) days of completion, along with a narrative
indicating that Behavior Support Services were not warranted as per the assessment.
DMH ID/DD Waiver Functional Behavior Assessment form 1 of 6
ID/DD Waiver Functional
Behavior Assessment
Name:
Assessment
Date(s):
ID Number:
DOB: Sex: M F
Respondents(s): Behavior Consultant/Credentials/Agency:
I. Description of Behavior(s)
A. What are the behavior(s) of concern? For each, define the topography (how it is performed),
frequency (how often it occurs per day, week, or month), duration (how long it lasts when it
occurs), and intensity (the magnitude of the behavior - low, medium, high - and if it causes harm).
Behavior and Topography: Frequency Duration Intensity
Behavior and Topography: Frequency Duration Intensity
Behavior and Topography: Frequency Duration Intensity
Behavior and Topography: Frequency Duration Intensity
B. Which of the behaviors described above occur together (e.g., occur at the same time; occur in a
predictable chain; occur in response to the same situation)?
II. Ecological Events That May Affect the Behavior(s)
A. What medications is the person taking (if any), and how do you believe these may affect his/her
behaviors?
B. What medical complications (if any) does the person experience that may affect his/her behavior
(e.g., asthma, allergies, rashes, sinus infections, seizures, etc.)?
DMH ID/DD Waiver Functional Behavior Assessment form 2 of 6
C. Describe the sleep cycles of the person and the extent to which these cycles affect his/her
behavior.
D. Describe the eating routines and diet of the person and the extent to which these routines may
affect his/her behavior.
E. Briefly list below the person’s typical daily schedule of activities:
6:00 am 3:00 pm
7:00 am 4:00 pm
8:00 am 5:00 pm
9:00 am 6:00 pm
10:00 am 7:00 pm
11:00 am 8:00 pm
12:00 pm 9:00 pm
1:00 pm 10:00 pm
2:00 pm 11:00 pm
F. Describe the extent to which you believe the activities that occur during the day are predictabl
for the person. (e.g., when to get up, eat dinner, shower, go to school/work, etc.)?
G. About how often does the person get to make choices about activities, reinforcers, etc.? In what
areas does the person get to make choices (e.g., food, clothing, social companions, leisure
activities, etc.)?
H. Describe the variety of activities performed on a typical day (exercise, community activities, etc.)
I. How many other people are in the setting (work/school/home)? Do you believe that the density
of people or interactions with other persons affect the targeted behaviors?
J. If the person is attending a day program, what is the staffing pattern? To what extent do you
believe the number of staff, training of staff, quality of social contacts with staff, etc., affect the
targeted behaviors?
K. If not attending a day program, describe some typical interactions of the person with others in the
home or other environments.
DMH ID/DD Waiver Functional Behavior Assessment form 3 of 6
L. Are the tasks/activities presented during the day boring or unpleasant for the person, or do they
lead to results that are preferred or valued?
M. If the person attends a day program, what outcomes are monitored regularly by staff (frequency
of behaviors, skills learned, activity patterns)?
N. If the person does not attend a day program, how do people in the home or other environments
monitor outcomes?
III. Events and Situations that Predict Occurrences of the Behavior(s)
A. Time of Day: When is the behavior(s) most likely and least likely to occur?
Most Likely Least Likely
B. Setting: Where is the behavior most likely and least likely to occur?
Most Likely Least Likely
C. Control: With whom is the behavior most likely and least likely to occur?
Most Likely Least Likely
D. What activity is most likely and least likely to produce the behavior(s)?
Most Likely Least Likely
E. Are there particular situations, events, etc., that are not listed previously that “set off” the
behavior(s) that cause concern (particular demands, interruptions, transitions, delays, being
ignored, etc.)?
F. What would be the one thing you could do that would be most likely to make the undesirable
behavior(s) occur?
IV. Function of the Undesirable Behavior(s)
A. Review each of the behaviors listed in Part I and define the function(s) you believe the behavior
serves for the person (i.e., what does he/she get and/or avoid by doing the behavior?).
Behavior:
What does he/she get? What does he/she avoid?
Behavior:
What does he/she get? What does he/she avoid?
DMH ID/DD Waiver Functional Behavior Assessment form 4 of 6
Behavior:
What does he/she get? What does he/she avoid?
Behavior:
What does he/she get?
What does he/she avoid?
B. Describe the person’s most typical response to the following situations:
1. Is the above behavior(s) more likely less likely unaffected if you present him/her
with a difficult task?
2. Is the above behavior(s) more likely less likely unaffected if you interrupt a
desired event (eating ice cream, watching TV, etc.)?
3. Is the above behavior(s) more likely less likely unaffected if you deliver a “stern”
request/command/reprimand?
4. Is the above behavior(s) more likely less likely unaffected if you are present but
do not interact with him/her?
5. Is the above behavior(s) more likely less likely unaffected if the routine is
changed?
6. Is the above behavior(s) more likely less likely unaffected if something the
person wants is present but he/she cannot get to it (i.e., a desired object that is out of
reach)?
7. Is the above behavior(s) more likely less likely unaffected if he/she is alone?
V. Efficiency of the Undesirable Behavior(s)
A. What amount of physical effort is involved in the behavior(s) (e.g., prolonged intense tantrums -
vs- simple verbal outbursts, etc.)?
B. Does engaging in the behavior(s) result in a “payoff” (getting attention, avoiding work) every
time? Almost every time? Once in a while?
C. How much of a delay is there between the time the person engages in the behavior(s) and gets
the “payoff”? Is it immediate, a few seconds, or longer?
DMH ID/DD Waiver Functional Behavior Assessment form 5 of 6
VI. Primary Method(s) Used by the Person to Communicate
A. What are the general expressive communication strategies used by or available to the person in
the following situations?
Request
attention
Request
Help
Request
preferred
food/objects/
activities
Show you
something
or a place
Indicate
physical
pain
Indicate
confusion
Protest/
reject
situation
Complex speech
Multiple words
One word utterances
Complex signing
Simple signs
Echolalia
Pointing
Leading
Grab/Reach
Increased movement
Moves away
Moves closer
Fixed gaze
Facial expressions
Aggression
Self-injury
Eye movements
Augmentative
communication
B. With regard to receptive communication:
1. Does the person follow requests or instructions? If so approximately how many?
2. Is the person able to imitate physical models for various tasks or activities?
3. Does the person respond to signed or gestural requests or instructions?
4. How does the person indicate yes or no?
DMH ID/DD Waiver Functional Behavior Assessment form 6 of 6
VII. Events, Actions, and Objects Perceived as Positive by the Person?
A. In general, what are the things (events/activities/objects/people) that appear to be reinforcing or
enjoyable for the person?
VIII. “Functional” Alternative” Behaviors Known by the Person?
A. What socially appropriate behaviors/skills does the person perform that may be ways of achieving
the same function(s) as the behavior(s) of concern?
B. What things can you do to improve the likelihood that a teaching session will occur smoothly?
C. What things can you do that would interfere with or disrupt a teaching session?
IX. History of the Undesirable Behavior(s) and Programs that Have Been
Attempted
Behavior
How long has this
been a problem? Programs Effect
1.
2.
3.
4.
X. Summary/ Recommendations
Based on the Functional Behavior Assessment, the following action(s)/behavior(s) were discovered:
Behavior Function Location
The results of the assessment(s) reflect that the action(s)/behavior(s)
demonstrated by the person pose a risk to the health and welfare of the
person and/or others.
Yes No
DMH ID/DD Waiver Functional Behavior Assessment form 7 of 6
If a risk(s) exist, list them below:
Behavior Risk to Self Risk to Others
Recommendations:
Behavior Support Consultant/Credentials Date
DMH ID/DD Waiver Behavior Support Plan guidance
ID/DD Waiver Behavior Support Plan
Purpose
The Behavior Support Plan is developed by the Behavior Consultant based on the
assessment(s) used to evaluate the person’s actions or behavior(s).
General
All areas indicated on the Behavior Support Plan must be addressed:
• Background information
• Summary of the Functional Behavior Assessment
• Tracking and reduction strategies
• Objectives
• Staff instructions for implementing the plan
Signatures
The following signatures must be obtained by the Behavior Support Consultant after completion
and review of the Behavior Support Plan:
The parent/legal representative, if appropriate, and the person receiving services,
indicating they agree with the contents of the Behavior Support Plan and consent for its
implementation,
The Behavior Consultant agreeing to implement the plan as written and to notify the
person/family/legal representative before making any changes or modifications,
The Behavior Support Specialist (when applicable) agreeing to implement the plan and
collect data to report to the Behavior Support Consultant as indicated in the plan,
The Director or Supervisor of the program the person attends (if the Behavior Support
Plan is to be implemented in such a setting), indicating he/she agrees with the content of
the Behavior Support Plan and will provide support as necessary. Also, he/she is
agreeing to allow appropriate staff to be trained by the Behavior Support Consultant
and/or a Behavior Support Specialist to ensure the plan continues to be successful after
the Consultant/Specialist has ceased providing services.
Timelines
The Behavior Support Plan must be completed within thirty (30) days of completion of the
Functional Behavior Assessment.
A copy of the Behavior Support Plan, along with the Functional Behavior Assessment and
Justification for Behavior Support Services, must be submitted to the Support Coordinator
within ten (10) days of completion of the Behavior Support Plan. The Support Coordinator
will submit the documentation to BIDD for review. The Behavior Support Plan must be
approved before services can begin. The Behavior Support Plan must be reviewed at least
quarterly.
A copy must be in the person’s record no later than the 10th day of the month following the
month it is approved by BIDD.
DMH ID/DD Waiver Behavior Support Plan Page 1 of 5
ID/DD Waiver Behavior Support Plan
Name:
Behavior
Consultant:
Medicaid #: Agency:
Address:
Contact
Number:
Phone
Number:
Background
Reason for
Referral:
History:
Psychiatric
Diagnoses:
Summary of Functional Behavior Assessment
Target Identification
Methods:
Description of
Assessment Procedures:
Target Behavior(s) and
Definitions:
Behavior(s) Definitions
DMH ID/DD Waiver Behavior Support Plan Page 2 of 5
Behavioral Findings:
Behavioral Description Antecedents Consequences
Relevant Findings from
Physiological
Issues/Illness/Injury
Assessment:
Relevant Findings from
Environmental and
Setting Assessment:
Relevant Findings from
Communicative
Functions:
Hypothesis and Summary
of Behavior Function(s):
Baseline Data:
Replacement Behaviors
Identified:
Tracking and Reduction
Behavior
Reduction:
Baseline Data:
Intervention
Expectation:
Replacement/
Alternative
Behavior:
Review Criteria:
DMH ID/DD Waiver Behavior Support Plan Page 3 of 5
Behavior
Reduction:
Baseline Data:
Intervention
Expectation:
Replacement/
Alternative
Behavior:
Review Criteria:
Behavior
Reduction:
Baseline Data:
Intervention
Expectation:
Replacement/
Alternative
Behavior:
Review Criteria:
DMH ID/DD Waiver Behavior Support Plan Page 4 of 5
Objective(s)
1.
2.
3.
4.
Staff Instructions
Preventive Measures:
Replacement
Behavior/Alternative Skill
Training:
Consequence Strategies:
Procedural Safeguards:
Medication Side Effects of
Concern:
DMH ID/DD Waiver Behavior Support Plan Page 5 of 5
Agreements and Signatures
I agree with the content of this Plan and give consent for its implementation. I have received
a copy of the plan. I understand the behavior management techniques that will be used with
this program. I may terminate the program at any time.
Person: Date:
Person/Legal
Representative:
Date:
I agree to implement the Plan as described. If any modifications are necessary, I will contact
the person/family before making any changes. I will ensure staff is trained before terminating
my services.
Behavior Support
Consultant:
Date:
I agree to the contents of this Plan and will support the Consultant/Interventionist as needed
to ensure implementation of the Plan. Appropriate staff will receive training to ensure the
Plan continues, as needed, after the Consultant/Interventionist terminates services.
Program Director:
Date:
Behavior
Consultant/Credential Date:
BIDD Use Only
Approved Denied
Signature of BIDD Staff Signature of BIDD Staff
DMH ID/DD Waiver Justification for Behavior Support Services guidance
ID/DD Waiver Justification for
Behavior Support Services
Purpose
The provider uses the ID/DD Waiver Justification for Behavior Support Services to justify
the type and amount of Behavior Support Services needed.
General
Based upon the Functional Behavior Assessment and Behavior Support Plan, indicate
the amount of Behavior Support Services needed to change/modify targeted behaviors or
whether or not only staff training is needed to change/modify targeted behaviors.
Timelines
The Justification for Behavior Support Services is submitted along with the Functional Behavior
Assessment and Behavior Support Plan to the appropriate Support Coordinator within ten (10)
days of initiation of the Behavior Support Plan. It must be maintained in the person’s record.
The SC then submits all documentation to BIDD for review.
DMH ID/DD Waiver Justification for Behavior Support Services form
ID/DD Waiver Justification for Behavior Support Services
Name: Medicaid Number:
Agency:
Based upon the Functional Behavior Assessment completed it is recommended
that Behavior Support services are warranted. (date)
It is anticipated that approximately hours for months will be required to implement
the Behavior Support Plan.
OR
Based upon the Functional Behavior Assessment completed, it is recommended
(date)
that direct Behavior Support services are not warranted but there is a need for staff training
It is anticipated that approximately hours will be required to adequately train staff to manage
identified behaviors.
Behavior Support Consultant
Signature/Credentials
Date
BIDD Signature Date
DMH Clean 2016 ID-DD Waiver Behavior Support Quarterly Review Report guidance
ID/DD Waiver Behavior Support
Quarterly Review Report
Purpose
The Behavior Consultant must complete a Behavior Support Quarterly Review Report for each
quarter services are provided. The report reflects the supports provided and the amount of
progress made during that particular quarter.
General
Based on data gathered during each quarter, the Behavior Consultant composes a report that
reflects medication changes, target behavior(s), information about Behavior Support Plan
implementation, and narrative information about baseline data or data from the previous
Quarterly Review Report as well as narrative information about the current quarter’s data.
The report includes next steps to be taken in implementation of the Behavior Support Plan. Next
steps could include actions such as continuing with the Behavior Support Plan as it is written or
modifying it to meet any changing needs. Modifications can be made to the intervention,
intervention techniques, target behaviors, training needs, timelines, etc.
The Behavior Support Quarterly Review Report must be signed and dated by the Behavior
Consultant and be filed in the person’s record by the 10
th of every month. BIDD staff will review
the Quarterly Reports onsite.
Timelines
The Quarterly Review Report is to be completed at the end of each three (3) months of service to
the person. It is to be submitted to the Support Coordinator by the 15
th of the month following the
month it is completed.
DMH ID/DD Waiver Behavior Support Quarterly Review Report form
ID/DD Waiver Behavior Support
Quarterly Review Report
Name: Date of Report:
Medicaid Number:
Behavior Consultant:
Behavior Specialist:
Support Coordinator:
Behavior Support Plan Approved:
Describe any changes in
behavior, medication
(include prescribing
doctor) and/or diagnosis:
Explain reasons for
changes:
Target Behaviors:
Locations of Behavior Support Plan implementation:
□ Home
□ Day Program
□ Community
□ Place of Employment
Behavior Support Plan structure:
□ Modeling
□ Reinforcement/Consequences
□ Training for staff/family
□ One-on-one supervision
□ Redirection & blocking
□ Verbal Prompting
□ Environmental accommodations
□ Other:
Describe baseline data or data collected for previous review as well as a narrative of the previous review:
DMH ID/DD Waiver Behavior Support Quarterly Review Report form
ID/DD Waiver Behavior Support
Quarterly Review Report
Name: Date of Report:
Medicaid Number:
Include a narrative of the current quarter’s data.
Next Steps:
Behavior Consultant Signature /Credentials Date
DMH ID/DD Waiver Request for Additional BS Hours
ID/DD Waiver Request for Additional
Behavior Support Services
Purpose
When additional Behavior Support Services are deemed necessary by the Behavior Consultant,
a Request for Additional Behavior Support Services form must be submitted to BIDD for
approval.
General
The Behavior Consultant indicates the amount of service needed, the target behaviors, the
number of Behavior Support service hours that have been used thus far, how they were used
and includes justification for the additional hours being requested. The desired goal(s) or
outcome(s) must be included.
The form and the most recent Quarterly Review Report are submitted to the appropriate Support
Coordinator for submission to the BIDD for review.
DMH ID/DD Waiver Request for Additional BS Hours 1
ID/DD Waiver Request for Additional
Behavior Support Services
(Use as many pages as necessary and attach most recent Quarterly Review Report)
Name: Date:
Medicaid #: Agency:
Behavior Consultant: Phone Number:
# Additional Hours
Requested:
# Hours utilized to
date:
Target
behavior(s):
Justification for
additional
services:
(why hours are
needed and how
they will be used)
Desired
goals/outcomes:
BIDD USE ONLY
Approved Disapproved
DMH ID/DD Waiver Request for Additional Crisis Support Hours
ID/DD Waiver Request for Additional
Crisis Support Services
Purpose
Crisis Support Services can be provided for up to thirty (30) days per a person’s certification
year. If additional Crisis Support Services are deemed necessary by the Program Supervisor, a
Request for Additional Crisis Services form must be submitted for approval.
General
The Program Supervisor indicates the additional number of days needed, the targeted behaviors,
the number of days that have been used thus far, how they were used and includes justification
for the additional days being requested. The desired goal(s) or outcome(s) must be included.
The form and any attached documentation are submitted to the appropriate Support Coordinator
for submission to the BIDD for review. The maximum number of days of Crisis Support someone
may receive without additional approval is thirty (30).
DMH ID/DD Waiver Request for Additional CS Hours
ID/DD Waiver Request for Additional
Crisis Support Services
(use as many pages as necessary)
Name: Date:
Medicaid #: Regional Program:
Program Supervisor: Phone Number:
Additional # Days
Requested:
# Days utilized to
date:
Targeted
behavior(s):
Justification for
additional
services:
(why days are
needed and how
they will be used)
Desired
goals/outcomes:
BIDD ONLY
Approved Disapproved
DMH ID/DD Waiver Request for CI Services
Request for ID/DD Waiver
Crisis Intervention Services
Purpose
The form must be completed when a person requests ID/DD Waiver Crisis Intervention services.
General
Crisis Intervention Services are approved on an individual’s Plan of Services and Supports when
there is a reasonable expectation, based on past occurrences or immediate situational
circumstances in which the individual is at risk of causing physical harm to him/herself, causing
physical harm to others, damaging property, eloping, or being unable to control him/herself in a
manner that allows participation in usual activities of daily life. The provider will be chosen at the
time the service is approved on the Plan of Services and Supports; therefore, if a crisis arises,
the provider can be dispatched immediately.
If a need for Crisis Intervention arises whereby a provider must provide immediate assistance,
but the service is not yet on the Plan of Services and Supports, the provider and Support
Coordinator must work together to gather justification for the need for the service and submit this
form to BIDD for review. The request must be submitted to BIDD within five (5) days of the
initiation of Crisis Intervention services.
Crisis Intervention can be requested for up to seven (7) days or 168 hours. If additional services
are deemed to be necessary, the provider must submit the ID/DD Waiver Request for Additional
Crisis Intervention Services from to the Support Coordinator who will then submit it to BIDD for
review.
The ID/DD Waiver Crisis Intervention Services provider notifies the Support Coordinator that
services have been utilized. The provider completes the form. It must be signed by the Clinical
Supervisor of the ID/DD Waiver Crisis Intervention Services Team.
Timelines
If a person receives Crisis Intervention services prior to the service being approved on their Plan
of Services and Supports, the Support Coordinator has five (5) days from the date services were
provided to work with the provider to get the form completed and submit it to BIDD for approval.
DMH ID/DD Waiver Request for Crisis Intervention Services
ID/DD Waiver Request for
Crisis Intervention Services
Name: Date of Request:
Medicaid Number: Regional Program:
Support Coordinator: Phone Number:
# of Days/Hours Being Requested:
Diagnoses:
Current Medications:
Target Behavior(s):
Frequency of behavior(s): Date of last occurrence of behavior(s):
Environment(s) where behavior(s) occur(red):
Desired goal/outcome of service:
Has the person received the service(s) before? ☐Yes ☐No
If so, list dates, provider(s), outcomes/goals achieved and why service ended:
Source(s) of Information:
Clinical Supervisor/Credentials Date
BIDD ONLY
Approved Disapproved
DMH ID/DD Waiver Crisis Intervention Plan guidance
ID/DD Waiver
Crisis Intervention Plan
Purpose
The ID/DD Waiver Crisis Intervention Plan is developed for people who utilize IDD Waiver Crisis
Intervention Services.
General
A Crisis Intervention Plan is developed for someone for whom the service is on his/her approved
Plan of Care and staff/family know his/her potential crisis(es), as well as for those people who
have experienced a crisis and received ID/DD Waiver Crisis Intervention Services. The person
can either have received the service on an episodic basis or it can be for someone who requires
the service on a 24/7 basis, depending on the nature of the crisis and the person’s individual
circumstances.
The ID/DD Waiver Crisis Intervention Plan is used to provide a plan for use in mitigating and
intervening in a person’s individual crisis situation. There can be multiple types of crises
addressed on a single plan. Describe the person’s relevant history in regard to the presenting
crisis(es) and the known trigger(s) for said crisis(es). The ID/DD Waiver Crisis Intervention Team
and the person/legal representative, Support Coordinator and providers, if applicable, then work
to develop the ID/DD Waiver Crisis Intervention Plan that can be implemented in the home, the
community, a day program or some combination of sites.
In addition to the case record, copies of the ID/DD Waiver Crisis Intervention Plan are to be
maintained in all settings where it may be implemented and the ID/DD Waiver Crisis Intervention
Team is to train all individuals who may have to implement components of the ID/DD Waiver
Crisis Intervention Plan.
The ID/DD Waiver Crisis Intervention Team also provides a Team member’s name and phone
number to contact in case of a crisis which cannot be resolved by implementing the ID/DD
Waiver Crisis Intervention Plan.
It is signed by the person/legal representative, the ID/DD Waiver Crisis Intervention Team
Clinical Supervisor, by ID/DD Waiver Crisis Team staff who is primarily responsible for
implementation, if applicable, a staff of another provider(s) who may have to implement the plan
as well other ID/DD Waiver Crisis Intervention Team staff who may have to implement the ID/DD
Waiver Crisis Intervention Plan.
Timelines
The ID/DD Waiver Crisis Intervention Plan must be developed within five (5) days of the provision
of or referral for ID/DD Waiver Crisis Intervention Services.
Copies of the ID/DD Waiver Crisis Intervention Plan must be sent to all applicable parties no
more than five (5) days following development. It must be in the person’s record no later than the
10th of the month following it is developed. The Crisis Intervention Plan must be submitted to the
Support Coordinator by the 15th of the month following the month it is developed.
DMH ID/DD Waiver Crisis Intervention Plan form
ID/DD Waiver Crisis
Intervention Plan
Name:
Medicaid Number:
Provider Agency:
Crisis Intervention Team Contact: Phone number:
Relevant History and Potential Crisis Situation(s): Current Medications
Known Triggers:
Action Steps for Home
Action Steps for Community Locations
(specify location(s))
Action Steps for Day Programs
Person/Legal Guardian Signature/Date Crisis Intervention Team Clinical Supervisor
Signature/Credentials/Date
Responsible Crisis Intervention Team Staff
Signature/Credentials/Date
Other Provider Signature/Credentials/Date Other Responsible Crisis Intervention Team Staff
Signature/Credentials/Date
Other Responsible Crisis Intervention Team Staff
Signature/Credentials/Date
DMH ID/DD Waiver Crisis Intervention Daily Service Note guidance
ID/DD Waiver
Crisis Intervention Daily Service Note
Purpose
This form is used during the provision 24/7 daily ID/DD Waiver Crisis Intervention Services.
General
The ID/DD Waiver Crisis Intervention Daily Service Note must include analysis of the behaviors
and contributing factors, progress in implementing the ID/DD Waiver Crisis Intervention Plan,
providing direct supervision or support, counseling and training family members and/or staff how
to remediate the current crisis and prevent its reoccurrence.
The form is designed to be a running document that allows staff to document activities/events
that take place during the provision of ID/DD Waiver Crisis Intervention Services on a 24/7 basis.
The time services begin as well as when they end must be documented. Use a.m./p.m. Notes
should run from the time the service actually begins on any given day until 11:59 p.m. Notes for
the next day begin at 12:00 a.m. and end on the day and time the person leaves the service.
There must be notes from all shifts detailing the person’s activities (meal times, leisure activities,
personal hygiene activities, attendance at a day program, etc.) as well as reactions to
implementation of the ID/DD Waiver Crisis Intervention Plan.
Timelines
ID/DD Waiver Crisis Intervention Daily Service Notes must be in the person’s record no later than
the 10th of the month following they month they were completed.
DMH ID/DD Crisis Intervention Daily Service Note form
ID/DD Waiver Crisis Intervention
Daily Service Note
Name
Agency
Medicaid #:
Page of
Staff Signature/Credentials Date
(m/d/yr)
Time In
(am/pm)
Time Out
(am/pm)
Total Time
Notes
DMH ID/DD Waiver Crisis Intervention Log – Episodic guidance
ID/DD Waiver Crisis Intervention Log - Episodic
Purpose
The ID/DD Waiver Crisis Intervention Log – Episodic is used to document the provision of
ID/DD Waiver Crisis Intervention Services as they occur episodically, not in the provision of 24/7
ID/DD Waiver Crisis Intervention Services.
General
Document the name, Medicaid number, time services began, time services ended, and
the total amount of time in service provision. The location(s) where services are provided
must be listed. This could be in the person’s home, in a community location, at a
program site or a combination of more than one (1) site. List the names of the people
involved in the situation and their relationship to the person. If someone else receiving
services is involved, simply list his/her relationship to the person. For example, list
“another person participating in the program” rather than Bob Smith.
Describe in detail the nature of the situation which required ID/DD Waiver Crisis
Intervention services. This could include elopement, damage to property, self, others,
etc. This is the justification for the provision of services.
Describe in detail the action(s) taken to address the situation before the arrival of Crisis
Intervention staff. This includes information about what staf f/family/others did to
intervene in or mitigate the crisis.
Describe action(s) taken by Crisis Intervention staff to resolve the crisis. This could
include counseling, the use of Mandt© techniques, removal from the situation to another
setting, etc.
Describe in detail the final resolution of the crisis. Indicate the person’s condition at the
end of the crisis. Part of the resolution of the crisis may be that the person is removed
from the setting for an extended period of time that may cover one or more days. Also
document if referrals were made to other agencies, which agencies, the reason for
referral and the appointment time, if applicable.
Indicate if the ID/DD Waiver Crisis Intervention Plan was implemented as written or if, as
a result of the current situation, it requires revision. If this is the first time services have
been provided, the ID/DD Waiver Crisis Intervention Plan must be developed within five
(5) days.
The staff who provided ID/DD Waiver Crisis Intervention Services sign and date the form
upon completion. Even though there is only one line for staff signature/credentials, if
more than one (1) staff participated in the event, include their signature and credentials
also.
Timelines
The ID/DD Waiver Crisis Intervention Log – Episodic must be completed each time services are
DMH ID/DD Waiver Crisis Intervention Log – Episodic guidance
provided. If it is the first time services are being provided, the Clinical Supervisor must notify
the person’s ID/DD Waiver Support Coordinator to request from BIDD that it be added to the
person’s ID/DD Waiver Plan of Care/Plan of Services and Supports within five (5) days of the
provision of ID/DD Waiver Crisis Intervention Services. The justification for the need for
services is documented on the ID/DD Waiver Request for Crisis Intervention Services form.
The provider completes the ID/DD Waiver Request for Crisis Intervention Services form and
submits it to the Support Coordinator who will then submit it to BIDD for review by the Behavior
Services Oversight Team.
All ID/DD Waiver Crisis Intervention Logs must be in the person’s record no later than the 10
th
of the month following the month they are completed.
DMH ID/DD Waiver Crisis Intervention Log- Episodic form
ID/DD Waiver Crisis
Intervention Log
(Episodic)
Name:
Medicaid Number:
Date Time Began Time Ended Total Time
Location(s) where services provided:
People Involved and Relationship:
Situation Requiring Support
(Use as much space as needed)
Action(s) Prior to Crisis Intervention Staff Arrival
(Use as much space as needed)
Action(s) of Crisis Intervention Staff
(Use as much space as needed)
Resolution
(Use as much space as needed)
Crisis Plan Implemented ☐ Crisis Plan Requires Revision ☐ Crisis Plan Needed ☐
Staff Signature/Credentials Date
Clinical Supervisor Signature/Credentials Date
DMH ID/DD Waiver Request for Additional CI Hours
ID/DD Waiver Request for Additional
Crisis Intervention Services
Purpose
When additional Crisis Intervention Services are deemed necessary by the Program Supervisor,
a Request for Additional Crisis Intervention Services form must be completed.
General
The Program Supervisor indicates the additional number of days/hours needed, the targeted
behaviors, the number of days/hours that have been used thus far, how they were used and
includes justification for the additional days/hours being requested. The desired goal(s) or
outcome(s) must be included.
Timelines
The form and any attached documentation are submitted to the appropriate Support Coordinator
for submission to the BIDD for review. The maximum number of hours of Crisis Intervention
someone may receive without additional approval is 168 hours.
DMH ID/DD Waiver Request for Additional CI Hours
ID/DD Waiver Request for Additional
Crisis Intervention Services
Name: Date:
Medicaid #: Agency:
Behavior Consultant: Phone Number:
# Additional hours
requested: OR
# Additional days
requested
# Hours utilized to
date:
# Additional Days utilized
to date:
Target
behavior(s):
Justification for
additional
services:
(why hours/days are
needed and how
they will be used)
Desired
goals/outcomes:
BIDD USE ONLY
Approved Disapproved
Section J
Substance Use
Disorder Services
Educational Activities/Risk Assessments for
TB/HIV/STD
Substance Abuse Monthly Capacity Management
and Waiting List Report
DMH Clean 2016 SA Educational Activities-Risk Assessments for TB-HIV-STD guidance
Risk Assessment Interview & Educational Activities
for TB/HIV/STDs
Purpose
All individuals receiving substance use treatment services (i.e., Outpatient/Intensive Outpatient
Services, Primary/Transitional Residential Services, Withdrawal Management Services, Opioid
Treatment Services, Recovery Support Services, DUI Diagnostic Assessment Services) must
receive a TB and HIV Risk Assessment Interview as well as educational information on
HIV/AIDS, TB, STDs, and Hepatitis.
Applicability
Under each section, if any of the items do not apply, document as “not applicable.”
Risk Assessment Interview for TB/HIV/STDs Form
The staff should verbally administer the interview questions and mark the individual’s responses
on the Risk Assessment Interview Form. Staff should indicate any additional information in the
comments section. After completion on the Assessment Interview, Staff should sign with
credentials and date the form.
Educational Activities & Risk Assessments for TB/HIV/STDs Form
Educational Activities
Lines 1-4: Record the month/day/year and total amount of time spent on each education topic.
A minimum of one hour of HIV Prevention Education is required for all individuals in treatment at
funded Substance Abuse Block Grant HIV Early Intervention Services programs (SABG HIV-
EIS). Educational activities can be conducted in group and/or individual sessions.
HIV Risk Assessment, Testing, & Counseling
Line 1 Record month/day/ year that the Risk Assessment Interview was completed for the
individual receiving substance use treatment services. Total Time is not applicable for
Line 1 item.
Line 2 Record the month/day/year and total time that the individual received HIV pre-test
counseling. This is applicable to all individuals receiving treatment services, even if
they opt out of HIV testing. For SABG HIV-EIS, a minimum of 30 minutes pre-testing
counseling is required.
Line 3 Record YES if the individual received HIV testing and the month/day/year the
individual was tested. Record NO if the individual receiving services opts-out of
testing. An Opt-Out form must be completed if NO is marked. Indicate the
month/day/year the Opt-Out form was completed and signed by the individual. Total
Time is not applicable for Line 3 items.
Line 4 Record the month/day/year and total time the individual receiving services was
provided post-test counseling. Post-test counseling can only be provided IF testing
was conducted. For SABG HIV-EIS, a minimum of 30 minutes of post-test counseling
is required, with 60 minutes for a reactive HIV test.
DMH Clean 2016 SA Educational Activities-Risk Assessments for TB-HIV-STD guidance
Tuberculosis Risk Assessment, Testing, & Referral
Line 1 Record the month/day/year the Risk Assessment Interview was completed for the
individual receiving primary substance use treatment services.
Check YES if results indicate further action is needed.
Check NO if results of risk assessment do not indicate that further action is warranted.
If an individual is determined to be high risk, the individual cannot be admitted to
treatment until testing confirms the individual does not have TB.
Line 2 If further testing is not required, document as “not applicable.”
If Skin Test is completed, record month/day/year when the skin test was administered
to the individual.
Check YES if further action will be taken after the skin test.
Check NO if results of skin test indicate that no further action appears warranted.
Line 3 If further testing is not required, document as “not applicable.”
If X-ray testing is required, record month/day/year that individual received an X-ray to
determine their TB status.
Check YES if further action will be taken after the X-ray.
Check NO if results of X-ray indicate that no further action appears warranted.
Line 4 If further treatment is not required, document as “not applicable.”
If TB treatment is required, record month/day/year when the individual was referred for
treatment for tuberculosis.
Individual Receiving Services Signature/Date
After receiving all applicable risk assessments/educational activities, the individual receiving
substance use treatment services must sign and date the form where indicated.
Staff Signature/Credentials/Date
After the individual has received all applicable risk assessments/educational activities, the staff
person responsible for verifying the administration of these risk assessments/educational
activities must sign, date, and record their credentials.
DMH Clean 2016 SA Educational Activities-Risk Assessments for TB-HIV-STD form
Risk Assessment
Interview
for TB/HIV/STDs
Name
ID Number
Date
1. Have you ever tested positive, been diagnosed with, or treated for tuberculosis
(TB)? Yes No
2. Has anybody you know or have lived with been diagnosed with or tested positive
for TB in the past year? Yes No
3. a.
Within the last month, have you had any of the following symptoms lasting for
more than 2 weeks? If yes, please check items below. No
Fever Drenching night sweats Coughing up blood
Losing weight Shortness of breath Lumps or swollen glands
Diarrhea lasting more than one week
b. Are you now living with someone with any of the following? No
Coughing up blood Drenching night sweats Active TB
4. Have you ever been told that you have a positive HIV test? (test for the AIDS virus) Yes No
5. Do you have a history of IV drug usage? Yes No
6. Have you used cocaine (I.E., powder, crack...etc.)? Yes No
7. Have you ever engaged in unprotected vaginal, anal or oral sex with multiple
partners and/or anonymous partners? Yes No
8. Have any of your current or previous sex partners used IV drugs or been HIV
positive? Yes No
9. Have you ever been paid to have sex or to exchange sex for food, shelter, etc.? Yes No
10. Have you ever been the victim of sexual assault? Yes No
11. Have you ever used alcohol or drug before or during sex? Yes No
12. Have you been diagnosed with or treated for hepatitis and/or a sexually transmitted
disease? Yes No
13. Have you ever lived on the street or in a shelter? Yes No
14. Have you ever been incarcerated or in jail? Yes No
15. Have you had a blood transfusion prior to 1992? Yes No
16. Were you born between the years 1945 and 1965? Yes No
Comments:
Staff Signature/Credentials Date
DMH Clean 2016 SA Educational Activities-Risk Assessments for TB-HIV-STD form
Educational Activities
& Risk Assessments
for TB/HIV/STDs
Name
ID Number
Educational Activities Date
Completed Total Time
1. HIV/AIDS Information (minimum of 1 hour required for funded
SABG HIV-EIS programs)
(including modes of transmission, universal precautions and other preventative
measures, current treatments and how to access them)
2. Sexually Transmitted Diseases (STDs)
(including modes of transmission, precautions to take against contraction, progression of
diseases, current treatment resources and how to access them)
3. Tuberculosis
(including modes of transmission, current treatment resources and how to access them)
4. Hepatitis
(including modes of transmission, precautions to take against contraction, current
treatments and how to access them)
HIV Risk Assessment, Testing, & Counseling Date
Completed Total Time
1. Completion of Risk Assessment Interview
2. Provided HIV Pre-Test Counseling (minimum of 30 minutes)
3. Provided HIV Testing
Yes
No Opt-out form completed for refusal of testing on:
4. Provided Post-Test Counseling if testing was conducted (minimum
of 30 minutes; 60 minutes for a reactive HIV test)
Tuberculosis Risk Assessment, Testing, & Referral Date
Completed
1. Completion of Tuberculosis Risk Assessment
Do results indicate further action? Yes No
2. Completion of Skin Test
Do results indicate further action? Yes No
3. Completion of X-ray
Do results indicate further action? Yes No
4. Referred for Tuberculosis Treatment
By signing, you acknowledge receipt of the educational information and all risk assessments listed above.
Individual Receiving Services Date Staff Signature/Credentials Date
DMH Clean 2016 SA Monthly Capacity Management and Waiting List Report guidance
Substance Abuse Monthly Capacity Management and Waiting List
Reports
Purpose
All substance abuse programs must give first priority to the acceptance and treatment of pregnant
women. Substance abuse programs must also provide treatment to IV drug users. Written
documentation of placement or assessment and referral of pregnant women and IV drug users
must be maintained and reported to the DMH.
Timeline
To assist with appropriate referrals and placement, all residential programs must report to DMH
when the census of the program exceeds 90% capacity and when the census drops below 90%
capacity. Report should be submitted to the Office of Consumer Support by fax within 24 hours of
crossing the 90% threshold.
Pregnant women must be admitted to a program for treatment within forty-eight (48) hours of an
initial contact. IV drug users must be placed in substance abuse treatment programs within forty -
eight (48) hours of an initial contact. Reports must be submitted to the Office of Consumer
Support by fax by the 10
th working day of the month following the reporting period.
The program must monitor and complete the process of securing the most appropriate program
for pregnant women and IV drug users. If the most appropriate program has not been secured by
the end of a reporting month, the report must be sent to the Office of Consumer Support by fax
indicating where the individual is in the process. The program must continue to submit the
information on the individual each month until he/she is admitted into the appropriate program.
DMH Clean 2016 SA Monthly Capacity Management form
Substance Abuse Capacity
Management
Timeline within 24 hours
Facility
Name
Date
At 90% capacity
No longer at 90% capacity
Fax or Email to:
Office of Consumer Support
Fax Number: (601)359-9570
DMH Clean 2016 SA Emergency Placement Pregnant Women Report form
Emergency Placement for
Pregnant Women
Timeline: within 48 hours of initial
contact
Date
Time of
Contact
Type of
Contact
Facility
Name
Client Information
Name
Address
Telephone Number
Other Contact Information
Fax or Email:
Office of Consumer Support
Fax Number: (601)359-9570
Date Submitted to DMH
DMH Clean 2016 SA Emergency Placement IV Drug User Report form
Emergency Placement for
IV Drug Users
Timeline: within 48 hours of initial
contact
Date
Time of
Contact
Type of
Contact
Facility
Name
Client Information
Name
Address
Telephone Number
Other Contact Information
Fax or Email:
Office of Consumer Support
Fax Number: (601)359-9570
Date Submitted to DMH
Section K
Administrative
Information
Disaster Preparedness and Response Guidance
Disaster, Fire, and COOP Drills for all Programs
DMH Plan of Compliance Template
Staff Verification of Training on Abuse or Neglect Reporting
Requirements
DMH Disaster Preparedness and Response Plan Development guidance
DISASTER PREPAREDNESS AND RESPONSE
Guidance for Operational Standards
This document contains guidance to assist your program with compliance with The Mississippi Department of Mental Health
Operational Standards for Disaster Preparedness and Response as well as the Continuity of Operations Plan (COOP). By using
this guidance, you will be more likely to meet the required elements for each standard listed. This guidance is not meant to be
copied and pasted into your Policy and Procedures Manual, but is simply a guide to assist you in meeting the agency’s standards.
Beneath each standard (in bold) you will find guidance that will assist you in meeting the desired outcome of that standard. Some
of the standards require completion of certain tasks. For example, in the introduction to the emergency/disaster response plan
section you must have a plan for each site that is “reviewed by the governing body”. You must have in your plan a statement that
the plan will be reviewed by the governing body, how often, and how you will document this.
If you have specific questions regarding these standards, please contact The Mississippi Department of Mental Health , Office of
Incident Management at 601-359-6652 or send email questions to randy.foster@dmh.state.ms.us.
Rule 13.9.A Providers must develop and maintain an emergency/disaster response plan for each service location/site,
approved by the governing body, for responding to natural disasters, manmade disasters (fi res, bomb
threats, utility failures and other threatening situations, such as workplace violence). The plan should
identify which events are most likely to affect the location/site. For example, the location/site is located
near an airport, railroad, nuc lear power plant, typical path of tornado, earthquake zone, coastal region,
etc. This plan must address at a minimum:
- You must have a plan for each service location/site. Each plan may have many of the same elements as other
sites, but each site is a little bit different and the plan should reflect those differences .
- This plan must be approved by your governing authority; you must have documentation of this in meeting
minutes.
- Each program should have as a part of the plan a response for each type of identified threat
Natural events such as tornado, hurricane, wild fire, etc.
Man-made events such as bomb threats, work place violence, etc.
To accurately assess the hazards that each location/site might be vulnerable to, it is suggested that you complete a H azard
Vulnerability Analysis (HVA) or contact the county to obtain county level HVA info. Please see attachment A for more
information on how to conduct a HVA.
1. Lines of authority and Incident Command
Identify who will be in charge for the whole agency and for each location/site in the event of an emergency/disaster. An
organizational chart would be helpful here in the event that the identified person is not available.
2. Identification of a Disaster Coordinator
Please designate one person that will act as your Disaster Coordinator. This individual will be in charge of making sure
the plan is accurate and up to date, drills are conducted appropriately, and that the agency and each location are prepar ed
to respond.
3. Notification and plan activation
This section must contain what triggers activation of the plan, who officially activates the plan, and once the plan has
been activated how staff and individuals who receive services are notified of the event. Part of this section should be
notification to DMH, and local emergency personnel that need to be notified based on the nature of the event (Fire,
Police, DEQ, Emergency Management, etc.).
4. Coordination of planning and response activities with local and state emergency management authoriti es
Your agency and programs must coordinate with the local emergency response agencies. Typically, these are the local
Fire Department, local Police Department, and local Emergency Management Agency. There may be other response
agencies, such as non-profit agencies or other state/local agencies, which you may benefit from coordinating with as
well. Each of these agencies may benefit from having a copy of your emergency/disaster response plan for review,
comment and reference.
DMH Disaster Preparedness and Response Plan Development guidance
5. Assurances that staff will be available to respond during an emergency/disaster
You must have sufficient staff to continue the essential functions of the agency. You should identify how you will
ensure that the needed staff is available to handle those responsibilities. This section should also address how your
agency will ensure that staff is available to respond to community needs during an event.
6. Communication with individuals receiving services, staff, governing authorities, and accrediting and/or licensing
entities
Outline how you will notify individuals receiving services, staff, your governing authorities, and your accrediting and/or
certifying entities that an event has occurred, your plan has been activated, and to what extent and for how long your
services will be affected.
7. Accounting for all persons involved (staff and individuals receiving services)
When the event occurs and directly affects your program, outline how you will make sure all of those present at the time
of the event, both staff and individuals receiving services, are safe and accounted for. This could be done with
attendance logs, lists of those staff that may be traveling, or other means of accounting for every one. There must be a
method to account for each individual.
8. Conditions for evacuation
Outline conditions that would cause you to evacuate your facility. A fire would be an example, but there are others as
well such as power failure, sewage and/or water failure, foreseen unsafe conditions (hurricane, etc.) , gas leaks (must
comply with EMA directives regarding evacuation for gas leaks) and others. You should address all of those here.
9. Procedures for evacuation
Outline procedures for evacuation. Here you should identify the different types of evacuation as well. For example, the
evacuation of your location for a fire is a different type of evacuation than leaving the location and area due to weather or
chemical exposure. This section should also address the plan if the decision is made to shelter in place.
10. Conditions for agency closure
Under what conditions would your agency close? Some reasons might include damage to the facility, prolonged utility
outage, infrastructure failure, and others.
11. Procedures for agency closure
If the conditions have been met for agency closure, what is the procedure? Who has the authority to orde r the agency
closure? Who will be responsible for notification procedures?
12. Schedules of drills for the plan
Drills are required to be held on a schedule to ensure that staff is prepared in the event of an actual emergency/disaster.
This schedule is the minimum requirement; more drills should be conducted if they are deemed necessary. The
minimum schedule of drills should be as follows:
Quarterly fire drills for day programs
Monthly fire drills for residential programs, conducted on a rotating schedule within the following time frames:
7 a.m. to 3 p.m.
3 p.m. to 11 p.m.
11 p.m. to 7 a.m.
Quarterly disaster drills, rotating the nature of the event for the drill based on the e mergency/disaster plan, for
each facility and program.
Annual drill of Continuity of Operations Plan for the agency.
DMH Disaster Preparedness and Response Plan Development guidance
Drills should be unannounced as much as possible to ensure they are as real as possible.
13. The location of all fire extinguishing equipment, carbon monoxide detectors (if gas or any other means of carbon
monoxide emission is used in facility) and alarms/smoke detectors
In your plan you should have a map that shows the location of these items or a written description of the location of these
items. The physical presence of these items in these locations will be checked on site visit.
14. The identified or established method of annual fire equipment inspection
All fire equipment must be inspected on a set schedule, usually annually and by a professional from either the Fire
Department or the equipment company. The method of inspection and documentation of inspection must be outlined
here.
15. Escape routes and procedures that are specific to location/site and the type of disaster(s) for which they apply.
A copy of the escape routes must be in the emergency/disaster response plan for reference. These signs should be posted
in visible locations, oriented to the location in the building, with a route for evacuation specific to that location.
CONTINUITY OF OPERATIONS PLAN REVIEW
*Understand that this Continuity of Operations Plan (COOP) is for the agency as a whole, not for specific
sites/locations. Only 1 COOP is required for the agency. Each site should be provided a copy of the agency’s
COOP.
Rule 13.9.B Providers must develop and maintain a Continuity of Operations Plan, approved by the governing body,
for responding to natural disasters, manmade disasters, fires, bomb threats, utility failures and other
threatening situations, such as workplace violence. This plan must address at a minimum:
The following standards address your Continuity of Operations Plan (COOP). This plan is in place in the event that an
emergency/disaster occurs. This plan ensures that essential functions can continue no matter what type of event occurs.
Your governing body should approve this plan and any changes to it. Please note that the following standards are the
minimum this plan should address.
1. Identification of provider’s essential functions in the event of emergency/ disaster
What are the essential functions of your agency? These are functions that your program’s clients would need even
during an emergency/disaster. Some examples could be medications, individual therapies, residential treatment, or any
other number of services.
2. Identification of necessary staffing to carry out essential functions
List the staff members (not specific names, but positions) that your agency will need to ensure that the essential functions
will continue. List the capacity in which these individuals will serve and backup staff if these individuals are not
available.
3. Delegations of authority
Who has the authority to assign tasks and duties? A COOP organizational chart that shows minimal staff and
responsibilities in the event that the COOP Plan is activated, might be useful here.
4. Alternate work sites in the event of location/site closure
You have identified essential functions and you must identify an alternate location for those functions to continue if your
location/site is not able to provide those functions. These sites must be identified and named with memorandum of
agreements (MOA) or understanding (MOU) in place with the location if needed. It is not sufficient to s imply state that
you will find a location if needed at the time of the event.
DMH Disaster Preparedness and Response Plan Development guidance
5. Identification of vital records and their locations
If you have vital records for staff or individuals served, those are to be identified here along with the location of those
records. Vital records may include case record, personnel records and financial records for agency. T his does not have to
include all records, but should include any records essential to continuing operations.
6. Identification of systems to maintain security of and access to vital records.
How will you maintain the security of these vital records during the event? Buildings may be compromised, the records
may need to be transported to other locations, and the security and confidentiality of those records is important and must
be addressed here. How are your records backed-up and how often does this back-up occur?
Rule 13.9.C Copies of the Emergency/Disaster Response Plans and the Continuity of Operations Plan must be
maintained on-site for each location/site and at the agency’s administrative offices.
You must have copies on site of both the Emergency/Disaster Response Plans and the Continuity of Operations Plan at
each location/site. This ensures that in any event, the staff at every location ha ve access to the needed materials to
follow these plans. These will be checked during the site visit for each program.
Rule 13.9.D Any revisions to the Emergency/Disaster Response Plans and the Continuity of Operations Plan must be
documented and approved by the agency’s governing body. Any revisions must be communicated in
writing to all staff.
Any changes to either plan must be reviewed and approved by the governing body and evidence of this must be
documented in the meeting minutes. You should note in the plan itself that these plans will be reviewed by your
governing body. These minutes will be reviewed by the site visit team. All staff must be notified of any changes to
these plans.
Rule 13.9.E All locations/sites must document, utilizing the standardized DMH form, implementation of the written
plans for emergency/disaster response and continuity of operations. This documentation of
implementation must include, but is not limited to the following:
1. Quarterly fire drills for day programs
For day programs, you must conduct a fire drill in each of the four quarters of the year:
Jan-Mar, Apr-Jun, Jul-Sept, and Oct-Dec.
2. Monthly fire drills for residential programs, conducted on a rotating schedule within the following time
frames:
7 a.m. to 3 p.m.
3 p.m. to 11 p.m.
11 p.m. to 7 a.m.
For residential programs, you must conduct a monthly fire drill rotating between the timeframes listed. For
example: Jan – 7A-7P, Feb 3P-11P, Mar 11P-7A.
This schedule would meet the minimum requireme nts of each shift participating in one drill each quarter. It
may be beneficial for each shift to have a drill each month, but it is not required.
3. Quarterly disaster drills, rotating the nature of the event for the drill based on the emergency/disaster
plan, for each facility and program.
There must be one drill each quarter for those disasters identified in the HVA. These drills should be rotated
to address the types of events most likely to occur based on the HVA.
4. Annual drill of Continuity of Operations Plan for the agency.
On an annual basis (on or before the date of the previous drill), you must conduct a drill for your Continuity
of Operations Plan. You should conduct this drill to test each level of the plan including activating essentia l
DMH Disaster Preparedness and Response Plan Development guidance
staff, movement of vital records, and activating agreement with alternate site location. This drill should be
documented and kept on file for review.
PLEASE SEE ATTACHMENT B FOR FURTHER GUIDANCE ON DRILLS AND MONITORING OF
DRILLS
Rule 13.9.F All supervised living, residential treatment programs, and/or Crisis Stabilization Units must maintain
current emergency/disaster preparedness supplies to support individuals receiving services and staff for a
minimum of seventy-two (72) hours post event. At a minimum, these supplies must include the following:
1. Non-perishable foods
2. Manual can opener
3. Water
4. Flashlights and batteries
5. Plastic sheeting and duct tape
6. Battery powered radio
7. Personal hygiene items.
For supervised living programs and residential substance abuse treatment programs, you must keep on site at a minimum
the items above. Any other items that are viewed as necessary should also be kept on site in the event of an
emergency/disaster. These will be viewed on site by the site visit team. Please be sure to monitor expiration dates as
expired products will be viewed as missing by the site visit team. You must list all items that you plan to keep on site for
such events in the Emergency/Disaster Response Plan. It is up to the program to determine the right amount to provide
these items for the clients on site.
Rule 13.9.G All supervised living, residential treatment programs, and/or Crisis Stabilization Units must have policies
and procedures that can be implemented in the event of an emergency that ensure medication,
prescription and nonprescription, based on the needs of the individuals in the program and guidance of
appropriate medical staff is available for up to seventy-two (72) hours post-event.
Each program must have policies and procedures that state they will not only have seventy-two (72) hour supply of all
prescription and non-prescription medication for each resident, but they must also have appropriate staff available to
administer those medications.
DMH Disaster Preparedness and Response Plan Development guidance
ATTACHMENT A – Hazard Vulnerability Analysis (HVA)
• An HVA is conducted to determine the risks associated with probable or possible disasters or events.
• An HVA identifies the events most likely to affect your organization and the probable impact if they do occur
• Depending on the evaluated level of preparedness, the facility must take necessary steps to ensure they are prepared to
meet the challenges presented by the hazards
There are Four Areas of Concern: Natural, Technological, Human, and Hazmat Events
These should be broken out into each individual type of event (i.e. tornado, fire, etc.)
Items to address for each event type:
• Probability
What is the known risk this will happen
- Low – Rare
- Moderate – Unusual
- High – High Potential or Have Experienced
Use of historical data about previous events can help predict the likelihood
• Response
How long would it take to have an on-scene response
How big will that response be
Historical evaluation of response success
• Human Impact
Potential for staff death or injury
Potential for patient death or injury
• Property Impact
Cost and time to replace/repair
Cost to set up temporary replacement
Time to recover
• Business Impact
Business interruption
Employees and/or patients unable to report to work
Interruption of critical supplies
Financial impact/burden
• Preparedness
Status of current plans (how ready are you for each type of event)
Frequency of drills
Availability of alternate sources for critical supplies/services
• Internal Resources
Types and amount of supplies on hand and will they meet the need
Staff availability
• External Resources
Types of agreements with community agencies
Coordination with local and state agencies
Coordination with nearby health care facilities
Coordination with treatment specific facilities
Community resources
DMH Disaster Preparedness and Response Plan Development guidance
ATTACHEMENT B – Disaster, Fire, and COOP Drill Guidance
Disaster, Fire, and COOP Drills for all Programs
Purpose
Each provider certified by the DMH must maintain an emergency/disaster response plan for each service location/site
for responding to natural disasters and manmade disasters (fires, bomb threats, utility failures and other threatening
situation such as workplace violence). Providers must maintain a Continuity of Operations Plan (COOP) describi ng
how operations will continue in the event of a natural or manmade disaster. Each location/site must document proof
of implementation of these written plans as evidenced by written reports of scheduled and conducted fire, disaster,
and COOP drills.
Timeline
• Disaster drills must be conducted and documented at least quarterly.
▪ Disaster drills must rotate the nature of the event for the drill based on each facility and program’s
emergency/disaster plan.
• Fire drills must be conducted and documented at least monthly for all supervised living and/or residential
programs and quarterly for all day programs.
▪ Fire drills for residential programs must be conducted on a rotating schedule across all three shift
schedules.
• COOP drills must be conducted and documented at least annually.
General Information
Each provider is responsible for developing report formats that will document all aspects of each type of drill in order
to ensure the safety of all persons involved in the drill. Elements to be recorded in each drill report include but are not
limited to:
• Name and location of the program
• Type/nature of the drill
• Date of the drill
• Time the drill began
• Time the drill ended
• Nature of the event (tornado, bomb, hurricane, other) for a disaster drill
• Number of participants
• Names of staff participating
• Assessment of the drill that addresses elements of the emergency/disaster or COOP plan as well as the
behavior of those participating in the drill
• Signature and title of the staff person completing the report
Providers are welcome to contact the Office of Incident Management at 601-359-6652 for technical assistance in the
development of drill reports.
DMH Clean 2016 Fire and Disaster Drills for all Programs guidance
Disaster, Fire, and COOP Drills for all Programs
Purpose
Each provider certified by the DMH must maintain an emergency/disaster response plan for
each service location/site for responding to natural disasters and manmade disasters (fires,
bomb threats, utility failures and other threatening situations such as workplace violence).
Providers must maintain a Continuity of Operations Plan (COOP) describing how operations will
continue in the event of a natural or manmade disaster. Each location/site must document proof
of implementation of these written plans as evidenced by written reports of scheduled and
conducted fire, disaster, and COOP drills.
Timeline
• Disaster drills must be conducted and documented at least quarterly.
▪ Disaster drills must rotate the nature of the event for the drill based on each facility
and program’s emergency/disaster plan.
• Fire drills must be conducted and documented at least monthly for all supervised living
and/or residential programs and quarterly for all day programs.
▪ Fire drills for supervised living residential treatment service must be conducted on
a rotating schedule across all three shift schedules.
• COOP drills must be conducted and documented at least annually.
General Information
Each provider is responsible for developing a report that will document all aspects of each type
of drill in order to ensure the safety of all persons involved in the drill. Elements to be recorded
in each drill report include but are not limited to:
• Name and location of the program
• Type/nature of the drill
• Date of the drill
• Time the drill began
• Time the drill ended
• Nature of the event (tornado, bomb, hurricane, other) for a disaster drill – must rotate
quarterly based on potential hazards
• Number of participants
• Names of staff participating
• Assessment of the drill that addresses elements of the emergency/disaster or COOP plan
as well as the behavior of those participating in the drill
• Signature and title of the staff person completing the report
Providers are welcome to contact the Division of Disaster Preparedness and Response at 601-
359-1288 for technical assistance in the development of drill reports.
DMH Clean 2016 Fire and Disater Drills for all Programs form
Fire and Disaster Drill
Report Form
Program Name_______________________
Date of Drill__________________________
Time of Drill (am/pm)_____________________
Type of
Drill :
Fire (quarterly for day programs, monthly
for residential programs)
Disaster (quarterly for all programs) Type of Disaster:
COOP (annual for all programs)
(Disaster type must rotate each quarter through all applicable disasters)
Exact Start Time of Drill: Exact End Time of Drill:
Amount of Time to Complete Drill :
Number of Participants (not staff) :
Staff Participating in Drill :
Written assessment of general performance on the drill :
(please be specific about actions that took place during the drill)
Signature of Staff Member Preparing Report :
Clean 2016 DMH Required Plan of Complaince guidance
Required Plan of Compliance
Purpose
All DMH Certified Providers must submit a Plan of Compliance in response to findings included
in a DMH Written Report of Findings. This template must be utilized by providers.
Timeline
The plan must be completed within the timeframe stated in the DMH Written Report of Findings.
Finding
Reference the DMH Operational Standard included in the DMH Written Report of Findings.
Program/Service
Reference the program or service (if there is not a specific physical location for the program)
included in the DMH Written Report of Findings.
Corrective Action Steps
Outline the action steps the provider will put in place to correct the findings. Do not include
justification. A request for a waiver of a DMH Operational Standard is not considered a
corrective action step.
Time Line
Include the implementation date and estimated date of completion for each corrective action.
Deficiencies related to Chapters 13, 32 and/or 34 of the DMH Operational Standards must be
corrected within 30 days of the date of this letter.
Plan for Continued Compliance
Outline the plan for how the agency will continue to comply with DMH Operational Standards
and the identified correction action plan(s).
Clean 2016 DMH Required Plan of Complaince Template
Required Plan of Compliance
Plan of Compliance
Please complete all requested information and mail completed
form and supporting documentation to:
Division of Certification
MS Department of Mental Health
239 North Lamar Street, Suite 1101
Jackson, MS 39201
In lieu of mailing the form, you may e-mail the completed
electronic form and supporting documentation to the Division of
Certification. For contact information call #601-359-1288.
Provider Name: Phone:
Provider Contact
Person for follow-up:
Fax:
Email:
Finding
(DMH Standard
Number)
Program/Service/
Record
Corrective Action(s) Time Line Plan for Continued Compliance
Implementation Date:
Projected Completion
Date:
Implementation Date:
Projected Completion
Date:
Implementation Date:
Projected Completion
Date:
Implementation Date:
Projected Completion
Date:
DMH Staff Verification of Training on Abuse or Neglect Reporting guidance
Staff Verification of Training on Suspected Abuse or Neglect
Reporting Requirements
Purpose
All provider staff must be informed of and trained on the procedures for reporting suspicions of
abuse or neglect in accordance with state reporting laws to include but not limited to the
Vulnerable Persons Act and Child Abuse or Neglect Reporting requirements.
Time Line
All provider staff must be informed of and trained on the procedures for reporting suspicions of
abuse or neglect of individuals receiving services in accordance with state reporting laws.
Individuals acknowledge receipt of the information and training during General Orientation
before service delivery. A copy of the verification must be maintained in the staff personnel
record.
Verification form is updated if training is repeated or new training is provided.
Clean 2016 Staff Verification of Training on Abuse or Neglect Reporting Requirements form
Staff Verification of Training on Suspected Abuse or
Neglect Reporting Requirements
I acknowledge that I have been informed of and trained on the procedures for reporting suspicions
of abuse or neglect in accordance with state reporting laws to i nclude but not limited to the
Vulnerable Persons Act and Child Abuse or Neglect Reporting requirements.
I understand that I have a personal responsibility to report suspicions of abuse or neglect in
accordance with state reporting laws.
Staff Signature/ Position or Credentials Witness/ Position or Credentials Date
Department of Mental Health
Record Guide
For
Mental Health, Intellectual and Developmental Disabilities,
and Substance Use Disorders Community Providers
2016 Revision
Mississippi Department of Mental Health
Diana S. Mikula, Executive Director
239 North Lamar Suite 1101
Jackson, MS 39201
DMH Record Guide Contents i
TABLE OF CONTENTS
Section A – General Information Page 1
Section B – All Records Page 5
Face Sheet
Consent for Receive Services
Rights of Individuals Receiving Services
Acknowledgment of Grievance
Consent to Release/Obtain Information
Medication/Emergency Contact Information
Section C – Required for All Mental Health and Substance Use Page 21
Records
Initial Assessment
Trauma History
Individual Service Plan
Individual Crisis Support Plan
Recovery Support Plan
Progress Note
Weekly Progress Note
Periodic Staffing/Review of the Individual Service Plan
Readmission Assessment Update
Substance Use Disorder Specific Assessment
Section D – As Needed for All Records Page 57
Initial Assessment and Crisis Contact Summary
Serious Incident Report
Medical Examination
Documentation of Healthcare Provider Visit
Self-Administration Medication Log
Telephone/ Visitation Agreement
Search & Seizure Report
Physical Escort Log
Time Out Log
Seclusion Behavior Management Log
Service Termination/Change Summary
Provider Discharge Summary
Section E – Day Service Programs Page 87
Acute Partial Hospitalization Services Summary Note
Individual Recovery Action Plan
Section F – Mental Health Services Page 93
DMH Record Guide Contents ii
Adult Making A Plan (AMAP) Case Summary
Adult Making A Plan (AMAP) Monthly Report
Crisis Stabilization Services Daily Note
Adult Pre-Evaluation Screening
Youth Pre-Evaluation Screening
Violence Risk Assessment for Certified Holding Facility
Suicide Risk Assessment for Certified Holding Facility
Section G – Alzheimer’s and Other Dementia Services Page 118
Life Story Narrative
Section H – Children and Youth Services Page 126
Therapeutic Foster Care Contact Log
MAP Team Report
MAP Team Case Summary
Wraparound Facilitation Individual Support Plan
Section I – Intellectual/Developmental Disabilities Services Page 144
IDD Plan of Services and Supports
IDD Activity Support Plan
IDD Service Note
IDD Weekly Service Note
ID/DD Waiver / IDD CSP Service Authorization
ID/DD Waiver Home and Community Supports Service Agreement
ID/DD Waiver In-Home Respite Service Agreement
ID/DD Waiver In-Home Nursing Respite Service Agreement
ID/DD Waiver In-Home Nursing Respite Service Note
IDD Employment Profile
ID/DD Waiver Job Discovery Profile
ID/DD Request for Behavior Support and/or Crisis Support Services
ID/DD Waiver Medical Verification for BS/ CI Services
ID/DD Waiver Functional Behavior Assessment
ID/DD Waiver Behavior Support Plan
ID/DD Justification for Behavior Support Services
ID/DD Waiver Behavior Support Quarterly Review Report
ID/DD Waiver Request for Additional Behavior Support Services
ID/DD Waiver Request for Additional Crisis Support Services
ID/DD Waiver Request for Crisis Intervention Services
ID/DD Waiver Crisis Intervention Plan
ID/DD Waiver Crisis Intervention Daily Service Note
ID/DD Waiver Crisis Intervention Log- Episodic
ID/DD Waiver Request for Additional Crisis Intervention Services
Section J – Substance Use Disorder Services Page 240
Risk Assessment Interview and Educational Activities for TB/HIV/STD
DMH Record Guide Contents iii
Substance Abuse Monthly Capacity Management & Waiting List Reports
Section K – Administrative Information Page 249
Disaster Preparedness and Response Guidance
Disaster, Fire, and COOP Drills for All Programs
DMH Plan of Compliance Template
Staff Verification of Training on Suspected Abuse or Neglect Reporting
Section A
General Information
DMH Strikethrough 2016 Record Guide Purpose & Guidance
2016 DMH Operational Standards Record Guide
Purpose
Documentation required in the Mississippi Department of Mental Health (DMH) Record Guide
serves as one of the methods for planning and evaluating services and supports provided by
agencies and providers certified by the DMH. The intent of the record system outlined in this
guide is to help ensure compliance with the DMH Operational Standards.
The emphasis of this Record Guide is on guidance needed to satisfy any and all
documentation requirements referenced in the DMH Operational Standards or otherwise
needed to ensure documentation of all services provided by agencies certified by DMH.
Because of the DMH mandatory data collection and reporting requirements, along with the
increasing use of electronic record keeping that many providers are implementing, the need
to maintain paper forms is declining. This guide seeks to describe the type and amount of
documentation that is necessary and provide a sample of a format with all information
needed to satisfy the DMH record keeping requirements.
Additional information may be added and the appearance of the form may be changed
by the local provider. However, if required data or information is deleted in the process of
modifying the form, it will no longer satisfy DMH Operational Standards for record keeping.
General Information
A single case record must be maintained for all individuals served by the agency/provider and
must contain specific mandatory data and information. Additional data or information may be
included to ensure that sufficient information is maintained to protect the privacy of all
individuals receiving services. Two years of documentation must be maintained in the active
record. All completed documentation should be present in the individual’s record no later than
the 10th day of the following month to the service was delivered unless more stringent
timelines are required by DMH.
The Record Guide is divided into sections that allow the user to identify those forms or data
tools required for all individual records, those that are used when the circumstances of the
individual receiving services dictates their use, those that are specific to an area of service,
and those that are administrative documentation that is not maintained in an individual’s
record.
Each form has specific guidance that states the purpose of the form/data tool. Also included
in the guidance are references to the DMH Operational Standards and specific information
regarding the nature and purpose of all forms/data tools.
References to “days” in the Record Guide mean calendar days.
Any section or area of a form that is not applicable must contain a strikethrough line that
clearly indicates the item was not overlooked or omitted and that it does not apply to the
individual receiving services.
DMH Strikethrough 2016 Record Guide Purpose & Guidance
Signatory Authority
Signatures are necessary to verify that information has been correctly and thoroughly shared
with individuals receiving services. Signatures are also necessary to create a legally binding
document. Forms in the Record Guide require signatures necessary for proper authorization
of a particular form. Each signature line provided is clearly marked as to who is expected to
sign. All signature lines on all forms must either be signed or marked as “not applicable” if
that is the correct response. For example, all of the signature lines provided may not be
necessary to document the individuals who participated in development of the Individual
Service Plan or the Periodic Staffing/Review of the Individual Service Plan.
Electronic signatures are allowed on any form in the Record Guide.
Signature of the Individual Receiving Services
The individual receiving services must sign for himself or herself unless one of the following
conditions applies or is present:
1. The individual is under 18 years of age.
2. A legal representative has been appointed for the person by a court of competent
jurisdiction.
3. If a person cannot physically sign or is not mentally/cognitively able to understand the
form, a parent or next of kin can sign if they indicate they are signing as such.
Physical, mental or cognitive ability to sign and understand the form must be
determined by a medical doctor or psychologist. Documentation must be maintained in
the record.
Signature of Individual Authorized to Give Consent or Sign in Lieu of the
Individual Receiving Services
If one of the conditions stated above applies and the person is unable to sign for himself or
herself, the person who is authorized to give consent or sign in lieu of the individual must sign
the form(s). If the individual is under 18 years of age, this authorized representative is the
parent unless a court ordered (legal) guardian or a conservator has been appointed for the
child/youth. If the individual receiving services, regardless of his/her age, has a court ordered
(legal) guardian or a conservator, the guardian/conservator must sign all forms on behalf of
the individual receiving services. In the case of a court ordered (legal)
guardian/conservator, a copy of guardianship/conservatorship papers must be
maintained in the record.
The legal guardian or conservator of an individual receiving service(s) must review and
sign the paperwork required in order for an individual to receive services.
Should the individual’s legal guardian or conservator choose to delegate his/her
responsibility and signatory authority to another individual for the completion of daily
paperwork (including delegating signature authority to the individual being served), DMH
will accept the signature of that individual. The legal guardian or conservator must
provide written documentation of such delegation and to whom the signatory authority
is being delegated. This must be maintained in the individual’s record. Daily signature
DMH Strikethrough 2016 Record Guide Purpose & Guidance
authority cannot be delegated to the service provider. However, the legal guardian or
conservator must continue to sign annual paperwork, such as the Consent for Services and
Individual Service Plan.
Signature of Witness/Credential
In the case of some DMH documentation, a witness must sign in order to verify that the
signature(s) are valid, particularly if a person is signing in lieu of the individual receiving
services. Forms requiring the signature of a witness will have a signature line provided for
the witness. This requirement will be reflected in the guidance for that particular form.
If an individual signs with a mark or an “X,” the signature of a witness is required. If the form
does not include a line for a witness, the witness will sign next to the mark or “X.”
If the witness is an employee of the facility or program, he/she must include his/her
credentials or position.
Billing
All questions concerning billing should reference the funding source. Questions concerning
Medicaid billing should reference the Medicaid Guidelines issued by the Division of Medicaid,
Office of the Governor.
Section B
Required For All
Records
Face Sheet
Consent to Receive Services
Rights of Individuals Receiving Services
Acknowledgment of Grievance Procedure
Consent to Release/Obtain Information
Initial Assessment
Trauma History
Medication/Emergency Contact Information
Individual Service Plan
Individual Crisis Support Plan
Recovery Support Plan
Periodic Staffing/ Review of the Individual Service Plan
Progress Note
Weekly Progress Note
DMH Face Sheet guidance
Face Sheet
Purpose
The Face Sheet contains relevant data and/or personal information necessary to readily identify
the individual receiving services. Information on the Face Sheet is used for routine service
provision activities such as scheduling, billing, and reference.
Timeline
The Initial Face Sheet must be prepared at admission as part of the intake process. The Face
Sheet must be updated whenever information or data changes and/or at least annually. When
changes in information or data are made, or at the annual update, a new/corrected Face Sheet
must be dated and placed in the individual record.
Face Sheet Information
Each DMH certified provider must maintain current and accurate data for submission of all
reports and data as required by DMH. The Face Sheet can be generated as a report by the
agency’s database system once all the data has been entered into the agency’s system.
Depending on the specific data collection and reporting system that the agency uses, additional
personal information may have to be added to complete the Face Sheet. The Face Sheet must
contain all 44 data elements required in the DMH Manual of Uniform Data Standards.
The required elements of the Face Sheet are provided on the following page. Providers should
reference the DMH Manual of Uniform Data Standards for applicable codes and should consult
with the agency employee responsible for data submission. Providers can also contact DMH
Division of Information Services for additional guidance, 601-359-1288.
DMH Face Sheet Required Elements
Required Data Elements for Face Sheet
1. Record transaction type (add, change, delete)
2. Organization code
3. Unique client ID within organization
4. Client status
5. Admission date (most recent) to organization
6. Admission type (primary, collateral, unregister)
7. Admission referral category
8. Admission referral organization code (referrals to/from a DMH operated program
only)
9. Legal status of client at admission
10. Client last name
11. Client first name
12. Client maiden name (if applicable)
13. Social Security Number (unique client identifier)
14. Birth date
15. Age of client (calculated from birth date)
16. Sex
17. Race
18. Hispanic origin
19. Education level: last grade completed
20. Marital status
21. County of residence prior to admission
22. Living arrangement
23. Type of residence
24. Employment status - Include place of employment if applicable.
25. Primary source of household income
26. Household annual income amount
27. No. of persons in household dependent on income
28. Is the individual pregnant?
29. Eligibility for SSI/SSDI
30. Eligibility for Medicaid
31. Expected principle source of payment
32. Veterans status
33. Physical impairment (1 of 2)
34. Physical impairment (2 of 2)
35. Presenting problem (1 of 2)
36. Presenting problem (2 of 2)
37. Treatment category (MH, MR, SA, dual)
38. Primary treatment category (if dual)
39. Is client seriously mentally ill (Y/N)
DMH Face Sheet Required Elements
40. Is client seriously emotionally disturbed child?
41. Medicaid number
42. State ID (generated by CDR upon 1st submission)
43. Client receives integrated treatment
44. Indicates whether client receives ACT/PACT Assertive Community Treatment
DMH Strikethrough 2016 Consent to Receive Services Guidance
Consent To Receive Services
Purpose
In addition to all rights of individuals receiving services, each individual must provide his/her
consent to receive services from the agency.
Time Line
Individuals receiving services must be informed of and consent to services at the time of the
intake admission and before services are provided.
Individuals must provide their consent for services at least annually, on or before the
anniversary date of the current consent, as long as the individual continues to receive services.
For ID/DD Waiver Support Coordination Services, individuals must provide their consent for
services at least annually, before the end of the person's certification period
For IDD providers, individuals must provide their consent at the time the Activity Support Plan is
developed and annually thereafter.
Consent to Receive Services
This section can be read by, or if necessary, read to the individual receiving services and/or a
person who is legally authorized to act on his/her behalf. In either case, the Consent To
Receive Services and the limits of confidentiality must be clearly explained to the individual
receiving services and/or a person authorized to act on his/her behalf.
Signatures
If the individual receiving services is unable to sign and the form is being signed by a court
ordered (legal) guardian/conservator, a copy of guardianship/conservatorship papers must be
maintained in the record.
The Consent to Receive Services, Rights of Individuals Receiving Services and
Acknowledgment of Grievance forms can be combined into one document as long as space is
included in the document for signature or initials of the individual receiving services or legal
guardian to acknowledge each separate action.
Strikethrough 2016 Consent to Receive Services form
Consent To Receive
Services
Name
ID Number
Service(s)
The information which I have provided as a condition of receiving services is true and complete to
the best of my knowledge. I consent to receive services as may be recommended by the
professional staff. I understand the professional staff may discuss the services being provided to
me, and that I may request the names of those involved. I further understand that my failure to
comply with therapeutic
recommendations of the professional staff may result in my being
discharged.
I understand that I have the freedom of choice to receive services in a setting that is integrated in
and supports full access to the greater community; and is a setting that facilitates individual choice
regarding services and supports, and who provides them.
I understand that State and federal laws and regulations prohibit any entity receiving confidential
information from redistributing the information to any other entity without the specific written
consent of the person to whom it pertains or as otherwise permitted by law and regulations.
I understand that confidential information may be released without my consent when necessary for
continued treatment services; when release is necessary for the determination of eligibility for
benefits, compliance with statutory reporting requirements, or other lawful purpose; if you
communicate to the treating physician, psychologist, master social worker or licensed professional
counselor an actual threat of physical violence against a clearly identified or reasonably identifiable
potential victim or victims; in compliance with reporting requirements under state law of incidents of
suspected child abuse or neglect, or by court order.
Individual/Legal Representative Signature Date
Staff Signature/Credentials Date
DMH Strikethrough 2016 Rights of Individuals Receiving Services guidance
Rights of Individuals Receiving Services
Purpose
Each individual who receives services from a DMH certified agency or provider has legal,
ethical, and privacy rights that must be protected. DMH certified agencies must maintain
documentation showing each individual who receives services has been informed of these
rights. This document also informs the individual receiving services of legal circumstances in
which the provider will be required to release information concerning his/her treatment/services.
After the individual receiving services has been informed of his/her rights, the individual is then
offered the opportunity to consent to receive services treatment
.
Time Line
Individuals receiving services must be informed of his/her rights during the intake admission
process and before services are provided.
Individuals must be informed of his/her rights at least annually, on or before the anniversary
date of the current form, as long as the individual continues to receive services.
For ID/DD Waiver Support Coordination Services, individuals must be informed of their rights at
least annually, before the end of the person's certification period
For IDD providers, individuals must be informed of their rights at the time the Activity Support
Plan is developed and annually thereafter.
Intake/Admission Date
The intake/admission date is the original date of intake/admission to the service. This date
remains the same from year to year as long as the person is continuously enrolled in the
service.
Rights
The rights can be read by, or if necessary, read to the individual receiving services and/or to a
person who is legally authorized to act on his/her behalf. The rights must be clearly explained
to the individual receiving services and/or a person authorized to act on his/her behalf. The
individual must be offered a copy of the form to take with them. Signed documentation of
receipt must be maintained in the record. Providers may omit #18-22 if those service types are
not provided by the agency.
The Consent to Receive Services, Rights of Individuals Receiving Services and
Acknowledgment of Grievance forms can be combined into one document as long as space is
included in the document for signature or initials of the individual receiving services or legal
guardian to acknowledge each separate action.
Strikethrough 2016 Rights of Individuals Receiving Services form
Rights of Individuals
Receiving Services
Name
ID Number
I, began receiving services provided by
Name Name of Provider
on and have been informed of the following:
Intake/Admission Date
1. My options within the program and of other services available
2. The program’s rules and regulations
3. The responsibility of the program to refer me to another agency if this program becomes unable to serve me or
meet my needs
4. My right to refuse treatment and withdraw from this program at any time
5. My right not to be subjected to corporal punishment or unethical treatment which includes my right to be free from
any forms of abuse, neglect, exploitation or harassment and my right to be free from restraints of any form that are
not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff
6. My right to voice my opinions, recommendations and to file a written grievance which will result in program review
and response without retribution
7. My right to be informed of and provided a copy of the local procedure for filing a grievance at the local level or with
the DMH Office of Consumer Support
8. My right to privacy and confidentiality in respect to facility visitors in day programs, residential treatment programs,
and community living programs as much as physically possible
9. My right regarding the program’s nondiscrimination policies related to HIV infection and AIDS
10. My right to be treated with consideration, respect, and full recognition of my dignity and individual worth
11. My right to have reasonable access to the clergy and advocates and have access to legal counsel at all times
12. My right to review my records, except when restricted by law
13. My right to fully participate in and receive a copy of my Individual Service Plan/Plan of Care Services and Supports
or Activity Plan. This includes: 1) having the right to make decisions regarding my care, being involved in my care
planning and treatment and being able to request or refuse treatment; 2) having access to information in my case
records within a reasonable time frame (5 days) or having the reason for not having access communicated to me;
and, 3) having the right to be informed about any hazardous side effects of medicati on prescribed by staff medical
personnel
14. My right to retain all Constitutional rights, except when restricted by due process and resulting court order
15. My right to have a family member or representative of my choice notified should I be admitted t o a hospital
16. My right to receive care in a safe setting
17. My right to confidentiality regarding my personal information involving receiving services as well as the compilation,
storage, and dissemination of my individual case records in accordance with standards outlined by the Department
of Mental Health and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), if applicable
Additionally, rights for individuals in supervised and residential treatment arrangements:
18. My right to be provided a means of communicating with persons outside the program
19. My right to have visitation by close relatives and/or significant others during reasonable hours unless clinically
contraindicated and documented in my case record
20. My right to be provided with safe storage, accessibility, and accountability of my funds
21. My right to be permitted to send/receive mail without hindrance unless clinically contraindicated and documented in
my case record
22. My right to be permitted to conduct private telephone conversations with family and friends, unless clinically
contraindicated and documented in my case record
I have been informed of, understand, and have received a written copy of the above information.
Individual Receiving Services Date Legal Representative Date
Staff/Credentials Date
DMH Strikethrough 2016 Acknowledgment of Grievance guidance
Acknowledgment of Grievance Procedures
Purpose
The provider’s grievance procedures must be provided to the individual and/or legal
representative during the intake admission process. The information can be read by, or if
necessary, read to the individual receiving services and/or a person who is legally authorized to
act on his/her behalf.
Time Line
Individuals receiving services must be informed of and provided a copy of the provider’s
Grievance Procedures at the time of the initial intake admission and before services are
provided. Each individual receiving services must be presented with the provider’s Grievance
Procedures when they are being asked to give his/her consent to receive services.
Individuals acknowledge receipt of the Grievance Procedures at least annually, on or before the
anniversary date of the current acknowledgment, as long as the individual continues to receive
services. A copy of the Grievance Procedures given to the individual receiving services should
be attached and kept with the signed form.
For ID/DD Waiver Support Coordination Services, individuals must sign the acknowledgment at
least annually, before the end of the person's certification period
For IDD providers, individuals must sign the acknowledgment at the time the Activity Support
Plan is developed and annually thereafter.
The Consent to Receive Services, Rights of Individuals Receiving Services and
Acknowledgment of Grievance forms can be combined into one document as long as space is
included in the document for signature or initials of the individual receiving services or legal
guardian to acknowledge each separate action.
DMH Strikethrough 2016 Acknowledgment of Grievance form
Acknowledgment of
Grievance Procedures
Name
ID Number
I have been informed of the policies and procedures for reporting a grievance concerning any
treatment or service that I receive.
Individual/Legal Representative Signature Date
Staff Signature/Credentials Date
DMH Strikethrough 2016 Consent to Release-Obtain Information guidance
Consent to Release/Obtain Information
Purpose
Providers must have prior written authorization before information regarding an individual
receiving service can be released. A fully executed Consent to Release/Obtain Information
must be in place in order to legally exchange, release, or obtain information between
individuals, agencies and/or providers. The original Consent to Release/Obtain Information
form must always be maintained in the individual’s case record.
Release/Obtain Information
Enter the name and address of the agency from which the action is required.
Complete the Release Information To when requesting a provider to send confidential
information about an individual to another entity.
Complete the Obtain Information From
section when confidential information regarding an
individual receiving/requesting to receive services needs to be obtained from another entity.
The specific purpose for which the information is needed must be indicated. Staff must specify
the exact reason for obtaining/releasing the information.
Extent/Nature of Information
The specific extent and/or nature of the information to be disclosed must be checked. If ‘Other’
is checked, the specific extent/nature of the disclosure must be described in detail. A generic
authorization for the non-specific release of medical or other personal information is not
sufficient for this purpose.
Date/Event/Condition
In order to clearly show the point in time when the Consent will expire, the following information
must be provided: 1) the month, day, and year, or 2) an event, or; 3) a condition that will deem
the Consent form expired; meaning no further action can be taken once the specific
date/event/condition is satisfied. An example of an event or condition may be, “30 days after
discharge or termination of services”.
For children and youth receiving services in a school setting, a date period that covers a specific
school year must be used.
The actions, conditions and limits of the consent must be clearly explained to the individual
receiving services and/or to a person who is legally authorized to act on his/her behalf.
The provider must clearly explain the conditions under which confidential information may be
released without consent. Confidential information may be released without consent when
necessary for continued services treatment
; when release is necessary for the determination of
eligibility for benefits, compliance with statutory reporting requirements, or other lawful purpose;
if you communicate to the treating physician, psychologist, master social worker or licensed
professional counselor an actual threat of physical violence against a clearly identified or
reasonably identifiable potential victim or victims; in compliance with reporting requirements
under state law of incidents of suspected child abuse or neglect or by court order.
DMH Strikethrough 2016 Consent to Release-Obtain Information guidance
Witness
The Consent to Release/Obtain Information requires the signature of a witness. If the witness
is an employee of the program, he/she must include his/her credentials (if applicable). If the
individual receiving services can only make their mark (for example “X”), place the mark in
quotations and write out beside it, John Doe’s Mark substituting individual’s name. A second
witness to the individual’s signature is required in this case.
DMH Strikethrough 2016 Consent to Release-Obtain Information form
Consent to
Release/Obtain Information
Name
ID Number
Date
I hereby give my consent/permission for
(Agency Name and Address)
To release information to:
(Agency/Person Name/Title and Address)
To obtain information from:
(Agency/Person Name/Title and Address)
For the specific purpose of:
Treatment
Coordination of Services
Other
The extent and nature of the information to be disclosed/obtained must be indicated (check all that apply):
Evaluations Diagnosis/Prognosis/Recommendations
Progress Notes Psychiatric Records
Substance Abuse Records Admission/ Discharge Summary
Contact Summaries Activity Support Plan
Identifying Information
Individual Service Plan/ Plan of Services &
Supports
Other
I understand that I may revoke this consent at any time except to the extent that action has been taken. I
further understand that this consent will expire upon
(Specific Date/Event/Condition)
and cannot be renewed without my consent. I understand that to revoke this authorization, Individual or Legal
Representative must provide a written request and the revocation will not apply to action or information that has
already been released/obtained in response to this authorization. Any information obtained as a result of this
release is confidential. State and federal laws and regulations prohibit any entity receiving confidential
information from redistributing the information to any other entity without the specific written consent of the
person to whom it pertains or as otherwise permitted by law and regulations. I understand the information I
authorize for release may include information related to history/diagnosis and/or treatment of HIV, AIDS,
communicable or sexually transmitted diseases and alcohol/drug abuse or dependency.
I understand that confidential information may be released without my consent when necessary for continued
treatment services; when release is necessary for the determination of eligibility for benefits, compliance with
statutory reporting requirements, or other lawful purpose; if you communicate to the treating physician,
psychologist, master social worker or licensed professional counselor an actual threat of physical violence
against a clearly identified or reasonably identifiable potential victim or victims; in compliance with reporting
requirements under state law of incidents of suspected child abuse or neglect or by court order.
By signing below, I acknowledge receipt of a copy of the signed authorization
Individual Receiving Services Date Legal Representative Date
Witness/Credentials Date
DMH Strikethrough 2016 Medication-Emergency Contact Information guidance
Medication/Emergency Contact Information
Purpose
Documentation of medications must be maintained while the individual is receiving services
from a DMH certified agency or provider. The Medication/Emergency Contact Information is not
to be used for the regular dispensing of medication. An important component is the
documentation of all the individual’s known allergic and/or adverse reactions. Emergency
contact information must be completed to ensure immediate and appropriate response in the
event of an emergency.
Timeline
The medications the individual is taking and the emergency contact information are recorded
during the intake admission process. The information must be updated when medications are
discontinued or added and at least annually.
Updates
The person entering updated information (new medications/changes to existing
medications/discontinuation of a medication) must write the date the changes were made and
sign the form in the designated space. The same form can be used until all spaces for
medications are filled. At that time, a new form must be completed to ensure clarity. Any time
the emergency contact information changes, a new form must be completed and placed in the
individual’s record.
Staff Signature/Date Initiated
Each medication entry must be signed by the person completing the form. If known, enter the
date the individual began taking the medication. If this information is unavailable, signify such
by entering “NK” in the “Date Initiated” column.
Current Medication
All sections must be addressed. ALL known and/or reported medications the individual is
currently taking must be listed, regardless of type or purpose, including over-the-counter (OTC)
medications the individual may be taking. The name of the medical professional prescribing
each medication must be listed. All known or reported prescribed medications must be
documented. Medication information regarding dosage and frequency must be listed exactly as
prescribed. If there are no prescribed or OTC medications, the person completing the form
must write “no prescription or OTC meds” and his/her initials.
Previous Medications/ Dietary Needs
Previously prescribed or taken medications listed; including any adverse reactions as reported
by the individual; any special dietary needs.
Date Terminated/Changed/Staff Signature
If a medication dosage or frequency is changed, enter the date in the column. This space is
also to be used if a medication is discontinued. The staff person entering the information must
sign the form.
Allergies/ Adverse Reactions
Each of the individual’s known allergies and his/her reactions to them must be documented.
Include unusual reactions if applicable. Allergies may include, but not be limited to,
medications, insect bites, plants, foods, fragrances/aromas, or anything else that produces an
allergic or adverse reaction.
DMH Strikethrough 2016 Medication-Emergency Contact Information form
Medication/Emergency
Contact Information
Name
ID Number
Name/Credentials of Staff Initially Completing the form:
Date Initially Completed:
CURRENT MEDICATIONS
List ALL known and/or reported medications the individual is currently taking regardless of type or
purpose to include over-the-counter (OTC) medications (use additional pages, if needed):
Staff
Signature/
Credential
Date
Initiated Name of Medication Prescribed by
Dosage/
Frequency
Date
Terminated/
Changed
Staff
Signature/
Credential
Known Allergies/Reactions:
PREVIOUS MEDICATIONS
Medication Directions Comments
(to include adverse reactions if applicable)
DMH Strikethrough 2016 Medication-Emergency Contact Information form
Special Dietary Needs (if applicable):
Emergency Information:
In case of emergency (when parent/legal representative cannot be reached) contact:
Name:
Phone Number:
(primary) (secondary)
Address:
Primary Doctor:
Doctor’s Phone:
Doctor’s Address:
Hospital Preference:
Insurance Carrier(s):
Policy Number(s):
Section C
Required For All
Mental Health and
Substance Use Records
Initial Assessment
Trauma History
Individual Service Plan
Individual Crisis Support Plan
Recovery Support Plan
Periodic Staffing/ Review of the Individual Service Plan
Progress Note
Weekly Progress Note
Readmission Assessment Update
Substance Use Disorder Specific Assessment
Strikethrough 2016 Initial Assessment guidance
Initial Assessment
Purpose
The Initial Assessment is used to document pertinent information that will be used as part of the
process for determining what service or combination of services might best meet an individual’s
stated/presenting need(s). The information gathered is both historical as well as what is currently
happening in an individual’s life.
*Note- An Initial Assessment is not required for ID/DD Waiver or 1915(i) Services. The
ID/DD Evaluation performed by the Diagnostic and Evaluation team to determine
eligibility for the ID/DD Waiver or the 1915(i) Community Support Program takes the
place of the Initial Assessment.
Responses of “No” or “Not Present”, are acceptable. If an entire section does not apply to
someone, the recorder can enter “Not Applicable.” However, if the answer is “Yes” or “Present”,
then additional narrative and explanation is required.
Timeline
The Initial Assessment is part of the intake process and must be completed wit hin the service
specific timeline requirements.
Admission Date
Enter the date the individual was admitted to service(s).
Assessment Date
Enter the date the Initial Assessment was started.
Informant
If assessment information is provided by someone other than the individual receiving services,
enter the person’s relationship to the individual requesting services. A Consent to Release/
Obtain Information must be completed if applicable.
Guardianship Information
If individual has a legal guardian record name and contact information.
Confidentiality
Mark yes if limits of confidentiality are discussed with individual/guardian. If not, mark no with an
explanation.
Description of Need
Record the reason(s) the individual gives as to why he/she is seeking services, current needs,
goals etc. If substance use disorder is indicated in this section, a Substance Use Specific
Assessment must be completed.
Strikethrough 2016 Initial Assessment guidance
Social / Cultural
Complete social information, current living situation, and family history sections as applicable with
information provided by the informant.
History
Complete the history section as applicable with information provided by informant.
The developmental history section should be completed for Children and Youth up to age 21 and
all individuals with IDD.
The school functioning education
section and additional information section should be completed
for all Children and Youth up to age 21.
The employment section should be completed for adults not employed at the time of the
assessment.
All items in the history sections must be completed. Responses of “No” or “Not Present”, are
acceptable. If an entire section does not apply to someone, the recorder can enter “Not
Applicable.” However, if the answer is “Yes” or “Present”, then additional narrative and
explanation is required.
Medical History
Complete the additional medical information as applicable with information provided by
informant.
All items in the history sections must be completed. Responses of “No” or “Not Present”, are
acceptable. If an entire section does not apply to someone, the recorder can enter “Not
Applicable.” However, if the answer is “Yes” or “Present”, then additional narrative and
explanation is required.
Individual Mental Health History
Complete the outpatient mental health and psychiatric hospitalization/ residential treatment
sections as applicable with information provided by informant.
All items in the history sections must be completed. Responses of “No” or “Not Present”, are
acceptable. If an entire section does not apply to someone, the recorder can enter “Not
Applicable.” However, if the answer is “Yes” or “Present”, then additional narrative and
explanation is required.
Initial Behavioral Observation
Record observations for all areas listed. All areas must be evaluated. Comments must be
included to further explain or clarify the specific observed behaviors.
Indication of Functional Limitation(s)
An assessment must be conducted and the results documented for the major life areas specified
for each individual seeking readmission to services.
Strikethrough 2016 Initial Assessment guidance
The Child and Adolescent Functional Assessment Scale (CAFAS) is required for all
children/youth receiving mental health services. The CAFAS must be completed within 630 days
for all children/youth receiving mental health services or within timelines as required by service.
An approved functional assessment is required for all adults receiving mental health services. An
approved functional assessment must be completed within 630
days for all adults receiving
mental health services or within timelines as required by service. DMH will review and approve a
functional assessment for use with the adult SMI population.
An approved functional assessment is required for all individuals receiving substance use
disorder services. DMH will review and approve a functional assessment for use with the SUD
population.
Summary/Recommendations
The person conducting the Initial Assessment must summarize the observations and findings to
include an analysis of the individual’s strengths and needs, both expressed and observed. Based
on the results of the Initial Assessment, services must be recommended and offered to the
individual. Referrals to other appropriate providers must also be offered to the individual.
Observations, findings and recommendations should support a life of recovery related to the
following dimensions:
Health- managing one’s disease; making informed, healthy choices that support physical and
emotional well-being
Home- having a stable and safe place to live
Community- having relationships and social networks that provide support, friendship, love and
hope
Purpose- conducting meaningful daily activities to participate in society
Initial Diagnostic Impression
Give the written diagnostic impression and appropriate codes.
Staff Qualifications
The Initial Assessment must be completed by an individual with at least a Master’s degree in
mental health or intellectual/developmental disabilities, or a related field and who has either (1) a
professional license or (2) a DMH credential as a Mental Health Therapist,
Intellectual/Developmental Disabilities Therapist or Substance Abuse Therapist (as appropriate
to the population being served).
For IDD programs, a QMRP may complete the Initial Assessment.
For Alzheimer’s Day Programs only, the program supervisor must complete the Initial
Assessment. A copy of the individual’s current history and physical, signed by an MD or
Psychologist must be provided to confirm diagnosis.
DMH Initial Assessment form Page 1 of 7
Initial Assessment
Name:______________________________________________
ID Number:__________________________________________
Admission Date:______________________________________
Assessment Date:____________________________________
Time In: Time Out: Total Time:
Informant: □ Individual Receiving Services □ Other: Relationship to Individual______________________
Does the person seeking services have an Outpatient Commitment Order? □ Yes □ No
GUARDIANSHIP INFORMATION
Name of Guardian / Custodian:
Guardianship Documentation Verified:
□ Yes □ No
Guardian / Custodian Address:
Guardian / Custodian Phone Number:
Is the family involved with the Department of Human Services? □ Yes □ No
If yes, has a consent to release information been obtained? □ Yes □ No
If yes, please explain and indicate the name of the assigned case worker: __________________________
CONFIDENTIALITY
Were the limits of confidentiality reviewed with Individual and/or Guardian? □ Yes □ No
If NO, please explain.
DESCRIPTION OF NEED
What is your reason for seeking services today? What specific needs do you currently have?
(Include a description/perception of difficulties according to the individual seeking services and any applicable family
members/legal guardian.)
Is the reason for seeking services today related to substance use? □ Yes □ No
If yes, the substance use specific assessment must also be completed.
What specific needs do you currently have?
What previous coping skills have been helpful in the past?
DMH Initial Assessment form Page 2 of 7
Thoughts of Suicide: □ Yes (If yes, explain) □ No
Attempts of Suicide: □ Yes (If yes, explain) □ No
Thoughts of Homicide: □ Yes (If yes, explain) □ No
(Indicate the need for “duty to warn”)
Acts of Self-Harm: □ Yes (If yes, explain) □ No
SOCIAL / CULTURAL
Identification of Support Systems:
(Address family relationships, interpersonal relationships, and community support systems)
Meaningful Activities, Cultural / Ethnic / Spiritual interests, Supports:
(Address hobbies, leisure activities, etc.)
Cultural / Ethnic / Spiritual interests, Supports:
Support Needs
(social supports, interpersonal, protective care, support groups, counseling, legal assistance, other):
Living Situation
What are your views on is your current living arrangements (strengths and concerns)? Who lives with you?
What are your views on your current arrangement?
Individuals Living in Household
Individual Relationship to Client Age
Quality of Support
According to the person
(circle one)
Good Fair Poor
Good Fair Poor
Good Fair Poor
Good Fair Poor
Good Fair Poor
DMH Initial Assessment form Page 3 of 7
Secondary Household (Minors Only)
Individual Relationship to Client Age Quality of Support
Good Fair Poor
Good Fair Poor
Good Fair Poor
Good Fair Poor
Needs Related to Living Situation
(money management, benefits, living arrangements, clothing, personal care, child care, rent, other)
Developmental History
(Complete only for Children & Youth up to age 21 and everyone with ID/DD)
During pregnancy, did mother use alcohol or other drugs? □ Yes □ No
Describe any problems with the pregnancy or birth:
Were developmental milestones met there any developmental issues? □ Yes □ No (If no, explain)
Was the child’s first year of life difficult, easy, other? □ Yes (If yes, explain) □ No
Describe any childhood accidents or injuries:
Education School Functioning (Children & Youth up to age 21)
Name of school:
Does child/youth receive Special Education Services?
□ Yes (If yes, complete release of information to obtain a copy of the current Individualized Education Plan (IEP) )
□ No
Additional Information (Children & Youth up to age 21)
Educational Issues/ Needs ( grades, attendance, suspensions, expulsions)Comments on Educational Classification /
Placement (please indicate if client is home schooled, in gifted program, etc.):
Grades: Attendance: Previous Grade Retentions: Suspensions / Expulsions:
Other Academic / School Concerns:
Employment (adults only)
(complete only if individual is not employed at the time of assessment)
Are you employed?Barriers to Employment: □ Yes □ No
If no, do you want to be employed?Employment Related Needs:
Employment Barriers/ Related Needs?
DMH Initial Assessment form Page 4 of 7
Previous Assessment History
Have psychological, educational or functional assessments been completed in the last twelve months?
□ Yes (If yes, complete release of information to obtain a copy of the applicable assessment.)
If yes, indicate type of assessment__________________________________________________________________
□ No
Current Legal Status
Has the individual been involved with the legal system within the past twelve months?
□ Yes □ No
Arrests: □ Yes □ No
If yes, indicate type and number of arrest(s):
Number of arrests in the past 30 days:
Pending Charges: □ Yes □ No
If yes, indicate type and number of pending charges:
Substance Use Related Legal Issues:
Is this person currently on parole and/or probation? □ Yes □ No
If applicable, indicate to whom reports should be submitted: ______________________________________
MEDICAL HISTORY
Appetite Issues:
Sleep Issues:
Current or Chronic
Diseases
□ high blood pressure □ diabetes □ thyroid □ other ____________________
Family History
□ high blood pressure □ diabetes □ thyroid □ other ____________________
Other Pertinent Medical Information:
Additional Medical History or Health and Safety Issues:
Health-Related Needs:
INDIVIDUAL MENTAL HEALTH HISTORY
Previous Assessment History
Have psychological, educational or functional assessments been completed in the last twelve months?
□ Yes (If yes, complete release of information to obtain a copy of the applicable assessment.)
DMH Initial Assessment form Page 5 of 7
If yes, indicate type of assessment__________________________________________________________________
□ No
Previous or Current Diagnoses:
Mental Health Needs:
Family History of Psychiatric or Substance Use Disorder(s) □ Yes □ No
If yes, please describe.
Outpatient Behavioral Health Agency
□ None Reported
Treatment Agency Services Received Dates of Service
Has Consent to
Release
Information
Been
Requested?
□ Yes □ No
□ Yes □ No
□ Yes □ No
Psychiatric Hospitalizations / Residential Treatment
□ None Reported
Treatments Reason (suicidal, depressed, etc.) Dates of Service
Has Consent to
Release
Information
Been
Requested?
□ Yes □ No
□ Yes □ No
□ Yes □ No
DMH Initial Assessment form Page 6 of 7
Initial Observations
General
Observations
Appearance:
□ Appropriate □ Disheveled □ Unclean □ Other __________________________________
Speech:
□ Appropriate □ Slow □ Mechanical □ Rapid □ Other _______________________________
Affect:
□ Appropriate □ Flat □ Labile □ Other __________________________________________
Delusions:
□ N/A
□ Description:
Hallucinations:
□ N/A
□ Description:
Mood
□ Appropriate □ Manic □ Depressed □ Labile □ Irritable □ Other _________________________
Orientation
□ Person □ Place □ Time □ Situation □ Other ________________________________________
Indication Of Functional Limitation(s):
(Check Major Life Areas Affected)
Basic living skills (eating, bathing, dressing, etc.)
Instrumental living skills (maintain a household, managing money, getting around the community,
taking prescribed medications, etc.)
Social functioning (ability to function within the family, vocational or educational function, other social
contexts, etc.)
SUMMARY / RECOMMENDATIONS
Health:
Home:
Community:
Purpose:
Other:
DMH Initial Assessment form Page 7 of 7
INITIAL DIAGNOSTIC IMPRESSION
Codes: Description:
SIGNATURES / CREDENTIALS
X Date: X Date:
X Date: X Date:
DMH Trauma History guidance
Trauma History
Purpose
The Trauma History is a screening tool designed to determine whether or not an individual
receiving services has experienced trauma in the past. This tool is not a standardized measure
and there are no scoring guidelines. This assessment should be administered in an interview
format that allows the clinician to explain questions in a developmentally appropriate manner to
ensure the client understands what is being asked. The interview process also allows the
clinician to observe nonverbal responses to questions that might indicate a trauma response
such as anxiety, fear, avoidance, shame, etc.
General
The timeline for completion of the Trauma History is determined by the type of service or
program the individual is entering.
All individuals receiving services must complete a trauma history questionnaire. Outpatient
Services must complete the trauma history questionnaire within 30 days, Day programs must
complete the trauma history questionnaire within 3 days of admission. Primary Residential
Services within 5 days of admission to the services. Crisis Stabilization Services must complete
the trauma history questionnaire within 48 hours. Results of trauma history questionnaire
should be incorporated into ISP and subsequent services.
The Trauma History Assessment is not a tool for gathering information or details about the
traumatic event. The clinician should maintain a neutral tone when asking each question. If the
client indicates he/she has experienced an event, then the therapist only asks at what age the
traumatic event(s) started and ended. If the client offers more information, the clinician
captures that content but does not attempt to elicit more details than offered, challenge nor
process the information shared.
If the client reports a positive trauma history, the clinician asks the client to identify the trauma
that is most distressing at that time. The identified trauma is then incorporated into the
Individual Service Plan and subsequent services and can be referred to when administering
formal trauma assessments.
DMH Trauma History form
Trauma History
Name
ID Number
Date
Time In: Time Out: Total:
Page 1 of 2
Please indicate if any of the following have happened to you and how it may have affected you.
Have you ever served in the military, law enforcement or as a first responder? □ Yes □ No
If yes, indicate the capacity in which you served.
Have you ever seen or been in a really bad accident?
Has someone close to you ever been so badly injured or sick that s/he almost died?
Has someone close to you ever died?
Have you ever been so sick that you or the doctor thought you might die?
Have you ever been unexpectedly separated from someone who you depend on for love or security for
more than a few days?
Has someone close to you ever tried to kill or hurt him/herself?
Has someone ever physically hurt you or threatened to hurt you?
DMH Trauma History form
Trauma History
Name
ID Number
Page 2 of 2
Have you ever been mugged or seen someone you care about get mugged?
Has anyone ever kidnapped you?
Have you ever been attacked by a dog or other animal?
Have you ever seen or heard people physically fighting or threatening to hurt each other? (In or outside
of the family)?
Have you ever witnessed a family member who was arrested or in jail?
Have you ever had a time in your life when you did not have a place to live or enough food?
Has someone ever made you see or do something sexual? Or have you seen or heard someone else
being forced to do sex acts?
Have you ever watched people using drugs, like smoking drugs or using needles?
Staff Signature/Credential Date
Individual Service Plan guidance
Individual Service Plan
Purpose
Each individual who receives services must have an Individual Service Plan that is based on the
identified strengths and needs of the individual, the goals that will help address his/her needs, the
services to be provided, and the activities that will take place toward achieving measurable
individual outcomes. The individual seeking/ receiving services must be involved in the
development of his/her service plan. For individuals under the age of eighteen (18) or who are
unable to effectively participate in the planning process, a parent, legal guardian or conservator
must participate in planning on the individual’s behalf.
The timeline for completion of the Individual Service Plan is determined by the type of service or
program the individual is entering.
The Individual Service Plan must be reviewed and revised when goals or objectives are achieved,
as needs of the individual change, or according to specific service requirements but at least
annually.
Individual Strengths
List strengths the individual possesses and/or demonstrates that will assist and promote
successful achievement of outcomes.
Goals
The individual receiving services establishes the long term goals. Staff helps the individual set
short term goals which will contribute to achievement of the long term goal(s).
Identified Barriers
List barriers that may prevent the individual from achieving successful outcomes. Barriers must
include but are not limited to functional impairments in basic living skills, instrumental living skills
or social skills, as indicated by an assessment instrument/ approach approved by DMH.
Individualized Areas of Need
Refer to the Initial Assessment to identify symptoms, observable behaviors, clinical areas of need
and elaborate on duration (how long the symptoms/behaviors have been present or observed),
frequency (how often the symptoms/behaviors are present or observed), and how the
symptoms/observable behaviors create a functional impairment for the individual. Symptoms,
behaviors and clinical areas of need should serve as the focus of treatment, services and
supports for individuals.
Interventions, Criteria/Outcomes, Initiation and Target Dates
In order to effectively work toward achieving the long term and short term goal(s) identified by the
individual receiving services, the objectives and interventions must be measurable. Each
objective and intervention must have specific criteria or outcomes which clearly indicate an
objective has been reached or an intervention has been completed. Each intervention must be
Individual Service Plan guidance
numbered, assigned to a service area (eg. Peer Support Services, Therapy Services, Community
Support Services, etc) and have a specified target date for achievement or completion. Services
identified and certified as necessary must be provided to the individual. All services that the
individual is receiving must be indicated in relation to an objective/ intervention.
Diagnosis
Give the written diagnosis and appropriate codes for the individual receiving services.
Community Supports
Community Support Services must be made available to the following populations: adults with
serious mental illness and children/youth with serious emotional disturbance. If the individual
refuses Community Support Services, the refusal must be documented in writing. Community
Support Services must be offered to these specified individuals during the intake process and at a
minimum of every twelve (12) months while they remain in services.
Signatory Authority
Each individual who participates in the development of the Individual Service Plan must sign the
plan as evidence of his/her participation in plan development. If the Individual Service Plan is
developed for adults with a serious mental illness (SMI), individuals with intellectual/
developmental disabilities, children and youth with serious emotional disturbance (SED), or
individuals with a substance use disorder, a licensed Physician, a licensed Psychologist, a
Psychiatric/Mental Health Nurse Practitioner, a Licensed Clinical Social Worker, Licensed
Marriage and Family Therapist, Licensed Professional Counselor, Physician Assistant or
Alzheimer’s Day Program Supervisor (for Alzheimer’s Day programs only) must sign the Individual
Service Plan, certifying the planned services are medically/therapeutically necessary.
DMH Individual Service Plan form
Individual
Service Plan
Name:_______________________________________________
ID Number:___________________________________________
Admission Date:_______________________________________
Date of Plan Implementation_____________________________
□ New □ Re-Write □ Addendum
INDIVIDUAL’S STRENGTHS
LONG TERM GOALS
(include hopes/dreams/goals) SHORT TERM GOALS
IDENTIFIED BARRIERS
(Based on Functional Assessment)
DMH Individual Service Plan form
INDIVIDUAL’S AREAS OF NEED
INDIVIDUALIZED PLAN FOR SERVICES
Objective #1:
Interventions Service Area
Assigned
Criteria / Outcomes for
Completion
Initiation
Date:
Target
Date:
1.
2.
3.
Objective #2:
Interventions Service Area
Assigned
Criteria / Outcomes for
Completion
Initiation
Date:
Target
Date:
1.
2.
3.
Objective #3:
Interventions Service Area
Assigned
Criteria / Outcomes for
Completion
Initiation
Date:
Target
Date:
1.
2.
3.
DMH Individual Service Plan form
DIAGNOSIS
Primary
Diagnosis(es)
Secondary
Diagnosis(es)
Community Support has been offered to me and I choose:
□ YES, I do want to participate (see Recovery Support Plan)
______(initials of individual receiving services)
□ NO, I do NOT want to participate
______ (initials of individual receiving services)
_____________________________ ___________ _____________________________ ___________
Individual Receiving Services Date Parent / Legal Guardian Date
_____________________________ ___________ _____________________________ ___________
Signature / Credentials Date Signature / Credentials Date
_____________________________ ___________ _____________________________ ___________
Signature / Credentials Date Signature / Credentials Date
_____________________________ ___________ _____________________________ ___________
Signature / Credentials Date Signature / Credentials Date
_____________________________ ___________ _____________________________ ___________
Signature / Credentials Date Signature / Credentials Date
_____________________________ ___________ _____________________________ ___________
Signature / Credentials Date Signature / Credentials Date
__________________________________________________________________________ ___________
Physician / Clinical Psychologist / Nurse Practitioner, LCSW, LMFT, Date
LPC, PA, Alzheimer’s Day Program Supervisor
Strikethrough 2016 Individual Crisis Support Plan guidance
Individual Crisis Support Plan
Purpose
Providers must develop an Individualized Crisis Support Plan for each individuals receiving
services in all populations served, including SMI, SED and Substance Use Disorders the
following priority groups:
• Individuals discharged from an inpatient psychiatric facility;
• Individuals discharged from an institution;
• Individuals discharged or transferred from Crisis Stabilization Services; and,
• Individuals referred from Crisis Response Services.
Identifying Information
Record the individual’s name, record number, date the plan was developed and the local toll-
free crisis phone number.
Treatment Information
Record the individual’s diagnosis as indicated on the Individual Service Plan. Explain relevant
history and current potential for crisis situation. List all medications the individual is currently
prescribed. Explain what may be a potential trigger for the individual to regress into a crisis
situation.
Action Steps
List the action steps the individual, crisis response team and family (if indicated) will take in
the event the individual is experiencing a crisis at home or in the community. Include who is
responsible for initiating the response with their phone number.
Requirements
The Crisis Support Plan must be developed within 30 days of admission for all individuals
receiving services except those individuals admitted through crisis services. Crisis Support
Plans must be developed for individuals admitted through crisis services within 72 hours of
admission.
The Crisis Support Plan must be developed by the team of individuals who will have
responsibilities for implementing the Plan in the event of a crisis. The Plan development
team members must have at least a Bachelor’s degree in mental health or a related field and
must sign the Crisis Support Plan where indicated.
The Crisis Support Plan identifies what could go wrong and how people should respond.
Crisis planning includes opportunities for family and team members to practice crisis
response by simulating a crisis in a safe, controlled environment. The Crisis Support Plan
must include who will notify who and when. The Crisis Support Plan must be portable in the
sense that all team members must have a copy to refer to when needed. The Individual
receiving services should also maintain a copy of the plan for reference.
DMH Strikethrough 2016 Individual Crisis Support Plan form
Individual Crisis Support
Plan
Name
ID Number
Date Plan
Developed
Toll-free Crisis
Phone Number
Diagnosis: Current Medications:
Relevant History and Potential Crisis: Known Triggers:
Action Steps for Home Person(s) Responsible and
Phone Number(s)
Action Steps for Community
Locations (specify)
Person(s) Responsible and
Phone Number(s)
Signature of Individual Receiving Services Date Signature/Position Date
Signature/Position Date Signature/Position Date
Recovery Support Plan guidance
Recovery Support Plan
Purpose
The Recovery Support Plan should be completed with the Individual Receiving Services and is
used as a tool to assist the individual in making plans to engage in activities and access
resources designed to help support him/her in achieving and maintaining recovery/resiliency.
The Recovery Support Plan replaces the previous Community Support Plan and the Substance
Abuse Recovery Support Plan. This plan is meant to be a flexible document that expounds
upon the information provided in the Individual Service Plan (ISP). This documentation is
required for individuals receiving Community Supports Services, Recovery Supports Services
and Peer Support Services but can be used in conjunction with any individual’s ISP.
The Recovery Support Plan must be developed within 30 days of admission for all individuals
receiving services.
The Recovery Support Plan must be developed by the team of individuals who will have
responsibilities for implementing the Plan during service delivery. The Plan development team
members must have at least a Bachelor’s degree in mental health or a related field and must
sign the Recovery Support Plan where indicated.
Needs Statement from Initial Assessment and ISP
Record the individual’s Needs Statement from their Initial Assessment and Individual Service
Plan.
Long Term Goal(s) from the ISP
Record the individual’s Long Term Goal(s) from the Individual Service Plan.
Objectives:
All Recovery Support Plans must have individualized objectives and they must be measurable.
Record what the individual hopes to accomplish or achieve while receiving Support Services.
Strategies:
Describe the strategies or activities that the individual will complete to achieve the desired
outcome.
Who is responsible?
Who is responsible for assisting with the completion of these objectives? This can be the
individual themselves, a natural support, or a staff member. Record the person or persons
responsible.
Target completion date
Explain how often activities will be conducted and the expected completion date.
Recovery Support Plan guidance
Signatures
The date, signature, and credentials (if applicable) of all persons responsible for completing
objectives should be recorded.
DMH Recovery Support Plan form
Recovery Support
Plan
Name:_____________________________________________
ID Number:_________________________________________
Needs Statement(s) from Initial Assessment and ISP:
Long Term Goal(s) from ISP:
Objectives:
Strategies:
Who is responsible:
Target Completion Date:
_____________________________ ___________ _____________________________ ___________
Individual Receiving Services Date Parent / Legal Guardian Date
_____________________________ ___________ _____________________________ ___________
Direct Service Provider Date Direct Service Provider Date
Strikethrough 2016 Progress Note guidance
Progress Note
Purpose
All programs must document single therapeutic support interventions and activities that take place
with/for an individual. The Progress Note can also be used “as needed” to provide supplemental
documentation that cannot be adequately captured in the Weekly Progress Note.
Location
Document the location where services were provided.
Time
Document the time services began and ended along with the total amount of time services were
provided.
General
Providers must document therapeutic interventions and activities (such as outpatient therapy,
community support services, supported and supervised living services) utilizing the SAP format.
Summary should address the summary of activities related to the service being provided for eac h
contact/ service event.
Assessment should address the progress made, or lack of progress made, toward the goals and
objectives on the plan directing the treatment, services and/or supports for the individual (ex.
ISP).
Plan should address the plan for future activities related to the service. This can include staff or
individual activities.
Signatures
Staff completing the Progress Note must sign and date the form at the end of each note. The
signature of a supervisor is not required but can be used to document supervision of provisionally
credentialed staff.
DMH Strikethrough 2016 Progress Note form
Progress Note
Name __________________________________
ID Number _____________________________
Service Type ____________________________
Day / Date Location Time Began
(am/pm)
Time Ended
(am/pm)
Total Time
S:
A:
P:
Provider Signature/Credentials
Supervisor Signature (if applicable)
Day / Date Location Time Began
(am/pm)
Time Ended
(am/pm)
Total Time
S:
A:
P:
Provider Signature/Credentials
Supervisor Signature (if applicable)
DMH Strikethrough 2016 Weekly Progress Note guidance
Weekly Progress Note
Purpose
Providers must maintain documentation to verify each individual’s weekly and monthly
progress toward the areas of need identified on his/her Individual Service Plan.
Time
Document the time services began and ended along with the total amount of time services
were provided. Indicate if an individual is absent or if it is a weekend.
Weekly Documentation
The provider must document in SAP format the activities an individual participates in or
completes during the week. All activities must be listed including, community integration, job
exploration, therapeutic activities, etc. Activities should be related and documented to an
individual’s goals/objectives/outcomes stated on the Individual Service Plan.
Staff completing the Weekly Progress Note must sign and date the form at the end of each
week.
Monthly Summary
At the end of the month, a summary of progress or lack of progress toward
goals/objectives/outcomes must be documented utilizing the SAP format.
Staff completing the Weekly Progress Note must sign and date the form at the end of the
month. For Day Treatment Services and Psychosocial Rehabilitation Services, the
Supervisor may use this form as part of the documentation of the required monthly
supervision.
DMH Strikethrough 2016 Weekly Progress Note form
Weekly Progress Note
Name ___________________________________________
ID Number _______________________________________
Service __________________________________________
Attendance during month of in the year of
Days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Time
In
Time
Out
Total
Time
Weekly
Dates Summary of Objective/Activity
1st Week
Objective(s):
S:
A:
P:
Date: Signature/Credential:
2nd Week
Objective(s):
S:
A:
P:
Date: Signature/Credential:
DMH Strikethrough 2016 Weekly Progress Note form
3rd Week Objective(s):
S:
A:
P:
Date: Signature/Credential:
4th Week Objective(s):
S:
A:
P:
Date: Signature/Credential:
5th Week
Objective(s):
S:
A:
P:
Date: Signature/Credential:
Monthly
Summary
S:
A:
P:
Date:
Staff Signature/Credential:
Date: Supervisor Signature/Credential:
DMH Strikethrough 2016 Periodic Staffing Review of ISP guidance
Periodic Staffing/Review of the Individual Service Plan
Purpose
The Periodic Staffing/ Review of the Individual Service Plan (ISP) is used to document periodic
review and revision in order to remain continuously current with regard to the goals and
outcomes the individual receiving services is seeking to achieve. As with the original ISP, all
reviews, revisions, or rewrites of the ISP must be a collaborative effort with the individual and/or
legal representative and the appropriate staff.
Timelines
Review and revision must occur whenever the individual receiving services experiences a
change in his/her life that impacts the goals of their current ISP. Life changes can be expected
to be initially reported in progress notes and may be in one or more of the areas listed below.
At a minimum, the ISP must be reviewed and revised/rewritten annually for adults and every six
months for children and youth.
Changes
Any or all changes in the following areas since the last ISP review must be documented in
specific detail:
• Change in diagnosis
• Change in symptoms
• Change(s) in service activities
• Change(s) in treatment/treatment recommendations
• Other significant life change
Plan Modification
After documenting any and all changes that have occurred since the last ISP review, careful
consideration should be given to the impact these changes have made on the ISP in t erms of
the needs expressed, goals and outcomes being pursued by the individual. The ISP should be
modified or rewritten if needed to ensure ongoing progress toward achievement of the
individual’s ISP goals. If the ISP needs to be rewritten, there must be involvement of the
treatment team and the Physician, Psychologist, Nurse Practitioner, Licensed Clinical Social
Worker, Licensed Marriage and Family Therapist, Licensed Professional Counselor, Physicians
Assistance or Alzheimer’s Day Program Supervisor (Alzheimer’s Day programs only) to
determine medical necessity.
Signatory Authority
Each individual who participates in the staffing/review of the Individual Service Plan must sign
the Periodic Staffing/Review of the ISP form as evidence of his/her participation in the
staffing/review process.
DMH Strikethrough 2016 Periodic Staffing Review of ISP form
Periodic Staffing/
Review of the
Individual Service Plan
Name
ID Number
Current Date
Date of Last
ISP/Review
Time In Time Out Total
Change in diagnosis since last review
Change in symptoms since last review
Change(s) in service activities since last review
Change(s) in household since last review
Change(s) in treatment/
service recommendations since last review
Other significant life change(s) since last review
Comments/Recommendations
Plan Modification No Yes Rewrite Plan
If yes, make additions/ modifications to the existing plan
Individual Receiving Services
Date
Staff Signatures/Credentials Date
Staff Signatures/Credentials
Date
Signature of Parent/Legal Guardian (if applicable) Date
DMH Strikethrough 2016 Readmission Assessment Update guidance
Readmission Assessment Update
Purpose
When an individual has been discharged from a provider agency and seeks to resume services
within one year of the discharge date, a Readmission Assessment Update may be utilized
instead of the Initial Assessment as part of the readmission process to update information that
has changed regarding the individual’s needs and status.
Instructions
Update identifying information and description of need. Document any changes relating to the
individual’s history occurring during the lapse of service.
Description of Need
Record the reason(s) the individual is seeking services.
Status Updates
Any changes relating to individual’s status areas (medical, mental health, substance abuse/use,
social/cultural, educational/vocational) that have occurred during the gap in service must be
documented in detailed narrative format. Responses of “Yes”, “No”, “Present”, “Not Present”
are not acceptable.
Indication of Functional Limitation(s)
An assessment must be conducted and the results documented for the major life areas
specified for each individual seeking readmission to services.
The Child and Adolescent Functional Assessment Scale (CAFAS) is required for all
children/youth receiving mental health services. The CAFAS must be completed within 60 days
for all children/youth receiving mental health services.
An approved functional assessment is required for all adults receiving mental health services.
An approved functional assessment must be completed within 60 days for all adults receiving
mental health services. DMH will review and approve a functional assessment for use with the
adult SMI population.
An approved functional assessment is required for all individuals receiving substance use
disorder services. DMH will review and approve a functional assessment for use with the SUD
population.
Staff Requirement
The Readmission Assessment Update must be completed by an individual with at least a
Master’s degree in mental health or intellectual/developmental disabilities, or a related field and
who has either (1) a professional license or (2) a DMH credential as a Mental Health Therapist
or Intellectual/Developmental Disabilities Therapist (as appropriate to the population being
served) or Alzheimer’s Day Program Supervisor (Alzheimer’s Day Programs only).
DMH Readmission Assessment Update form
Readmission
Assessment Update
Name
ID Number
Readmission Date
Informant: Individual receiving services Other Relationship to individual:
LEGAL INFORMATION
Name of Guardian / Custodian:
Guardianship Documentation Verified:
□ Yes □ No
Guardian / Custodian Address: Guardian / Custodian Phone Number:
DESCRIPTION OF NEED
What is your reason for seeking services today?
What specific needs are you currently having?
Why was the record closed?
Status Updates
Medical Status (Record current medications on the Medication/Drug Use Profile):
Allergies
Physical impairments
Surgeries
Special diets
Appetite issues or problems
Sleep issues or problems
Current or chronic diseases (high blood pressure, cancer, other)
Other pertinent medical information
(For women only) Are you pregnant?
DMH Readmission Assessment Update form
Mental Health Status:
Recent psychiatric issues
Homicidal behavior
Suicidal behavior
Other counseling and/or therapeutic experiences
Traumatic Event Or Exposure Status (Note Or Describe As Appropriate):
Serious accidents
Natural disaster
Witness to a traumatic event
Sexual assault
Physical assault (with or without weapon)
Close friend or family member murdered
Homeless
Victim of stalking or bullying
Other (specify)
Substance Use Status:
Use or abuse by the individual
Age of onset
Patterns of use/abuse: How much?
How often?
Methods of use: smoke snort inject insert inhale
Resulting circumstances?
DMH Readmission Assessment Update form
Social/Cultural Status:
Immediate household/family configuration
Marital status
Relationship with family members
Type of family support available
Type of social support available
Types and amounts of social involvement/leisure activities
Any religious/cultural/ethnic aspects that should be considered
Educational/Vocational Status:
Highest grade completed
If currently in school (child or youth), regular classroom placement? Yes No
List all additional educational services child is receiving
Any repeated grades? No Yes Explain:
Suspensions/expulsions? No Yes Describe:
Other education issues
Vocational training, if any
Current employment
Previous employment
Comments:
Indication Of Functional Limitation(s):
(Check Major Life Areas Affected)
Basic living skills (eating, bathing, dressing, etc.)
Instrumental living skills (maintain a household, managing money, getting around the community, taking
prescribed medications, etc.)
Social functioning (ability to function within the family, vocational or educational function, other social
contexts, etc.)
Signature/Credentials Date
DMH Substance Use Disorder Specific Assessment guidance
Substance Use Disorder Specific Assessment
Purpose
This information must be documented if substance use disorder services are provided or if
substance use disorder is suspected. This form must be completed in addition to the Initial
Assessment and is applicable to youth and adults. This form should specifically address how
substance use history has created impairment.
Treatment Modality Abbreviations
OP Outpatient Services
IOP Intensive Outpatient Services
PR Primary Residential
TR Transitional Residential
PHP Partial Hospitalization
Detailed Substance Use History
This section of the assessment allows the evaluator to document details of the individual’s
history of substance use. The evaluator should document the substance use; include the age of
onset, and the pattern of use.
Prior Substance Use Disorder Treatment
This section of the assessment allows the evaluator to document the individual’s prior history of
substance use disorder treatment. Location, date, completion of prior treatment, outc ome and
length of treatment should all be documented in this section.
Evaluator’s Assessment of Attitude
This part of the assessment allows the evaluator to document the individual’s level of denial
and/or willingness to change with regard to their use of alcohol and other drugs.
Family History of Alcohol and/other Drugs
This section of the assessment allows the evaluator to document the individual’s family history
of substance use.
DMH Substance Use Disorder Specific Assessment form
Substance Use Disorder
Specific Assessment
Name
ID Number
Date
Time In: Time Out: Total:
Admission Date: Treatment Service: OP___ IOP ___PR ___TR ___ PHP ___
DUI Specific History
DUI Offender? First time 2+Offenses Not applicable
Is the individual’s driver’s license currently suspended?
Yes No
If yes, was the individual enrolled in or referred to a certified DUI Treatment Program? Yes No
Substance Use History (Explain use, drug of choice, include age of onset, and pattern of use)
How much money would you say you’ve spent on substances during the past 30 days? _________________________
What was your longest period of abstinence? __________ How was abstinence maintained? ___________________
On a scale of 1-5, how important is treatment to you now? (5 being most important) ____________
Prior Substance Use Disorder Treatment (Location, date, completion status, outcome, length of recovery after treatment)
Evaluator’s Assessment of Individuals Attitude Regarding Use of Alcohol and/or Other Drugs
Level of Denial: (circle one) None Low Moderate High Unsure
Willingness to Change: (circle one) None Low Moderate High Unsure
Family History of Alcohol and/or Other Drugs
SIGNATURES / CREDENTIALS
Staff Signatures/Credentials Date
Section CD
As Needed
Substance Use Disorder Specific Assessment
Initial Assessment and Crisis Contact Summary
Readmission Assessment Update
Serious Incident Report
Medical Examination
Documentation of Healthcare Provider Visits
Self-Administration Medication Log
Telephone/ Visitation Agreement
Search and Seizure Report
Physical Restraint/Escort Log
Time Out Log
Seclusion Behavior Management Log
Service Termination/ Change Summary
Provider Discharge Summary
DMH Initial Assessment and Crisis Contact Summary for Crisis Response Contacts guidance
Initial Assessment and Crisis Contact Summary for Crisis
Response Contacts
Purpose
The Initial Assessment and Contact Log for Crisis Response Contacts is used to document the
provision of emergency/crisis contacts with individuals seeking services from a provider who are
not already receiving other mental health services from the provider.
Identifying Information
Record the name of the individual receiving crisis services. Issue and record a client
identification number. The Date of Contact will also be the Date of Admission. Enter the
individual’s Social Security and Medicaid numbers. Record the time the contact began and
ended. Indicate the type of crisis service delivered (Mobile Crisis Services, Telephone Crisis
Response, or Walk-in Crisis Response). If the contact was made Face to Face, include the
location where the contact took place and if the contact was made by phone, include the phone
number of the caller. List by relationship any other individuals involved with the emergency/
crisis or any referral source (i.e. sister).
Presenting Need
Document the reason(s) the individual is seeking emergency/crisis services.
Actions Taken by Staff
Document the steps taken to assess and resolve the emergency/crisis. Record if anyone was
contacted on behalf of the individual in crisis. If no one else was notified, indicate why it was not
necessary.
Initial Behavioral Observations
Document the staff’s impressions of the individual’s behaviors. Include additional comments at
the end of the section.
Resolution
Document the condition of the individual at the end of the contact; indicate where the individual
and/or family were referred and if a subsequent appointment was made for the individual with
the provider, note the date and time of the appointment.
Required Data
This information is required by the Department of Mental Health and is to be submitted to the
Central Data Repository. If you are unable to obtain this information, please mark as “unknown.”
The staff person responding to the individual in crisis and documenting the contact must sign
this form and include their professional credentials.
DMH Initial Assessment and Crisis Contact Summary for Crisis Response Contacts form
Initial Assessment
and Crisis Contact
Summary for Crisis
Response Contacts
Name:_____________________________________________
ID Number:_________________________________________
Contact/ Admit Date:_________________________________
Medicaid #:_______________ SS#______________________
Time In: Time Out: Total Time:
Type of Contact:
□ Mobile Crisis Service Location: _________________________
□ Telephone Crisis Response Number: __________________________
□ Walk-in Crisis Response
Others Involved:
Presenting Needs (the factors indicating a need for Crisis ResponseServices)
Actions Taken by Staff:
Initial Behavioral Observations
Speech: Appropriate Slowed Mechanical Rapid Other
Behavior: Appropriate Withdrawn Bizarre Volatile Other
Appearance: Appropriate Disheveled Unclean Inappropriately dressed
Other Phone Contact
Mood: Appropriate Manic Depressed Labile Irritable Other
Affect: Appropriate Flat Labile Other
Oriented to: Place Time Person Situation Other
Thought Content: Appropriate Incoherent Obsessive Delusional Paranoid Other
Memory: Appropriate Repressed Confused Other
Intelligence: Average Above Average Below Average
Judgment/Insight: Appropriate Impaired Suicidal Homicidal Other
Hallucinations: Auditory Visual Tactile Other
Comments:
DMH Initial Assessment and Crisis Contact Summary for Crisis Response Contacts form
Resolution
Condition of the Individual at Conclusion
of Contact
Referrals Made by Staff
Appointment with the Provider
Date:
Time:
Required Data
(Please mark as Unknown if Information is Unavailable)
Birth Date:
Age: Gender:
Race:
Education Level: Marital Status:
County of Residence:
Living Arrangement: Type of Residence:
Employment Status:
Legal Status: Primary Income Source:
Annual Income:
# in Household: SSI/SSDI Eligibility:
Veteran Status:
Physical Impairments: Service Code:
Staff Signature/Credentials:
DMH Strikethrough 2016 Serious Incident Report guidance
Serious Incident Report
Date of Report: The date this report was written
Date of Incident: The date the incident occurred
Time of Incident: The time the incident occurred; make sure to check am or pm
Provider Name: The name of the Provider (example: Region X Mental Health)
Program Name: The Name of the specific program within the Provider agency (example:
Golden Rainbows PSR). In some instances the Provider Name may
actually be the Program; for instance with a smaller private Provider.
Service: The name of the specific Service for which the Program is certified.
(example: Psychosocial Rehabilitation Services)
Reported by: The name of the person completing the incident report. If the incident was
reported to the person completing the form, the names of the initial
reporter(s) will be included in the Description of Incident, Person(s)
Involved in Incident and Witnesses sections.
Event Codes:
SU Suicide attempt, or Completed Suicide
EMG Treatment received at an Emergency Room. Do not include trips to
Emergency Room that do not result in treatment
SR Any Seclusion or Restraints
ACL An unexpected absence from a community living program
ABN Any abuse or neglect of an individual receiving services, either suspected
or confirmed
WKV Any workplace violence occurring on the property of a certified Provider, or
at a Provider sponsored event
ELP Elopement of an individual receiving services
DIS Any Disaster that effects the normal functioning of a certified Provider. Do
not include reports of Disaster Drills.
MED Any confirmed Medication Errors
DMH Strikethrough 2016 Serious Incident Report guidance
INJ Any serious injuries sustained by an individual receiving services. Minor
injuries need not be reported. Injuries resulting in fractures, stitches or
sutures (or preliminary x-rays to determine extent of injury) are considered
serious.
EVC Any event that requires evacuation of the premises. Do not include drills.
OTH Any incident that is deemed serious by the Provider, but is not listed above.
Details should be given in the Description of Incident section.
Description of Incident:
Give as detailed an account as possible of the incident in the space
provided.
Person(s) Involved In Incident:
List first and last names (if known) of all individuals involved in the incident.
This should include all alleged victims and alleged perpetrators (if
applicable). Use the provided check boxes to indicate whether or not the
individual(s) is on the ID/DD waiver.
Witnesses: List the names of any verified or potential witnesses to the incident.
Possible Contributing Factors:
List any identified possible contributing factors to the incident. (example: a
wet floor that resulted in a fall which caused a hip fracture)
Consequences/Follow Up Actions:
List any actions that the Provider has taken since the incident occurred to
lessen the chances of it happening again. Any disciplinary actions that
have been taken should also be included (example: Administrative Leave)
Any and all authoritative bodies to which this incident has been reported and the
dates of those reports. (example: Department of Health, 12/3/12; Attorney General’s
Office, 12/4/12)
Has A Report Been Made Within the Agency:
Mark “yes” here to acknowledge that a report of the incident has been
made to the proper authoritative body within the agency. For example, the
agency may have a Risk Management Department to which all incidents
should be reported internally. Or, if the agency does not have a formal Risk
Management Department, mark “yes” if a report has been made to the
Executive Director.
DMH Strikethrough 2016 Serious Incident Report guidance
If yes, to whom has the Report of Incident been made?
Provide the names and positions of each person to whom the incident has
been reported.
At the time of this report, is the Agency conducting an Internal Investigation?
Mark “yes” if the agency is conducting its own internal investigation.
If yes, is the Agency’s Investigation Active or Closed?
If the investigation is ongoing, mark “Active.” If the investigation has been
completed, mark “closed.”
Is this a high visibility Incident?
Visibility refers to the likelihood that the incident will be reported by the
media. If there is a good possibility that the incident will be reported in the
media, check “yes.”
DMH Strikethrough 2016 Serious Incident Report form
Serious Incident Reporting Form
Date of Report:
Date of Incident: Time of Incident: □ am □ pm
Provider Name:
Program Name:
Service:
Reported By:
Event Codes (Check All That Apply)
□ SU Suicide (Attempt or Completed)
□ EMG Emergency Room Treatment □ SR Seclusion/Restraint
□ ACL Absence from Community Living
□ ABN Abuse/Neglect □ WKV Workplace Violence
□ ELP Elopement
□ DIS Disaster □ MED Medication Error
□ INJ Injury
□ EVC Evacuation □ OTH Other (describe below in narrative)
Description of Incident:
DMH Strikethrough 2016 Serious Incident Report form
Page 1 of 2
Individual(s) Involved In Incident (include case # with name if known)
Is this individual on the
ID/DD Waiver?
□ Yes □ No
If yes, was Support Coordination notified?
□ Yes □ No
Witnesses:
Possible Contributing Factors:
Consequences/Follow Up Actions:
Any and all authoritative bodies to which this incident has been reported and the dates of those reports.
Has a Report of Incident been made within the agency? □ Yes □ No
If yes, to whom has the Report of Incident been made?
____________________________________________ ____________________________________________
Name Position
____________________________________________ ____________________________________________
Name Position
____________________________________________ ____________________________________________
Name Position
At the time of this report, is the Agency conducting an Internal Investigation? □ Yes □ No
If yes, is the Agency’s Investigation Active or Closed?
Is this a high visibility Incident? □ Yes □ No
DMH Strikethrough 2016 Medical Examination Report guidance
Medical Examination
The DMH Operational Standards require that each individual served in any DMH certified
supervised living and residential treatment program must have a documented Medical
Examination in the individual’s record. The examination must take place within 72 hours of
admission or not more than 30 days prior to admission and be conducted by a licensed
physician, certified nurse practitioner or certified physician’s assistant. No individual may
remain in the program unless a medical examination is completed and documented.
Components of the medical examination and report include but are not limited to:
• Individual’s personal information
• Physician’s information (name, contact information, other)
• Examination information (blood pressure, pulse, height, weight, current diagnosis,
current medications, statement of freedom from communicable disease, physical and
dietary limitations, and allergies)
The medical examination report must be signed by a licensed physician/nurse practitioner/
certified physician’s assistant.
For ID/DD Waiver, the medical exam obtained as part of the admission process can be used
for up to one year from the date of the exam.
Medical Examination
Physician’s Name:
Date of
Evaluation
Physician’s Address:
Physician’s
Phone #
Person Receiving Examination: DOB
Age
Height: Temperature: Blood Pressure:
Weight Head
Circumference:
General Appearance:
Check Normal Abnormal Remarks
1. Head
2. Fontanelle
3. Skin
4. Lymph Nodes
5. Facies
6. Eyes a. Right
b. Left
7. Ears a. Right
b. Left
8. Nose
9. Mouth
10. Teeth and Gums
11. Tongue
12. Pharynx & Palate
13. Neck
14. Thorax
15. Heart
16. Lungs
17. Abdomen
18. Breasts
19. Genitals
20. Spine
21. Extremities
22. Neurological:
a. Cranial
b. Reflexes
c. Neuromuscular
d. Stand and Gait
e. Mood/ Behavior
23. Urine
24. CBC
Current Medications:
Special Dietary Requirements:
Based upon the results of this examination and the additional information provided, this person is
sufficiently free from disease and does not have any health conditions that would create a hazard
for other people.
_______________________________________ ___________________
Signature of Healthcare Provider Date
DMH Strikethrough 2016 Documentation of Healthcare Provider Visits guidance
Documentation of Healthcare Provider Visits
Purpose
This form ensures that Supervised Living Services, Shared Supported Living Services,
Supported Living Services and Therapeutic Group Home Services providers are assisting
individuals in accessing routine healthcare services. This form is required for Supervised
Living Services and Therapeutic Group Home Services but can be used by any service
provider to document access to routine healthcare.
Timelines
This form must be completed each time the individual interacts with a healthcare provider of
any type.
Name/Type of Healthcare Provider
List the name and type of the healthcare provider. List the credential(s) of the provider.
Types of healthcare providers are physicians, nurses, pharmacists, optometrists, etc.
Reason for Visit
Provide a detailed description of why the individual is meeting with the healthcare provider.
Outcomes/Results
Provide a detailed description of the outcome of the meeting with the healthcare provider.
This includes any diagnosis(es), procedures conducted during the visit, and any
procedures/follow-up required. If a procedure of any type is scheduled, provide the date.
Medications
Medications ordered or changed must be documented on the Medication/ Emergency
Contact Information Form.
Change(s) in Existing Prescriptions
If the healthcare provider changes a currently prescribed medication(s), provide the same
information as required above and include the reason for the change(s). Update the
Medication/Emergency Contact Information form as needed.
DMH Strikethrough 2016 Documentation of Health Care Provider Visits form
Documentation of Healthcare
Provider Visits
Name
ID Number
Date
Name of Health Care Provider:
Type of Health Care Provider:
Reason for Visit:
Outcomes/Results
Diagnosis(es) (if applicable):
Procedure(s) conducted:
Procedure(s) ordered: Date:
Describe any needed follow up, including dates:
Source of Information
Provider/ Staff participated in the visit
Family/ Guardian participated in the visit and provided results of the visit to the program
Provider assisted with access to healthcare but did not participate in the visit
Release of records completed
Records requested from healthcare provider
Staff Signature/Credential Date
DMH Strikethrough 2016 Self Administration Medication Observation Log guidance
Self-Administered Medication Observation Log
Purpose
This form should be used to document all medications that are self-administered in day
programs and in all Supervised Living settings. This form is not intended for use by nurses
administering medication.
Forms can be prepared or generated by the pharmacy for up to one month for regularly
prescribed medication. Agencies must have policies and procedures to account for changes to
medications mid cycle. Signatures must be original at the time of observation.
Identifying Information
Enter the name and ID number of the individual.
Documentation
The provider must enter all required information.
Signature
The signature of the staff completing the log must be included. Two or more medications,
administered at the same time, can be signed with a single signature on a diagonal line across
rows. Signatures must be original and cannot be typed.
DMH Strikethrough 2016 Self Administration Medication Observation Log form
Self-Administered
Medication
Observation Log
Name __________________________________
ID Number ______________________________
Program ________________________________
Time/ Date Medication Dosage Individual Signature
Staff Observation
Signature/
Credential
DMH Strikethrough 2016 Telephone and Vistation Agreement guidance
Telephone/Visitation Agreement
Purpose
Individuals receiving services have the right to privacy as it pertains to the acknowledgement
of their presence in the program with regard to visitors as much as physically possible.
Individuals receiving services also have the right to determine from whom they will accept
phone calls and/or visitation. The fully executed Telephone/Visitation Agreement serves to
allow acknowledgement of the individual’s presence in the program to those listed in and
according to the terms detailed in the Agreement. This form is required for Substance
Use Residential Treatment programs, Supervised Living programs, Shared Supported Living
programs and Crisis Stabilization programs.
Timeline
The Telephone/Visitation Agreement must be completed upon admission/re-admission when
required. The Agreement must be reviewed or updated upon the request of the individual
receiving services.
Telephone Calls
Check only the box that applies. If the individual agrees to accept all telephone calls
regardless of source, the first box should be checked. If the individual agrees to only accept
calls from specific individuals, the second box should be checked and the name(s), phone
number, and relationship of those individuals must be documented.
Visits
Check only the box that applies. If the individual agrees to accept all visitors, the first box
should be checked. If the individual agrees to only accept visits from specific individuals, the
second box should be checked and the name(s), phone number, and relationship of those
individuals must be documented.
Staff and Facility-specific Visitors
By signing the Telephone/Visitation Agreement, the individual receiving services also
acknowledges their understanding that the program cannot be held responsible for
disclosures made by other individuals who may enter the premises.
DMH Strikethrough 2016 Telephone and Visitation Agreement form
Telephone/Visitation
Agreement
Name
ID Number
While receiving
services from:
(Provider)
I give consent to receive phone calls and visits from those specific persons named in the sections below
and who are outside the program/facility for support and coordination of my treatment services.
C
I agree to have my participation in this program acknowledged and accept telephone calls from any
individuals.
C
I agree to have my participation in this program acknowledged and accept telephone calls only from
the following named individuals:
Name Telephone Number(s) Relationship
C
I agree to accept any individual as a visitors.
C
I agree to accept as visitors the following named individuals only:
Name Telephone Number(s) Relationship
I understand this consent will expire upon my discharge from the program. I may revoke this consent at
any time except to the extent that action has already taken place.
I understand that interns and delivery/maintenance people enter the premises on occasion and I will not
hold the service provider staff responsible for any visitors that may disclose my presence in this
program.
Individual Receiving Services Date Authorized Representative Date
Signature/Credential Date Relationship to Individual
DMH Strikethrough 2016 Search and Seizure Report guidance
Search and Seizure Report
Purpose
The form serves as documentation that a search of an individual and/or his/her possessions
and/or space was conducted by a DMH certified provider. A separate form must be completed
for each individual receiving services who is included in the search.
Reason for the Search
Explain the specific reason the search was conducted.
Description of Search
Describe, in detail, all aspects of the search. Indicate the type of search conducted. Document
the specific location (room, building, program area, other), specific items searched, method of
search, and duration of search.
Items Seized
List all of the items seized as a result of the search. Specify source or location of items seized
if items were seized from more than one location or source.
Staff Involvement
The staff person who authorized the search is to sign the form and list his/her credentials and
position title. The same is true for any other staff involved in or witnessing the search.
DMH Strikethrough 2016 Search and Seizure Report form
Search and Seizure
Report
Name
ID Number
Date
Time AM PM
Reason for Search
Description of Search
Type of Search
Person Room Locker Possessions Other
Location
List of Items Seized and Source(s) of Items
Staff Involvement
Authorized By
Signature/credentials/position title
Conducted By
Signature/credentials/position title
Other person(s) involved in or witnessing the search (signature/credential/position title):
DMH Strikethrough 2016 Physical Escort Log guidance
Physical Escort Log
Purpose
When an individual is physically escorted away from a service or living area due to
inappropriate behavior, the intervention must be documented. A physical escort is the
temporary holding of the hand, wrist, arm, shoulder, or back for the purpose of inducing an
individual who is acting out to walk to a safe location.
Identifying Information
Enter the name and record number of the individual being escorted.
Presenting Need
The time, date and detailed description of the events necessitating an escort must be
documented. Describe in detail the individual’s behavior and the type of escort used. All staff
physically involved in the escort must be documented. Describe all other attempts to deescalate
the individual’s behavior. If less restrictive methods of de-escalation are bypassed, explain staff
reasoning. The supervisory staff person must document the face- to-face assessments provided
during the escort, including the time the assessments began and ended. List all dates the
individual was escorted within the last thirty (30) days. Indicate any treatment recommendations
and date Individual Service Plan was modified (if necessary.) The primary staff implementing
the escort must sign the documentation. Staff who witnessed but did not participate in the
escort must also sign the finalized log.
Requirements
Physical Escort cannot be utilized more than three (3) times in a thirty (30) day period unless a
Behavior Support Plan has been developed and approved by the program’s Clinical Director
and ordered by a physician or other licensed practitioner. Physical Escort cannot be used as
part of a standing order or on an as needed basis. If an individual is physically escorted, the
treating physician must be consulted within twenty-four (24) hours.
Timeline
Documentation of the physical assessments must take place when they occur. The form must
be completed in its entirety by the end of the working day in which the intervention took place.
DMH Strikethrough 2016 Physical Escort Log form
Physical
Escort Log
Name
ID Number
Date
Page 1 of 2
Time intervention began: AM/PM ended: AM/PM
Describe the precipitating events necessitating escort:
Describe the behavior warranting escort:
Describe type of escort used:
List all staff members (regardless of position) that were involved in escort:
Describe ineffective/less restrictive alternatives attempted prior to escort:
Describe individual’s behavior during escort:
DMH Strikethrough 2016 Physical Escort Log form
Page 2 of 2
Supervisory staff person’s face-to-face assessment of the individual’s mental and physical well
being during escort:
Time 1st assessment began: AM/PM Ended: AM/PM
Time 2nd assessment began: AM/PM Ended: AM/PM
Time 3rd assessment began: AM/PM Ended: AM/PM
Signature/credentials of
supervisor staff:
Date(s) individual restrained in
the last 30 days:
Is a Behavior Support Plan warranted? Yes No
Name of treating physician consulted: Date: Time:
Treatment Recommendations:
Date Individual Service Plan Modified:
Signature of Staff Implementing
Restraint/Escort ______________________________________________
Signature(s) of Other Staff Witness(es)
______________________________________________
______________________________________________
______________________________________________
DMH Strikethrough 2016 Time Out Log guidance
Time Out Log
Purpose
When an individual is placed in time out due to inappropriate behavior, the intervention must be
documented.
Identifying Information
Enter the name and record number of the individual being placed in time out.
Presenting Need
The time, date and detailed description of the events necessitating the time out must be
documented. Describe in detail the individual’s behavior. All staff physically involved in the time
out must be documented. Describe all other attempts to de- escalate the individual’s behavior. If
less restrictive methods of de-escalation are bypassed, explain staff reasoning. Document the
visual assessments provided during the time out. Indicate any treatment recommendations and
date Individual Service Plan was modified (if necessary.) The primary staff implementing the
restraint/escort must sign the documentation. Staff who witnessed but did not participate in the
restraint/escort must also sign the finalized log.
Requirements
The use of time out must be justified and approved in the Individual Service Plan. Prior to the
use of time out, there must be a written Behavior Support Plan, which is developed in
accordance with the Individual Service Plan, and must be approved by the program’s clinical
director. An individual cannot be placed in timeout for more than one (1) hour. The individual
must be visually observed by staff during time out at least once every twenty (20) minutes.
Time out cannot be used for persons who have IDD.
Timeline
Documentation of visual assessments is made at the time of each observation. The form must
be completed in its entirety by the end of the working day in which the time out took place.
DMH Strikethrough 2016 Time Out Log form
Time Out Log
Name
ID Number
Date
Time intervention began: AM/PM ended: AM/PM
Describe the precipitating events necessitating time out
Describe the behavior warranting time out
Describe ineffective/less restrictive alternatives attempted prior to time out
Describe individual’s behavior during time out, based on visual assessments
Does the Individual Service Plan require modification? Yes No
Signature of Staff Implementing Time Out Signature of Staff Observing Time Out
Signature/credentials of Supervisory Staff
DMH Strikethrough 2016 Seclusion Behavior Management Log guidance
Seclusion Behavior Management Log
Purpose
The DMH only allows seclusion to be used in a Crisis Stabilization Unit (CSU) and only in
accordance with the order of a physician or other licensed independent practitioner, as
permitted by State licensure rules/regulations governing the scope of practice of the
independent practitioner. Programs utilizing Seclusion as part of an approved Individual
Service Plan (ISP) must document all aspects of the Seclusion intervention using the
Seclusion Behavior Management Log. There must be a written Behavior Support Plan
developed in accordance with the ISP and with signature approval by the Clinical Director.
Seclusion cannot be used for persons who have IDD.
Timeline
The Seclusion Behavior Management Log must be completed during the Seclusion
intervention in order to accurately record all aspects of the intervention. Each written order
for Seclusion must be limited to four (4) hours. After the original order expires, a physician or
licensed independent practitioner as provided above must see and assess the individual in
Seclusion before issuing a new order. Staff must observe the individual in seclusion every
15 minutes and record the observation.
Completion of the Log
The time the Seclusion intervention began and ended must be documented.
The precipitating event(s) and behavior(s) causing the Seclusion intervention to be
implemented must be documented in detail.
The less-restrictive interventions that were implemented prior to the use of Seclusion must be
documented in detail.
Visual observation by staff while the individual is in Seclusion and a description of the
individual’s behavior while in Seclusion must be documented in detail.
Staff Signatures
The Seclusion Behavior Management Log must be signed by both the staff person
implementing the Seclusion and the staff person observing the Seclusion.
DMH Strikethrough 2016 Seclusion Behavior Management Log form
Seclusion
Behavior
Management Log
ID#
Name of Individual Being Placed in Seclusion
Time Intervention Began: Ended: Date:
Precipitating Events Necessitating Seclusion:
Behavior Warranting Intervention:
List all Staff (regardless of position) that were involved in seclusion:
Ineffective Less Restrictive Alternatives Attempted Prior to Intervention:
Description of Individual’s Behavior During Seclusion:
Signature of Staff Implementing Seclusion Signature of Other Staff Witness(es)
Physician or Other Licensed Practitioner’s Evaluation of the Need for Seclusion (within one hour
of onset):
Signature of Physician or other Licensed Practitioner
15 Minute Observations Indicated by Staff Signature
1. 7.
2. 8.
3. 9.
4. 10.
5. 11.
6. 12.
DMH Strikethrough 2016 Service Termination Change Summary guidance
Service Termination/Change Summary
Purpose
Documentation must be provided and maintained when an individual receiving services
transfers between services or between service staff within a provider agency. The Service
Termination/Change Summary serves to document an individual’s change(s) of service(s) with
the current provider which may include transfers from one program or service area to another,
as well as transfers from one staff member to another .
For example: if an individual receives Service A and Service B and will no longer receive
Service A- a Service Termination/ Change Summary must be completed for Service A.
Service(s) initiated must be part of the Individual Service plan. If they are not on the ISP at the
time of change, a revision to the ISP must be completed and certified by those with signatory
authority and signed by the individual receiving services or legal representative.
Service Termination/Change Information
The staff member completing the Service Termination/Change Summary must provide as much
information as necessary to clearly describe the transfer that is taking place. It must be
documented if the transfer is expected to be temporary or permanent, with dates provided when
appropriate or available.
Date of Transfer
The date must indicate the point at which the transfer will become effective. One Service
Termination/Change Summary can be used for more than one service change that all become
effective the same date. Separate forms must be used for transfers that have different effective
dates.
Signatory Authority
The staff member authorizing the change must sign and date the form.
DMH Strikethrough 2016 Service Termination Change Summary form
Service
Termination/Change
Summary
Name
ID Number
Date
Service Termination
Service Change
Effective Date of Service Change/Termination:
___________________
Service Termination or Change is expected to be Temporary Permanent
Reasons for Service Termination/ Change (Check all that apply):
Change in Diagnosis Change in Symptoms Change in Service Activities
Change in Treatment Recommendations Appropriate for Less Intensive Service
Change in Service Staff
Other_________________________________________________
List Service(s) Discontinued
List Service(s) Initiated
Service Change Instructions or Information:
Signature/Credentials Date
DMH Strikethrough 2016 Provider Discharge Summary guidance
Provider Discharge Summary
Purpose
When an individual is no longer receiving services from the agency, a Discharge Summary must
be completed and placed in the individual’s record. The Discharge Summary must be completed
to summarize the services provided, the reason for the discharge from the provider agency, and
any referrals made at the time of discharge.
Timeline
The effective date of the discharge must be documented.
Reason for Discharge
Indicate which category most appropriately describes the reason for discharge.
Referral Information
If the individual was referred to another provider or to other services, this should be indicated by
selecting one or more categories that most appropriately describes the service or provider
referral(s).
Instructions/Additional Information
If any instructions were provided to the individual or legal representative at the time of discharge,
these must be described and individual receiving information must sign to acknowledge.
Additional information specific to the discharge may be included.
If the individual participates in the ID/DD Waiver program, a copy of this form must be provided to
the Individual’s Support Coordinator within 5 days of discharge.
DMH Strikethrough 2016 Provider Discharge Summary form
Provider Discharge
Summary
Name
ID Number
Date
Effective Date of Discharge
Reason For Discharge:
Evaluation Only Moved from service area
Treatment Completed Deceased
Provider Terminated Treatment No contact in 12 months
Individual Referred Elsewhere Individual requested discharge
Other _______________________
Referred To:
DMH Behavioral Health Program Family/Friend Private PRTF
Other MS CMHC School/Education Private ICF/IDID
DMH IDD Program Employer/EAP Other_____________
Private Psychiatric Hospital Police / Sheriff
Other MH Provider Courts/Corrections
Other IDD Provider Probation/ Parole
Other A&D Provider Self Help Program
Gen/Hospital/Other Health Voc Rehab/Job Placement
Self Licensed Personal Care Home
Discharge Instructions provided to Individual Legal Representative
Discharge Instructions/Additional Information:
Individual/Legal Representative Date
Signature/Credentials Date
Section ED
Day Service Programs
Acute Partial Hospitalization Services Summary Note
Individual Recovery Action Plan
DMH Strikethrough 2016 Acute Partial Hospitalization Services Summary Note guidance
Acute Partial Hospitalization Services Summary Note
Purpose
Documentation must be maintained when an individual receives Acute Partial Hospitalization
Services. There must be documentation of medical supervision and follow along to include
on-going evaluation of the medical status of the individual. Support services for families and
significant others must be documented. Discharge criteria and follow-up planning must be
documented.
Identifying Information
Record the name, record number, date of service and total amount of time the individual
received the service.
Services
Indicate which services were provided during the day by checking the appropriate box,
specify the time the service began and ended and list the name of the staff providing the
service.
Therapeutic Activities Provided
List all activities the individual participated in during the day, specify the time the activity
began and ended and list the name of the staff providing the service.
Daily Summary Note
The Master’s level staff must summarize the progress of the individual receiving services in
SAP format as it relates to the Individual Service Plan.
Timeline
APH Services must be documented daily with a summary note that records services
provided.
DMH Strikethrough 2016 Acute Partial Hospitalization Services Summary Note form
Acute Partial Hospitalization
Services
Summary Note
Name
ID Number
Date
Total Time
Services Check Time In Time Out Name of Service Provider
Medical Supervision
Nursing
Intensive Psychotherapy
Individual Therapy
Group Therapy
Family Therapy
Therapeutic Activities Provided
Activity Time In Time Out Name of Activity Coordinator
Daily Summary Note
S
A
P
Signature/Credential
DMH Individual Recovery Action Plan guidance
Purpose
Individuals attending the PSR program must have a Wellness Recovery Action Plan
(WRAP), Person-Centered Plan (PCP), or an IRAP (Individual Recovery Action Plan).
Individuals must participate in the development of his/her plan.
The IRAP mu st be reviewed and revised when the problems or goals change or as
needs of the individual change. At a minimum, the IRAP must be reviewed and
revised/rewritten annually.
Definition of Quality of Life
Individuals must define what he/she considers quality of life.
Barriers to Quality of Life
List barriers which prevent the individual from achieving the quality of life he/she
desires.
Goal
List the goals that are the focus of PSR services.
Action Step to Obtain Goal
List the action steps that ne ed to be accomplished in order to achieve the goal(s).
Address the identification and integration of natural supports to connect to the
community and the utilization of formal and informal resources to support goals and
desired outcomes.
Desired Outcome:
List the individual’s desired outcomes.
Date Goal Achieved
Document the date the goal was achieved.
Individual Recovery Action Plan
DMH Individual Recovery Action Plan form
Individual Recovery Action Plan
Name ___________________________________________________
ID Number _______________________________________________
Date ____________________________________________________
Definition
of Quality
of Life
Barriers
to Quality
of Life
Goals
Dates Achieved
Action
Steps
DMH Individual Recovery Action Plan form
Linked and
Followed
up to
Resources
In
Community
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
PSR
Staff: Date:
Individual
Receiving
Services: Date:
Section FE
Mental Health Services
Adult Making A Plan (AMAP) Case Summary
Adult Making A Plan (AMAP) Monthly Reporting
Crisis Stabilization Services Daily Note
Adult Pre-Evaluation Screening
Youth Pre-Evaluation Screening
Violence Risk Assessment for Certified Holding Facility
Suicide Risk Assessment for Certified Holding Facility
DMH Adult Making A Plan Case Summary guidance
Adult Making A Plan (AMAP) Case Summary
Purpose
Adult Making a Plan (AMAP) Teams address the needs of adults with serious mental illness
who require services from multiple agencies and multiple program systems due to
multiple/frequent in-patient treatment admissions or commitments. The purpose of the AMAP
Team is to develop and implement new and different systems of wrap- around support in order
to treat individuals in the community rather than an institutional setting. All Community Mental
Health Centers must document participation in at least one AMAP Team in their region.
Documentation
If DMH funds are utilized to assist individuals referred to the AMAP Team, all questions in all
sections of the Case Summary form must be answered in as much detail as possible in order to
justify the need for AMAP Team intervention.
Timeline
The AMAP Case Summary form must be completed, attached to the Mobile Crisis Response
Team (M-CeRT) cash request, and submitted to the Department of Mental Health by the 15 th of
the following month.
DMH Adult Making A Plan AMAP Case Summary form
Signature of AMAP Team Coordinator _ __________ __________
AMAP Team
Case Summary Form
Name: ______________________
Date of Review ______________
Why was this individual referred to the AMAP Team? (How many inpatient tx/over what period of time)
Why was this individual considered to be at-risk?
Recommendations of the team (include how they differ from past interventions) :
If DMH funds will be used for this individual, indicate estimated amounts for each
recommended service/support agreed upon by the team.
If DMH funds will be used for this individual, how will the use of these funds maintain this
individual in his/her home and community? How will the service/support continue after the use
of DMH funds?
DMH Adult Making A Plan Monthly Report guidance
Adult Making A Plan (AMAP) Monthly Report
Purpose
Adult Making a Plan (AMAP) Teams address the needs of adults with serious mental illness
who require services from multiple agencies and multiple program systems due to
multiple/frequent in-patient treatment admissions or commitments. The purpose of the AMAP
Team is to develop and implement new and different systems of wrap- around support in order
to treat individuals in the community rather than an institutional setting.
Documentation
Document the county where the AMAP meeting was held and the month the meeting took
place. Document the number of each staff representing the agencies involved with the AMAP
Team. Have each team member sign the attendance log and write the name of their agency on
the same line.
Timeline
The AMAP Monthly Reporting form must be completed, attached the Mobile Crisis Response
Team (M-CeRT) cash request, and submitted to the Department of Mental Health by the 15
th of
the following month.
DMH Adult Making A Plan AMAP Monthly Report form
AMAP Team
Monthly Reporting
County _____________________
Month ______________________
Monthly Reporting Forms must be submitted to the Department of Mental Health by the
10th of each month. Case summary forms, for each adult reviewed, must be submitted
with the monthly reporting form. Cash requests will not be processed without this
information.
Referral Information
1. Number of cases reviewed _____
2. Number of follow-ups from previous month _____
3. Number of referrals from:
Mental Health Center in your county Mental Health Center Region-Wide
Mental Health Center (other Region) Chancery Court/Clerk
MDMH State Hospital Sheriff’s Department
Crisis Stabilization Unit Police Department
Behavioral/Mental Health Court Family Member(s)
Other
AMAP Team Member Participation
Please indicate, using a checkmark, which of the following agencies that were
represented at your AMAP Team Meeting(s) for the month.
Community Mental Health Center MDMH State Hospital
Chancery Court Crisis Stabilization Unit
Sheriff’s Department Police Department
______Families ______ Individual Receiving Services
______ NAMI ______ Other *please identify
DMH Adult Making A Plan AMAP Monthly Report form
AMAP Team Member Participation
Attendance Log
Team Member Agency Represented
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
DMH Crisis Stabilization Services Daily Activity/ Daily Progress Summary Note
Purpose
Documentation must be maintained with an individual receives Crisis Stabilization
Services. Each therapeutic activity must be documented along with a summary of
progress for each day the individual receives services. All psychiatric care, nursing
services and mental health therapy will be documented in the Individualized Progress
Note format.
Identifying Information
Record the name, record number, date of service and total amount of time the individual
received the service.
Therapeutic Activities Provided
Indicate the nature of the therapeutic activities being provided, specify the time the
activity began and ended and list the name of the staff leading the services.
Daily Summary Note
A Master’s level therapist must summarize the progress of the individual receiving
services as it relates to the Individual Service Plan.
Timeline
Crisis Stabilization Services must be documented daily with a summary note that
records services provided.
Crisis Stabilization Services (i.e. counseling, therapy, recreational, education, and
social/interpersonal activities) can be provided seven (7) days per week but must at a
minimum be;
a. Provided five (5) days per week.
b. Provided five (5) hours per day.
c. Provided two (2) hours per day for children/youth enrolled and attending
school full time.
Crisis Stabilization Services
Daily Activity/Daily Progress Summary Note
DMH Strikethrough 2016 Crisis Stabilization Services Daily Activity Daily Progress Summary Note form
Crisis Stabilization Services
Daily Activity/Daily Summary
Note
Name
ID Number
Date
Total Time
Therapeutic Activities Provided
Activity Time In Time Out Name of Activity Coordinator
Daily Summary Note
Signature/Credential
DMH Youth and Adult Pre-Evaluation Screening guidance
Youth and Adult Pre-Evaluation Screening
Purpose
The Pre-Evaluation Screening is required under Mississippi Civil Commitment Statutes. The
Pre-Evaluation Screening must take place prior to the Civil Commitment Exam and can only
be completed by staff from a Community Mental Health Center. The Pre-Evaluation
Screening is used to gather information pertaining to an individual to be used by the
Chancery, Family and/or Youth Court in determining the need for civil commitment.
Timeline
The Pre-Evaluation Screening must take place within 48 hours after an affidavit has been
filed in Chancery, Family and/or Youth Court.
General
The Pre-Evaluation Screening must be filled out as completely as possible. Do not leave
any spaces blank. If you are unable to gather certain information then make a notation in
that space. Information can be gathered from informants, the individual and the individual’s
record.
The Adult Pre-Evaluation is to be used with individuals 18 years and older. The Youth Pre-
Evaluation is to be used with individuals 14 – 17 years of age.
Once the Pre-Evaluation Screening is completed, recommend to the court if a Civil
Commitment Exam should take place. If you recommend that the Civil Commitment Exam
does not need to take place, indicate on the form why and list appropriate referrals that
have been made or should be made. Include any additional comments that you think are
pertinent to the court.
A copy of the completed form must be kept in the individual’s record.
Signature
The staff person completing the Pre-Evaluation Screening must sign the report to include
credentials.
1
Adult Pre-Evaluation
Date: Time In: Time Out: Interview Location:
Individuals Present:
Interpretative Aids/Assisted Devices: Pending Felony Charges: ☐ Yes ☐ No
Case Number: CMHC Region:
In the court of County Voluntary CSU Admission Sought : ☐ Yes ☐ No
Mobile Crisis Involvement : ☐ Yes ☐ No
Information from this interview will be reported on a standardized form and submitted to the chancery court and civil commitment
examiners. You have the right to refuse to participate. Other sources of information including a review of your legal medical
records and interviews with family member and the affiant requesting commitment will be included in this report.
Respondent Demographics
Name: DOB: 0T Age: Gender: Race:
Social Sec #: Medicaid #: Medicare#:
Home Address: Phone Number:
Respondent resides with minor children: ☐ Yes ☐ No Name & Ages of Children:
Respondent has visitation rights to minor children: ☐ Yes ☐ No
Respondent has legal guardian/conservator: ☐ Yes ☐ No
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Affiant Demographics
Affiant Name: Relation of Respondent:
Phone Number: Home Address:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Respondent Psychosocial Information
Current Living: ☐Alone ☐Family/Friends ☐Assisted Living ☐Homeless ☐Other/Describe:
Housing: Dwelling: Home Address:
Employed: ☐ Yes ☐ No Employer/Position: Length of Job:
If unemployed (most recent job?): Highest Level of Education Completed:
Religious Preference or Practice:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Psychiatric History
Current Psychotropic Medications:
Dosage & Date/Time Last Taken:
Is the medication helpful or problematic:
Psychiatric Hospitalizations:
Locations/Dates:
Outpatient Treatments: Locations/Dates:
Psychological Testing: Provider/Dates:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
2
Medical Status & Treatment History
Current Medications (not listed above):
Dosage & Date/Time Last Taken:
Is the medication helpful or problematic:
Known Medication Allergies:
Currently Under Physician Care For: Physician’s Name:
Conditions Treated In The Past: Provider/Dates:
Medical Hospitalization History: Physical Disabilities:
Current Communicable Diseases:
☐HIV/AIDS ☐Hepatitis A ☐Hepatitis B ☐Hepatitis C ☐TB(Tuberculosis)
☐MRSA ☐Influenza ☐Head Lice ☐Scabies ☐Body Lice ☐STIs ☐Other
Currently Pregnant: ☐ Yes ☐ No
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Developmental Disability
History of Special Education Ruling: ☐ Yes ☐ No If yes, describe:
Documented IQ below 70: ☐ Yes ☐ No If yes, describe:
Documented sub-average intellectual functioning before age 18: ☐
Yes ☐ No If yes, describe:
Documented Adaptive Functioning Deficits: ☐ Yes ☐ No If yes, describe:
Specific Observed Adaptive Functioning Deficits:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Mental State Exam
Oriented to Date: Time: Place:
*Cue for three words (provide words)
President:
Counting Response:
Word Recall:
Completed Written Command: ☐ Yes ☐ No If no, describe:
What do you understand the reason for our meeting today to be?
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Psychiatric Symptoms Past Month
Respondent( R ) Informant(I)
Depressive Symptoms R I Anxiety Symptoms R I Somatic Symptoms R I
☐ Depressed mood most of the day ☐ ☐ ☐ Worry ☐ ☐ ☐Headaches ☐ ☐
☐ Lack of Interest/Pleasure ☐ ☐ ☐ Restlessness ☐ ☐ ☐Chest Discomfort/Pain ☐ ☐
☐ Appetite Change or Sig Weight
Change ☐ ☐ ☐ Easily Fatigued ☐ ☐ ☐Faintness ☐ ☐
☐ Insomnia (Difficulty Falling Asleep) ☐ ☐ ☐ Irritability ☐ ☐ ☐ Hot or Cold Flashes ☐ ☐
☐ Feelings of Worthlessness ☐ ☐ ☐ Muscle Tension ☐ ☐ ☐Stomach Aches/Pains ☐ ☐
☐ Fatigue or Loss of Energy ☐ ☐ ☐ Difficulty Concentrating ☐ ☐ ☐ Heart Palpitations ☐ ☐
☐ Diminished Concentration ☐ ☐ ☐ Sleep Disturbance ☐ ☐ ☐ Dizziness or Vertigo ☐ ☐
3
Depressive Symptoms R I Anxiety Symptoms R I Somatic Symptoms R I
☐ Indecisiveness ☐ ☐ ☐ Other ☐ ☐ ☐Shaking/Trembling ☐ ☐
☐ Hypersomnia (Sleeping Excessively) ☐ ☐ ☐Tingling in hands or feet ☐ ☐
☐ Recurrent Thoughts of Death ☐ ☐ ☐Excessive Sweating ☐ ☐
☐ Motor Retardation ☐ ☐ ☐ Other ☐ ☐
☐ Motor Agitation ☐ ☐
☐ Feelings of Hopelessness ☐ ☐
☐ Other ☐ ☐
Psychiatric Symptoms Past Month
Respondent( R ) Informant(I)
Mania & Hypomania Symptoms R I R I
☐ At least 1 week ☐ ☐ ☐More talkative than usual ☐ ☐
☐ 4 consecutive days < weeks ☐ ☐ ☐Excessive involvement in activities with high potential for
painful consequences ☐ ☐
☐ Flight of ideas/racing thoughts ☐ ☐ ☐Distractibility ☐ ☐
☐ Decreased need for sleep ☐ ☐ Persistent elevated, or irritable mood and significant increases in
goal directed activity ☐Yes ☐No ☐ ☐
☐ Increased self-esteem of Grandiosity ☐ ☐
Thought Disorder Symptoms R I
☐ Hallucinations ☐ ☐ ☐ Absence of emotions ☐ ☐
☐ Auditory ☐Visual ☐Olfactory ☐ ☐ ☐Absence of speech ☐ ☐
☐ Tactile ☐Gustatory ☐ ☐ ☐Absence of movement ☐ ☐
Specific Hallucinations:
☐ ☐ ☐ Lack of Hygiene ☐ ☐
☐ Delusions ☐ ☐ ☐Lack of eating/feeding ☐ ☐
☐Persecutory ☐Grandiose ☐Paranoid ☐
Other ☐ ☐
Specific Delusions:
Obsessive Compulsive Symptoms
Obsessive Thoughts ☐Yes ☐No ☐ ☐ Obsessive Thoughts ☐Yes ☐No ☐ ☐
Severity: ☐Mild ☐Moderate ☐Severe ☐ ☐ Severity: ☐Mild ☐Moderate ☐Severe ☐ ☐
Specific Obsessions: ☐ ☐ Specific Obsessions: ☐ ☐
TRAUMA HISTORY
Trauma Exposure ☐Yes ☐No (type/approx. Date)
Trauma Triggers:
Environmental ☐ Crowding ☐Room checks ☐Confusing signs ☐ Slamming doors
☐ Leaving bedroom door open ☐ Dark room ☐ Too hot or too cold ☐ Noise
Interpersonal ☐ Lack of privacy
☐ Being approached by
men or women ☐Arguments ☐People Yelling
☐ Confined spaces ☐Being touched ☐ People too close ☐Contact with Family
☐ Being stared at ☐ Being ignored ☐Feeling pressured
☐ Being ordered to do
something
☐ Being approached by women ☐ Being Teased/picked on
☐ People focusing on my
symptoms ☐ Smells
☐ Tall or large people
Other Triggers ☐ Taste ☐ Time of Day ☐ Sounds ☐ Sights ☐ Sensations/textures ☐ Wringing hands
Warning Signs of
Emotional
escalations
☐ Heart Pounding
☐ Clenching teeth
☐Bouncing legs
☐ Shortness of Breath
☐ Flushed/red face
☐Singing
☐ Breathing Hard
☐ Crying
☐Can’t sit still
☐Wringing hands
☐Clenching fists
☐Cursing/swearing
☐ Sweating ☐ Rocking ☐Pacing ☐Giggling
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
4
Suicide Assessment
Prior Attempts: Friend or Family Member Completed Suicide:
Approximate Date: Approximate Date:
Method of attempt: Method of suicide:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Behaviors Exhibited by Respondent
History or Present Danger to Others ☐ Yes ☐ No (If Yes, mark appropriate statement(s) below)
☐ Thoughts of suicide ☐ Threats of suicide ☐ Plan for Suicide ☐Pre-occupation with death
☐ Suicide gesture ☐ Suicide attempts ☐ Family history of suicide ☐ Self-mutilation
☐ Inability to care for self ☐ High risk behavior ☐ Provoking harm to self from others
☐ Other
Describe:
Violence Risk Assessment
Current thoughts about harming another person ☐ Yes ☐ No
If Yes, whom:
If yes, how long have you had these thoughts
If yes, specific plan:
Access to means to carry out plan:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Violence Risk Factors Present
Present Unknown Present Unknown
☐ ☐ Male Gender ☐ ☐ Substance Abuse
☐ ☐ Suspiciousness/Perception of hidden threat ☐ ☐ Comorbid MI & Substance Use Dx
☐ ☐ Early offense history ☐ ☐ Anger
☐ ☐ Psychopathy ☐ ☐ Antisocial Personality Diagnosis
☐ ☐ Violent Fantasies Frequency, type, recency
☐ ☐ Previous violence against other people Frequency, severity, type
☐ ☐ Childhood physical abuse Frequency, severity
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Substance Use
Do you currently use?
Past Use Amount Frequency Age of Initiation
Alcohol
Marijuana
Opioids
Amphetamines
Hallucinogenic
Prescription Medication
Over the counter medication
History of legal charges related to substance use? ☐ Yes ☐ No Describe:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
5
Physical Appearance
Attire Hair Nails Skin
☐ Glasses ☐ Appropriate for occasion ☐ Clean ☐ Clean ☐ Clean ☐ Bruised
☐ Contacts ☐ Appropriate for weather ☐ Dirty ☐ Dirty ☐ Dirty ☐ Cuts/Scrapes
☐ Hearing Aids ☐ Clean ☐ Disheveled ☐ ☐ Tattoos
Describe: ☐ Dirty ☐ Styled
☐ Torn/worn through ☐ ☐ Sores
☐ Other ☐
Teeth Unusual alterations or distinguishing features:
☐ Clean
☐ Dirty
☐ Decay
☐ Missing
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Behavioral Observations
Motor Activity
Diminished Normal Excessive Unusual
☐ Frozen ☐ Purposeful ☐ Restless ☐ Other
☐ Catatonic ☐ Coordinated ☐ Squirming
☐ Almost motionless ☐ Other ☐ Fidgety ☐ Little animation ☐ Constant movement
☐ Psychomotor
retardation ☐ Hyperactive
☐ Slowed reaction
time ☐ Other
☐ Other
Speech
Slowed Normal Pressured Verbose Unusual
☐ Minimal response ☐ Initiates ☐ Excessively wordy ☐ Over productive ☐
☐ Unspontaneous ☐ Alert/responsive ☐ Expansive ☐Long winded
☐ Sluggish ☐ Productive ☐ Rapid ☐Non stop
☐ Paucity ☐ Animated ☐ Fast ☐ Frequent run ons
☐ Impoverished ☐ Spontaneous ☐ Rushed ☐Flight of ideas
☐ Single word
answers ☐Smooth ☐ Other ☐Hyper verbal
☐ Other ☐ Other ☐Other
Thought Process
Attention Insight Preoccupations
☐ Normal ☐ Good ☐ Somatics ☐ Self
☐ Unengaged ☐ Fair ☐ Children ☐ Finances
☐ Distractible ☐ Poor ☐ Spouse/Sig Other ☐ Other
☐ Hyper vigilant ☐ No insight ☐ Job
☐ Hyper focused
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Affect
☐Flat ☐ Blunted ☐ Constricted ☐ Normal ☐Broad
6
Facial Expression
☐ Vacant ☐ Blank ☐ Strained ☐Pained ☐ Grimacing
☐ Smiling ☐ Other
Summary & Recommendations
Based on the data gathered for the current Pre Evaluation Screening:
☐ It is NOT recommended that this respondent receive a civil commitment exam.
1) Current available information indicates that present symptomatology is due to
☐Dementia ☐Intellectual/Developmental Disability ☐ Epilepsy ☐Chemical Dependency ☐Mental Illness
2) The following referrals for appropriate evaluation or treatment have been provided:
a.
b.
c.
☐ It IS recommended that this respondent receive a civil commitment exam. Based on the data available for the current Pre Screening Evaluation the
following symptomatology cannot be managed/treated in a less restrictive environment:
1)
2)
3)
4)
Comments:
___________________________________________
Signature-Credentials
1
Youth Pre-Evaluation
Date: Click for date Time In: 0T Time Out: 0T Interview Location: 0T
Individuals Present: 0T
Interpretative Aids/Assisted Devices:0T Pending Felony Charges: ☐ Yes ☐ No
Case Number: CMHC Region: 0T
In the Court court of County Voluntary CSU Admission Sought: ☐ Yes ☐ No
Mobile Crisis Involvement: ☐ Yes ☐ No
Information from this interview will be reported on a standardized form and submitted to the chancery court and civil commitment
examiners. You have the right to refuse to participate. Other sources of information including a review of your legal medical
records and interviews with family member and the affiant requesting commitment will be included in this report.
Respondent Demographics
Name: 0T DOB: 0T Age: Gender: Race:
Social Sec #: e.g. 123-12-1234 Medicaid #: Medicare#:
Home Address: 0T Phone Number: 0T
Does the respondent have a legal guardian or conservator: ☐ Yes ☐ No
Guardian/Conservator Contact Information 0T
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Affiant Demographics
Affiant Name: 0T Relation of Respondent:
Phone Number: 0T Home Address: 0T
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Respondent Psychosocial Information
Current Living: 0T
Current Grade in School: Name of School: 0T
History of IEP or 504C: ☐ Yes ☐ No Date of most recent IEP or 504C: 0T
Juvenile Justice Involvement: ☐ Yes ☐ No Describe: 0T
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Psychiatric History
Current Psychotropic Medications:
0T
Dosage & Date/Time Last Taken:
0T
Is the medication helpful or problematic:
0T
Psychiatric Hospitalizations:
0T
Locations/Dates:
Enter Location and Date
Outpatient Treatments: 0T Locations/Dates: 0T
Psychological Testing: 0T Provider/Dates:
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
2
Medical Status & Treatment History
Current Medications (not listed above):
0T
Dosage & Date/Time Last Taken:
0T
Is the medication helpful or problematic:
0T
Known Medication Allergies:0T
Currently Under Physician Care For: 0T Physician’s Name: 0T
Conditions Treated In The Past: 0T Provider/Dates:
Medical Hospitalization History: Physical Disabilities:
Current Communicable Diseases:
☐HIV/AIDS ☐Hepatitis A ☐Hepatitis B ☐Hepatitis C ☐TB(Tuberculosis)
☐MRSA ☐Influenza ☐Head Lice ☐Scabies ☐Body Lice ☐STIs ☐Other
Currently Pregnant: ☐ Yes ☐ No
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Developmental Disability
Pregnancy/Delivery Complications: ☐ Yes ☐ No Describe:
Met Developmental Milestones On Time:
Walked ☐ Talked ☐ Crawled ☐ Toilet Trained ☐ Feeding ☐ If no, describe: escribe
History of Special Education Ruling: ☐ Yes ☐ No If yes, describe: Describe
Documented IQ below 70: ☐ Yes ☐ No If yes, describe: Describe
Documented sub-average intellectual functioning before age
18: ☐ Yes ☐ No If yes, describe: Describe
Documented Adaptive Functioning Deficits: ☐ Yes ☐ No If yes, describe: Describe
Specific Observed Adaptive Functioning Deficits: 0T
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Mental State Exam
Oriented to Date: select date Time: Enter Time Place:0T
*Cue for three words (provide words)
President: Enter Response
Counting Response: 0T
Word Recall: 0T 0T 0T
Completed Written Command: ☐ Yes ☐ No If no, describe: 0T
What do you understand the reason for our meeting today to be? 0T
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Psychiatric Symptoms Past Month
Respondent( R ) Informant(I)
Mood Symptoms R I Mood Symptoms R I Behavioral Symptoms R I
☐ Depressed mood/Appears Sad ☐ ☐ ☐ Dizzy ☐ ☐ ☐Attempts to “ Annoy” Others ☐ ☐
☐ Enjoys Very Little ☐ ☐ ☐ Shaking/Trembling ☐ ☐ ☐ Defies Requests ☐ ☐
☐ Cries Frequently ☐ ☐ ☐Excessive Sweating ☐ ☐ ☐ Angry & Resentful ☐ ☐
☐ Decrease in Appetite ☐ ☐ ☐ Shortness of Breath ☐ ☐ ☐ Sullen ☐ ☐
☐ Increase in Appetite ☐ ☐ ☐ Tingling in Hands or Feet ☐ ☐ ☐ Irritable ☐ ☐
3
Mood Symptoms continues R I Mood Symptoms
continues R I Behavioral Symptoms
continues R I
☐ Fatigued or Underactive (without
reason) ☐ ☐ ☐ Headache ☐ ☐ ☐ Tantrums ☐ ☐
☐ Difficulty Sleeping ☐ ☐ Behavioral Symptoms R I ☐ Lying ☐ ☐
☐ Nightmares/Nigh Terrors ☐ ☐ ☐Impulsive ☐ ☐ ☐ Cheating ☐ ☐
☐ Withdrawn From Peers ☐ ☐ ☐ Fails to Finish Tasks ☐ ☐ ☐ Steals ☐ ☐
☐ Bullied or Rejected by Peers ☐ ☐ ☐ Talks Excessively ☐ ☐ ☐ Physically Harms People ☐ ☐
☐ Engages in Self Harm ☐ ☐ ☐ Loud ☐ ☐ ☐ Physically Harms Animals ☐ ☐
☐ Talks About Killing Self Wishes to die ☐ ☐ ☐ Blurts Words/Interrupts ☐ ☐ ☐ Destroys Property ☐ ☐
☐ Clings to Adults/Dependent ☐ ☐ ☐ Difficulty Sitting Still,
Restless ☐ ☐ ☐ Sets Fires ☐ ☐
☐ Fears Specific Situations or Objects
Describe: ☐ ☐ ☐ Fidgets ☐ ☐ ☐ Threatens Others ☐ ☐
☐ Reports Fearing School ☐ ☐ ☐ Easily Distracted ☐ ☐ ☐ Physical Fights With Peers ☐ ☐
☐ Worries ☐ ☐ ☐ Disorganized ☐ ☐ ☐ Skips School ☐ ☐
☐ Tense ☐ ☐ ☐ Forgetful/Misplaces
Belongings ☐ ☐ ☐ Used a Weapon ☐ ☐
☐ Stomach Aches or Pains ☐ ☐ ☐ Loses Temper Frequently ☐ ☐ ☐ Delinquent Peers ☐ ☐
☐ Heart Palpitations ☐ ☐ ☐ Argues with Adults
☐ Home ☐ School ☐ ☐
Psychiatric Symptoms Past Month
Respondent( R ) Informant(I)
Thought Disorder Symptoms R I R I
☐ Hallucinations ☐ ☐ ☐ Absence of emotions ☐ ☐
☐ Auditory ☐ Visual ☐ Olfactory ☐ ☐ ☐ Absence of speech ☐ ☐
☐ Tactile ☐Gustatory ☐ ☐ ☐ Absence of movement ☐ ☐
Specific Hallucinations:
0T ☐ ☐ ☐ Lack of Hygiene ☐ ☐
☐ Delusions ☐ ☐ ☐ Lack of eating/feeding ☐ ☐
☐Persecutory ☐Grandiose ☐ Paranoid
☐Other ☐ ☐
Specific Delusions:
0T
Obsessive Compulsive Symptoms
Obsessive Thoughts ☐Yes ☐ No ☐ ☐ Obsessive Thoughts ☐Yes ☐ No ☐ ☐
Severity: ☐Mild ☐Moderate ☐Severe ☐ ☐ Severity: ☐Mild ☐Moderate ☐Severe ☐ ☐
Specific Obsessions:0T ☐ ☐ Specific Obsessions:0T ☐ ☐
TRAUMA HISTORY
Trauma Exposure ☐Yes ☐No (type/approx. Date) Click here to enter text.
Trauma Triggers:
Environmental ☐ Crowding ☐ Room checks ☐ Confusing signs ☐ Slamming doors
☐ Leaving bedroom door open ☐ Dark room ☐ Too hot or too cold ☐ Noise
Interpersonal Lack of privacy
☐ Being approached by
☐ Arguments ☐People Yelling
4
Suicide Assessment
Prior Attempts: 0T Friend or Family Member Completed Suicide: 0T
Approximate Date: 0T Approximate Date: 0T
Method of attempt: 0T Method of suicide: 0T
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Behaviors Exhibited by Respondent
History or Present Danger to Others ☐ Yes ☐ No (If Yes, mark appropriate statement(s) below)
☐ Thoughts of suicide ☐ Threats of suicide ☐ Plan for Suicide ☐Pre-occupation with death
☐ Suicide gesture ☐ Suicide attempts ☐ Family history of suicide ☐ Self-mutilation
☐ Inability to care for self ☐ High risk behavior ☐ Provoking harm to self from others
☐ Other
Describe:
Violence Risk Assessment
Current thoughts about harming another person ☐ Yes ☐ No
If Yes, whom: 0T
If yes, how long have you had these thoughts 0T
If yes, specific plan: 0T
Access to means to carry out plan: 0T
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Violence Risk Factors Present
Present Unknown Present Unknown
☐ ☐ Male Gender ☐ ☐ Substance Abuse
☐ ☐ Suspiciousness/Perception of hidden threat ☐ ☐ Comorbid MI & Substance Use Dx
☐ ☐ Early offense history ☐ ☐ Anger
☐ ☐ Psychopathy (PCL:SV>12) ☐ ☐ Antisocial Personality Diagnosis
☐ ☐ Violent Fantasies Frequency, type, recency 0T
☐ ☐ Previous violence against other people Frequency, severity, type 0T
☐ ☐ Childhood physical abuse Frequency, severity 0T
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Substance Use
Do you currently use?
Past Use Amount Frequency Age of Initiation
men or women
☐ Confined spaces ☐ Being touched ☐ People too close ☒Contact with Family
☐ Being stared at ☐ Being ignored ☐ Feeling pressured ☐ Being ordered to do something
☐ Being approached by women ☐ Being Teased/picked on ☐ Tall or large people ☐ Smells
☐People focusing on my symptoms
Other Triggers ☐ Taste ☐ Time of Day ☐Sounds ☐ Sights ☐ Sensations/textures ☐ Wringing hands
Warning Signs
of Emotional
escalations
☐ Heart Pounding
☐ Clenching teeth
☐ Bouncing legs
☐ Shortness of Breath
☐ Flushed/red face
☐Singing
☐ Breathing Hard
☐ Crying
☐Can’t sit still
☐Wringing hands
☐Clenching fists
☐Cursing/swearing
☐ Sweating ☐ Rocking ☐Pacing ☐Giggling
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
5
Caffeine 0T 0T 0T 0T
Nicotine 0T 0T 0T 0T
Alcohol 0T 0T 0T 0T
Marijuana 0T 0T 0T 0T
Opioids 0T 0T 0T 0T
Amphetamines 0T 0T 0T 0T
Hallucinogenic 0T 0T 0T 0T
Prescription Medication 0T 0T 0T 0T
Over the counter medication 0T 0T 0T 0T
History of legal charges related to substance use? ☐ Yes ☐ No Describe: 0T
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Physical Appearance
Attire Hair Nails Skin
☐ Glasses ☐ Appropriate for occasion ☐ Clean ☐ Clean ☐ Clean ☐ Bruised
☐ Contacts ☐ Appropriate for weather ☐ Dirty ☐ Dirty ☐ Dirty ☐ Cuts/Scrapes
☐ Hearing Aids ☐ Clean ☐ Disheveled ☐ ☐ Tattoos
Describe: 0T ☐ Dirty ☐ Styled
☐ Torn/worn through ☐ ☐ Sores
☐ Other ☐
Teeth Unusual alterations or distinguishing features:
0T ☐ Clean
☐ Dirty
☐ Decay
☐ Missing
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Behavioral Observations
Motor Activity
Diminished Normal Excessive Unusual
☐ Frozen ☐ Purposeful ☐ Restless ☐ Other 0T
☐ Catatonic ☐ Coordinated ☐ Squirming
☐ Almost motionless ☐ Other 0T ☐ Fidgety
☐ Little animation ☐ Constant movement
☐ Psychomotor
retardation ☐ Hyperactive
☐ Slowed reaction
time ☐ Other 0T
☐ Other 0T
Speech
Slowed Normal Pressured Verbose Unusual
☐ Minimal response ☐ Initiates ☐ Excessively wordy ☐ Over productive ☐ 0T
☐ Unspontaneous ☐ Alert/responsive ☐ Expansive ☐Long winded
☐ Sluggish ☐ Productive ☐ Rapid ☐Non stop
☐ Paucity ☐ Animated ☐ Fast ☐ Frequent run ons
☐ Impoverished ☐ Spontaneous ☐ Rushed ☐Flight of ideas
☐ Single word
answers ☐Smooth ☐ Other 0T ☐Hyper verbal
☐ Other 0T ☐ Other 0T ☐Other 0T
Thought Process
Attention Insight Preoccupations
☐ Normal ☐ IGood ☐ Somatics ☐ Self
☐ Unengaged ☐ Fair ☐ Children ☐ Finances
☐ Distractible ☐ Poor ☐ Spouse/Sig Other ☐ Other 0T
6
☐ Hyper vigilant ☐ No insight ☐ Job
☐ Hyper focused
Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other
Affect
☐Flat ☐ Blunted ☐ Constricted ☐ Normal ☐Broad
Facial Expression
☐ Vacant
☐ Blank
☐ Strained
☐Pained
☐ Grimacing
☐ Smiling
☐ Other 0T
Summary & Recommendations
Based on the data gathered for the current Pre Evaluation Screening:
☐ It is NOT recommended that this respondent receive a civil commitment exam.
1) Current available information indicates that present symptomatology is due to
☐Dementia ☐Intellectual/Developmental Disability ☐ Epilepsy ☐Chemical Dependency ☐Mental Illness
2) The following referrals for appropriate evaluation or treatment have been provided:
a.
b.
c.
☐ It IS recommended that this respondent receive a civil commitment exam. Based on the data available for the current Pre Screening Evaluation the
following symptomatology cannot be managed/treated in a less restrictive environment:
1) 0T
2) 0T
3) 0T
4) 0T
Comments:
___________________________________________
Signature-Credentials
DMH Strikethrough 2016 Violence Risk Assessment for Certified Holding Facility guidance
Violence Risk Assessment for Certified Holding Facility
Purpose
A DMH approved Violence Risk Assessment must be conducted on each individual who is
being housed in a DMH Certified Holding Facility. The results of the Violence Risk
Assessment will determine if a follow-up assessment by a nurse or physician is needed or if
immediate violence prevention protocols must be initiated.
Timeline
The Violence Risk Assessment must be conducted immediately upon arrival of an individual
at the Holding Facility.
Signature/Credentials
The Violence Risk Assessment must be conducted by the designated Screening Officer of
the Holding Facility.
DMH Strikethrough 2016 Violence Risk Assessment for Certified Holding Facility form
Violence Risk
Assessment for
Certified Holding
Facility
Detainee’s Name
Date of Birth
Date
Name of Facility
Screening Officer
FEMALE MALE Most serious charge:
Scoring Instructions: Collect information about each of the 10 risk factor items on the checklist using
examples given. Place a check in the box to indicate the degree of likelihood that the risk factor applies to this
individual. Use the following indicator scale:
No: Does not apply to this person Yes: Definitely applies to a severe degree
Maybe: Applies/present to a moderately severe degree Do not know: Too little information to answer
Results: If 5 or more questions are checked YES or MAYBE, notify supervisor and other Holding Facility staff.
Initiate proper safety protocols.
1. Previous and/or current violence
Physical attack, including with various weapons, towards another individual
with intent to inflict severe physical harm. “Yes” means individual has
committed at least 3 moderately violent aggressive acts or 1 severe violent act.
“Maybe/moderate” means less severe aggressive acts such as kicks, blows
and shoving not resulting in severe harm to the victim.
No Maybe
Yes Do not know
2. Previous and/or current threats (verbal/physical)
Verbal: Statements, yelling, other that involve threat of inflicting physical harm
Physical: Movements and gestures that warn of physical attack
No Maybe
Yes Do not know
3. Previous and/or current substance abuse
History of abusing alcohol, medication and/or other substances including
abuse of solvents, glue, similar. “Yes” means extensive abuse/dependence
with reduced occupational/educational functioning, reduced health and/or
reduced participation in leisure activities.
No Maybe
Yes Do not know
4. Previous and/or current major mental illness
Individual has or has had a psychotic disorder (schizophrenia, delusional
disorder, psychotic affective disorder, other)
No Maybe
Yes Do not know
5. Personality Disorder
Eccentric (schizoid, paranoid), impulsive, uninhibited (emotionally unstable,
antisocial) types
No Maybe
Yes Do not know
6. Shows lack of insight into illness and/or behavior
Degree to which individual lacks insight into his/her mental illness regarding
medication, social consequences of behavior related to illness or personality
disorder
No Maybe
Yes Do not know
7. Expresses suspicion
Expresses verbal or nonverbal suspicion towards others; appears to be “on
guard” toward environment/surroundings
No Maybe
Yes Do not know
8. Shows lack of empathy
Appears emotionally cold, without sensitivity towards others’ thoughts or
emotional situations
No Maybe
Yes Do not know
9. Unrealistic planning
Unrealistic plans for future. Unrealistic expectation of support from family and
professional/social network. Assess ability to cooperate with/follow plans.
No Maybe
Yes Do not know
10. Future stress situations
Ability to cope with future stress; ability to tolerate boundaries, physical
proximity to possible victims of violence, substance use, homelessness, violent
environment, easy access to weapons, other.
No Maybe
Yes Do not know
DMH Strikethrough 2016 Suicide Risk Assessment for Certified Holding Facility guidance
Suicide Risk Assessment for Certified Holding Facility
Purpose
A DMH approved Suicide Risk Assessment must be conducted on each individual who is
being housed in a DMH Certified Holding Facility. The results of the Suicide Risk
Assessment will determine if a follow-up assessment by a nurse or physician is needed or if
immediate suicide prevention actions must be instituted.
Timeline
The Suicide Risk Assessment must be conducted immediately upon arrival of an individual
at the Holding Facility.
Signature/Credentials
The Suicide Risk Assessment must be conducted by the designated Screening Officer of
the Holding Facility.
DMH Strikethrough 2016 Suicide Risk Assessment for Certified Holding Facility form
Suicide Risk
Assessment for
Certified Holding
Facility
Detainee’s Name
Date of Birth
Date and Time
Name of Facility
Screening Officer
FEMALE MALE Most serious charge:
Check YES or NO for each numbered item below. Each YES response requires support documentation
Personal Data Questions YES NO Support Documentation
1. Individual lacks support of family of friends
2. Individual has a history of drug or alcohol
abuse
3. Individual is very worried about problems
other than legal issues (financial, family,
medical condition, other)
4. Individual has experienced a significant
loss within the last 6 months (loss of job or
relationship, death of a close family
member)
5. Individual is expressing feelings of
hopelessness
6. Individual is thinking about killing
himself/herself
7. Individual has previous suicide attempt(s)
8. Attempt occurred within last month
Total number of YES checks
Officer’s/Staff’s Comments/Impressions:
Action: If total number of YES checks is 4 or more or if item # 6 is checked or if screener believes it is
necessary, notify the supervisor and initiate Constant Watch for the individual.
Supervisor Notified Yes No
Constant Watch Initiated Yes No
Signature of Screening Officer Badge Number
Medical/Mental Health Personnel Actions
(to be completed by medical/MH staff):
Section GF
Alzheimer’s and Other
Dementia Services
Life Story Narrative
DMH Strikethrough 2016 Life Story Narrative guidance
Life Story Narrative
Purpose
As Alzheimer’s disease progresses, individuals lose developmental skills and abilities and
appears to “move backward in time.” A Life Story gives those around them the ability to assist
and be with them as they remember the past and work through the stages of the disease. The
Life Story Narrative should include specific details about pertinent events and the lifestyle of the
individual. Traumatic events that occurred in the individual’s life or family should also be
included in the narrative.
Timeline
The Life Story Narrative must be completed as part of the initial assessment process and must
be included in the individual’s record. Program staff must review the individual’s narrative prior
to initial contact with the individual. The Life Story Narrative must also be reviewed whenever
the Individual Service Plan is reviewed.
Narrative Completion
The Program Supervisor is responsible for completing the narrative and should ask the family
and/or responsible party for assistance in completing the narrative. All those individuals who
participate in developing the Life Story Narrative must sign where indicated.
List any significant traumatic events in the “Other” section of the narrative that coincides with
the time of life that the trauma occurred. For example, if the individual had a sibling to die in
early childhood, list that in the “Other” section of the “Childhood” narrative. If the individual had
a stillborn baby or suffered miscarriages, include that information in the “Other” section of the
“Young Adulthood” narrative.
DMH Strikethrough 2016 Life Story form
Life Story Narrative
Name
ID Number
Date
Page 1 of 6
Childhood (Birth - 12 years)
Birth date and birth place:
Parents and grandparents:
Brothers and Sisters:
Birth Order:
Friends:
Significant relatives:
House (s) lived in:
Towns lived in:
Church (s) attended and activities:
Schools attended:
Early education events:
Interest/activities/sports/games/ etc:
Pets:
Other:
DMH Strikethrough 2016 Life Story form
Life Story Narrative
Name
ID Number
Date
Page 2 of 6
Adolescence (13-21 years)
Name and location of school (s):
Favorite/least favorite classes:
Friends/relationships:
Interests/hobbies/activities/sports/etc:
Behavior problems:
First Job:
Church (s) attended and activities:
School(s) attended:
House(s) lived in:
Town (s) lived in:
Pets:
Specific happy/sad events:
Other:
DMH Strikethrough 2016 Life Story form
Life Story Narrative
Name
ID Number
Date
Page 3 of 6
Young Adulthood (21-39 years)
College and work:
Military Service:
Marriage(s)/Relationship(s):
Family:
Clubs/community involvement:
Church (s) attended and activities:
First home:
Other Homes:
Interests/hobbies/sports:
Town(s) lived in:
Pets:
Specific happy/sad events:
Other:
DMH Strikethrough 2016 Life Story form
Life Story Narrative
Name
ID Number
Date
Page 4 of 6
Middle Age (40-65 years)
Work Role:
Family Role:
Marriage(s)/Relationship(s):
Family:
Grandchildren:
Clubs/community involvement:
Church (s) attended and activities:
Homes lived in:
Interests/hobbies/sports:
Town(s) lived in:
Pets:
Specific happy/sad events:
Other:
DMH Strikethrough 2016 Life Story form
Life Story Narrative
Name
ID Number
Date
Page 5 of 6
Later Years (66+ years)
Work Role:
Family Role:
Marriage(s)/Relationship(s):
Family:
Grandchildren:
Clubs/community involvement:
Life achievements and accomplishments:
Church (s) attended and activities:
Homes lived in:
Interests/hobbies/sports:
Town(s) lived in:
Pets:
Specific happy/sad events:
Other:
DMH Strikethrough 2016 Life Story form
Life Story Narrative
Name
ID Number
Date
Page 6 of 6
Questions to Enrich the Story
1. How would the individual have enjoyed spending holidays? (New Year’s Eve, Christmas, Fourth of July,
Memorial Day, etc.)?
2. What are their favorite books/music/artists/athletes/movies stars, etc?
3. If the individual was stuck on a desert island, what three (3) things would they wish to have with them?
(Assume there is food, drink, and shelter.)
4. How would the person’s desk, kitchen shelves/drawers, tool box, etc., be organized?
5. Would he/she have looked at life thinking the glass is half -full (optimist) or half-empty (pessimist)?
6. Where did he/she travel?
7. What special skills did he/she have?
8. What special awards did he/she acquire?
Other
Section HG
Children and Youth
Services
Therapeutic Foster Care Contact Log
MAP Team Report
MAP Team Case Summary
Wraparound Facilitation Individual Support Plan
DMH Strikethrough 2016 Therapeutic Foster Care Contact Log guidance
Therapeutic Foster Care Contact Log
Purpose
The Therapeutic Foster Care (TFC) Specialist must document face-to-face contact with TFC
parents including home visits. Documentation must be maintained that each TFC home has no
more than one child/youth with serious emotional disturbance (SED) placed in the home at one
time.
Timeline
Documentation of at least one family session per month with the foster parent(s) must be
maintained.
DMH Strikethrough 2016 Therapeutic Foster Care Contact Log form form
Therapeutic Foster
Care Contact Log
Foster Parent’s
Name
Foster Parent’s
Case Number
Date
Type of Contact
(in-home, monthly group,
meeting, other)
Total # of
children/youth
in the home
Total # of
children/youth
with SED in the
home
Staff Signature/
Credential
DMH Strikethrough 2016 MAP Team Report guidance
MAP Team Report
Purpose
Making a Plan (MAP) Teams address the needs of children/youth with Serious Emotional
Disorder (SED) who require services from multiple agencies and multiple program systems and
who can be diverted from inappropriate institutional placement. MAP Teams are a significant
piece of the statewide System of Care for children/youth with serious emotional/behavioral
disorders. Quarterly reports are required for data collection purposes.
Timelines
The MAP Team Reporting form must be completed and submitted to the DMH, Division of
Children & Youth Services by the 10th of each quarter; January 10th for October – December,
April 10th for January – March, July 10th for April – June, and October 10th for July – September.
Case Summaries
If MAP Team grant funds are used, Case Summary forms for each child/youth reviewed must be
submitted with the MAP Team Report. Cash requests will not be processed without this
information.
Strikethrough 2016 MAP Team Report form
MAP Team
Report
MAP Team
Months/Quarter
Referral Information
1. Number of new cases reviewed
2. Number of children/youth in DHS
custody (of the new cases only)
3. Number of follow-ups from previous
quarter
4. Number of children/youth not
Medicaid eligible
5. Number of referrals from new cases only:
Mental Health Center in your
county
Mental Health Center Region-Wide
DHS - Family & Children’s
Services
Youth Court
Therapeutic Group Home Therapeutic Foster Care
Acute Psychiatric Hospital Psychiatric Residential Tx Facility
Local School District Parent(s)
Faith-Based Agency/Church A.O.P
MYPAC College/University
Substance Abuse Residential
Facility
Other (specify)
MAP Team Member Participation
Check the following agencies that were represented at your MAP Team Meeting(s) for the
quarter
Families/Parents (Local Family Partners – must be parent(s) or primary caregiver(s) of a
child/youth with SED. Use Families As Allies Partners when available.)
Community Mental Health
Center
DHS – Family & Children Services
Youth Court Local School District
Vocational Rehabilitation Health Department
Boys & Girls Club Law Enforcement
Substance Abuse Residential
Facility
A. O. P.
Youth Villages MYPAC
Faith-based Agency/Church Other (specify)
DMH Strikethrough 2016 MAP Team Case Summary guidance
MAP Team Case Summary
Purpose
Making a Plan (MAP) Teams address the needs of children/youth with Serious Emotional
Disturbance (SED) who require services from multiple agencies and multiple program
systems and who can be diverted from inappropriate institutional placement. All Community
Mental Health Centers must document participation in at least two MAP Teams in their
region.
Timeline
If DMH flexible funds are utilized, a MAP Team Case Summary form must be completed for
each child/youth and submitted to the DMH, Division of Children & Youth Services by the 10th
of each quarter; January 10th for October – December, April 10th for January – March, July
10th for April – June and October 10th for July – September along with the MAP Team
Monthly Reporting form.
Identifying Information
To ensure confidentiality, the child/youth’s ID number (CMHC or other provider) is entered on
the MAP Team Case Summary in place of the child/youth’s name.
Referral Information
All questions in all sections must be answered with as much detail as possible in order to
justify the need for MAP Team intervention. Space is provided for the specific
recommendations of the MAP Team after all aspects of the case have been considered by
the team.
DMH Strikethrough 2016 MAP Team Case Summary form
MAP Team
Case
Summary
MAP Team Name
ID Number
SED Dx
ID/DD Dx
Age Race Sex
Transitional Needs? □ Yes □ No
Why was this
child/youth’s case
referred to the MAP
Team?
Why is this child/youth
considered to be at-risk
for an institutional mental
health placement?
Recommendations of the
MAP Team
If MAP Team flexible funds will be used for this child/youth,
indicate the estimated amount agreed upon by the Team.
If MAP Team flexible funds will be
used for this child/youth, how will
the use of these funds keep the
child/youth in the community in a
manner that makes it possible for
the child/youth to be diverted
from an inappropriate 24-hour
institutional mental health
placement?
Signature of MAP Team Coordinator/Credentials Date
DMH Wraparound Facilitation Individualized Support Plan guidance
Wraparound Facilitation
Overview of Wraparound
Wraparound is an approach to individualized care planning encompassing the concept of wrapping
services and supports around children, youth and families, utilizing both clinical treatment services
and natural supports. Wraparound is built on the collective action of a committed group of family,
friends, community, professionals, and cross-system supports mobilizing resources and talents from
a variety of sources. This results in the creation of an Individualized Support Plan that is the best fit
between the family vision and story, strengths, needs, team mission, and strategies.
Target Population
Wraparound facilitation is for children/youth with serious emotional disturbances (SED) who have
highly complex needs and/or have multiple agency involvement and are at risk of out -of-home
placement. With ratios of 1 Wraparound Facilitator to 10 families and youth, youth can be diverted
from residential placements and served in their communities and homes.
Key Elements of the Wraparound Process
Grounded in a Strengths Perspective
Strengths are defined as interests, talents, and unique contributions that make things better for the
family and youth. Within an entire process that is grounded in a strengths perspective, the family
story is framed in a balanced way that incorporates family strengths rather than a focus solely on
problems and challenges. A strengths perspective should be overt and easily recognized, promoting
strengths that focus on the family, team, and community, while empowering and challenging the team
to use strengths in a meaningful way.
Driven by Underlying Needs
Needs typically define the underlying reasons why behaviors happen in a situation. In a needs-driven
process, the set of underlying conditions (needs) that cause a behavior and/or situation to exist are
both identified and explored in order to understand why a behavior and/or situation happened. These
needs would be identified across family members in a range of life areas beyond the areas defined by
the system. These underlying conditions would be articulated with overt agreement with the family
and all team members about which to select for action or attention first. The process involves
flexibility of services and supports that will be tailored to meet the needs of the family and youth.
Supported by an Effective Team Process
Wraparound is a process that requires active investment by a team, comprised of both formal and
informal supports willing to be accountable for the results. Measurable target outcomes are derived
from multiple team member perspectives. The team’s overall success is demonstrated by how much
closer the family is to their vision and how well the family needs have been addressed.
Determined by Families
A family-determined process includes both youth and caregivers with the family having the authority
to determine decisions and resources. Families are supported to live a life in a community rather than
in a program. The critical process elements of this area inc lude access, inclusion, voice, and
DMH Wraparound Facilitation Individualized Support Plan guidance
ownership. Family access is defined as inclusion of people and processes in which decisions are
made. Inclusion in decision making implies that families should have influence, choice and authority
over services and supports identified in the planning process. This means that they should be able to
gain more of what is working and less of what they perceive as not working. Family voice is defined
as feeling heard and listened to, and team recognition that the families are important stakeholders in
the planning process. Therefore, families are critical partners in setting the team agenda and making
decisions. Families have ownership of the planning process in partnership with the team when they
can make a commitment to any plans concerning them. In Wraparound, the important role of families
is confirmed throughout the duration of care.
Wraparound Facilitation
Wraparound Facilitation is the creation and facilitation of a child and family team for the purpose of
developing a single plan of care to address the needs of youth with complex mental health challenges
and their families. The child and family team will meet regularly to monitor and adjust the plan of care
if necessary or if progress is not being made. Wraparound facilitation is intended to serve individuals
with serious mental health challenges that exceed the resources of a single agency or service
provider, experience multiple acute hospitals stays, are at risk of out -of-home placement or have
been recommended f or residential care. Individuals who have had interruptions in the delivery of
services across a variety of agencies due to frequent moves, failure to show improvement, lack of
previous coordination by agencies providing care, or reasons unknown can also be served through
wraparound facilitation.
Wraparound facilitation must be provided in accordance with high fidelity (as outlined below) and
quality wraparound practice.
1. Services comprised of a variety of specific tasks and activities designed to carry out the
wraparound process, including:
a. Engaging the family;
b. Assembling the child and family team;
c. Facilitating a child and family team meeting at a minimum every thirty (30) days;
d. Facilitating the creation of a plan of care, which includes a plan for anticipating, preventing
and managing crisis, within the child and family team meeting;
e. Working with the team in identifying providers of services and other community resources
to meet family and youth needs;
f. Making necessary referrals for youth;
g. Documenting and maintaining all information regarding the plan of care, including revisions
and child and family team meetings;
h. Presenting plan of care for approval by the family and team;
i. Providing copies of the plan of care to the entire team including the youth and
family/guardian;
j. Monitoring the implementation of the plan of care and revising if necessary to achieve
outcomes;
k. Maintaining communication between all child and family team members;
l. Monitoring the progress toward needs met and whether or not the referral behaviors are
decreasing;
m. Leading the team to discuss and ensure the supports and services the youth and family
are receiving continue to meet the caregiver and youth’s needs;
DMH Wraparound Facilitation Individualized Support Plan guidance
n. Educating new team members about the wraparound process; and
o. Maintaining team cohesiveness.
2. Child and family team membership must include:
a. The wraparound facilitator;
b. The child’s service providers, any involved child serving agency representatives and other
formal supports, as appropriate;
c. The caregiver/guardian;
d. Other family or community members serving as informal supports, as appropriate; and
e. Identified youth, if age nine (9) or above, unless there are clear clinical indications this
would be detrimental. Such reasons must be documented clearly throughout the record.
3. Wraparound facilitation is limited to one hundred (100) units (15 minute unit) per state fiscal year
and eight (8) units per day.
4. Provider requirements
a. Wraparound facilitators and supervisors of the process must have completed and show
evidence of completion of the Introduction to Wraparound 3-day training.
b. Wraparound facilitators and supervisors must participate in ongoing coaching and training
as defined by the Division of Medicaid and the Department of Mental Health.
c. The provider organization providing Wraparound f acilitation must be participating in the
wraparound certification process through the Division of Medicaid or its designee.
d. Providers must ensure case load size for each wraparound facilitator of no more than ten
(10) cases.
Wraparound Facilitation Additional Documentation Requirements
All contacts, specific tasks and activities must be documented in Progress Note and filed in the
child/youth’s record.
DMH Wraparound Facilitation Individualized Support Plan form
Wraparound Facilitation
Individualized Support Plan
Youth Name (First, MI, Last):
Client #:
TAN #:
Date:
Guardian Name:
DOB:
Phone:
Address:
Initial
Review
Discharge
Start Date:
Target Completion Date:
Vision/Mission/Strengths
Family Vision/Preference Statement:
Team Mission:
Strengths/Abilities:
Youth, Family
Members, & Team
DMH Wraparound Facilitation Individualized Support Plan form
Client Name Case #
Crisis Plan
Diagnosis:
Medications:
Brief History:
Triggers:
Potential Crisis:
Action Steps for home and school to meet Identified Needs re: Potential Crisis:
Persons Responsible and phone numbers:
Crisis Debriefing after Resolution:
DMH Wraparound Facilitation Individualized Support Plan form
Client Name Case #
Needs Statements/Strategies
Needs
Statement
1
Start Date:
End Date/Duration:
Outcome:
Life Domain Area of need:
Family Residence Social Education/Vocation
Medical/Physical Health Community Psychological/Emotional/Behavioral
Safety Basic Physical Needs Financial Leisure/Recreation
Youth
Strategies
Parent/Guardian/Community Strategies:
Strategy Completion
Date:
Strategy Discontinue Date:
Reason for Discontinuation:
DMH Wraparound Facilitation Individualized Support Plan form
Client Name Client #
Needs
Statement
2
Start Date:
End Date/Duration:
Outcome:
Life Domain Area of need:
Family Residence Social Education/Vocation
Medical/Physical Health Community Psychological/Emotional/Behavioral
Safety Basic Physical Needs Financial Leisure/Recreation
Youth
Strategies
Parent/Guardian/Community Strategies:
Strategy Completion
Date:
Strategy Discontinue Date:
Reason for Discontinuation:
DMH Wraparound Facilitation Individualized Support Plan form
Client Name Client #
Needs
Statement
3
Start Date:
End Date/Duration:
Outcome:
Life Domain Area of need:
Family Residence Social Education/Vocation
Medical/Physical Health Community Psychological/Emotional/Behavioral
Safety Basic Physical Needs Financial Leisure/Recreation
Youth
Strategies
Parent/Guardian/Community Strategies:
Strategy
Completi
on Date:
Strategy Discontinue Date:
Reason for Discontinuation:
DMH Wraparound Facilitation Individualized Support Plan form
Client Name Client #
Needs
Statement
4
Start Date:
End Date/Duration:
Outcome:
Life Domain Area of need:
Family Residence Social Education/Vocation
Medical/Physical Health Community Psychological/Emotional/Behavioral
Safety Basic Physical Needs Financial Leisure/Recreation
Youth
Strategies
Parent/Guardian/Community Strategies:
Strategy Completion
Date:
Strategy Discontinue Date:
Reason for Discontinuation:
DMH Wraparound Facilitation Individualized Support Plan form
Client Name Client #
Team Contacts/Resources
Support
Name/Signature
Contact and Organization Role
Discharge
Support Summary:
Further Recommendations:
Youth Signature: Date:
Parent/Guardian Signature: Date:
Wraparound Facilitator Signature: Date:
Supervisor Signature: Date:
Other Signature (Name/Relationship): Date:
Other Signature (Name/Relationship): Date:
DMH Wraparound Facilitation Individualized Support Plan form
Case # __________________
Wraparound Team Meeting
Wraparound team for __________________________ and Family
Date: ______________________ Start – End Time: ___________________
* I am aware that everything said in this meeting is confidential. Confidentiality means that what we discuss is
private and should not be discussed outside of this meeting or with others not involved in this family’s
Wraparound process. By signing, I agree to preserve the confidentiality of all information discussed. I agree
that this information will be used for the purposes outlined in the Wraparound planning process only. I
understand that if any abuse or neglect is disclosed in this process, mandated reports will be made.
Name of Family Team
Member*
Role, Agency, or Relationship
to Youth
Phone Number(s) To be filled out by
Wrap Facilitator:
Release authorized?
Wrap Facilitator
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
Y or N
“Wraparound
is a family centered, community-oriented, strengths-based, highly individualized planning
process aimed at helping people achieve important outcomes by helping them meet their unmet needs both
within and outside of formal human services systems, while the y remain in their neighborhoods and homes,
whenever possible” (wraparoundsolutions.com).
Section IH
Intellectual/ Developmental
Disabilities Services
IDD Plan of Services and Supports
IDD Activity Support Plan
IDD Service Note
IDD Weekly Service Note
ID/DD Waiver/IDD CSP Service Authorization
ID/DD Waiver Home and Community Supports Service Agreement
ID/DD Waiver In-Home Respite Service Agreement
ID/DD Waiver In-Home Nursing Service Agreement
ID/DD Waiver In-Home Nursing Respite Service Note
IDD Employment Profile
ID/DD Waiver Job Discovery Profile
IDD Request for Behavior Support and/or Crisis Support Services
ID/DD Waiver Medical Verification for Behavior Support/Crisis Intervention Services
ID/DD Waiver Functional Behavior Assessment
ID/DD Waiver Behavior Support Plan
ID/DD Waiver Justification for Behavior Support Services
ID/DD Waiver Behavior Support Quarterly Review Report
ID/DD Waiver Request for Additional Behavior Support Services
ID/DD Waiver Request for Additional Crisis Support Services
ID/DD Waiver Request for Crisis Intervention Services
ID/DD Waiver Crisis Intervention Plan
ID/DD Waiver Crisis Intervention Daily Service Note
ID/DD Waiver Crisis Intervention Log- Episodic
ID/DD Waiver Request for Additional Crisis Intervention Services
DMH IDD Plan of Services and Supports guidance
Plan of Services and Supports
General
The Plan of Services and Supports is to be used by Support Coordinators, Targeted Case
Managers, Transition Coordinators and providers of non-Waiver/IDD Community Support
Program (CSP) services.
If a person receives non-Waiver Supervised Living and Work Activity Services and/or
Supported Employment Services, the Supervised Living provider is responsible for arranging
the PSS meeting and having all providers present. If a person receives only Work Activity or
non-Waiver/IDD CSP Supported Employment services, that provider is responsible for
arranging for the PSS meeting.
Timelines
Support Coordinators: The PSS must be revised and submitted to BIDD within 45 days of a
person’s recertification date.
Targeted Case Managers: The PSS must be revised and submitted to BIDD within 45 days of
a person’s recertification date.
Non-Waiver/IDD CSP Providers: The PSS is to be completed annually or within 30 days of
admission to a service. It is to be kept in the file for BIDD review. The Activity Support Plan
is to be developed within 30 days of the date the PSS was developed.
PLAN OF SERVICES AND SUPPORTS INSTRUCTIONS
Plan of Services and Supports Overview
The Plan of Services and Supports (PSS) document reflects a person’s vision of their desired life. It
includes a description of the person’s strengths, what is important to and for them, and supports
necessary to live their best life. The PSS contains the outcomes that lead to the development of a
person’s supports and services. The outcomes indicate what a person wants their life to look like. The
PSS is developed by the person with the involvement of others identified by the person, such as
family, friends, and service providers, and is facilitated by the person’s ID/DD Waiver Support
Coordinator (SC), IDD Community Support Program Targeted Case Manager (TCM), or a Regional
Program’s Transition Coordinator (TC). The planning team uses the PSS as a guide to developing
needed paid supports and services as well as natural and unpaid supports from the community. It is
the fundamental document used to assist the person in achieving their desired outcomes and thus
their best life. The PSS meeting and the 4th Quarterly meeting can be combined.
Plan of Services and Supports Format
The PSS document is divided into six (6) parts:
I. Essential Information
II. Personal Profile
III. Person Centeredness
IV. Signatures
V. Shared Planning
VI. Activity Support Plans
DMH IDD Plan of Services and Supports guidance
Part I
Essential Information (EI)
This part is completed prior to the Plan of Services and Supports meeting. For the person’s first PSS,
the Essential Information should be gathered during a conversation with the person/legal
representative/family member either via phone or in person. The SC/TCM will keep the Essential
Information current throughout the year. Address each section for which information is available,
regardless of whether or not it is a required section to be completed through the LTSS system. For
example, the Employment Section is not required for submission of the PSS to BIDD. However, it
must be completed if the person is eighteen (18) years old or above.
Parts II – IV
Personal Profile, Person-Centeredness, and Signatures
These parts contain information that will be gathered during the PSS meeting. Each member of the
person’s planning team must contribute information that will best help others learn about the person
and how to support them.
Part V
Shared Planning – Outcomes
Ideas for outcomes must be developed during the PSS meeting.
Part VI
Activity Support Plans (ASP)
Activity Support Plans are developed by providers, based on the outcomes developed in Part V-
Shared Planning, after they receive the BIDD approved PSS from the SC/TCM.
Information Gathering
The Plan of Services and Supports should paint a picture of the focus person’s life. The person is the
expert on his/her life and should contribute as much information as possible. Other team members
should consist of the supports in the person’s life that are closest and know him/her the best. All
providers that work closely with the person are required to contribute to the PSS. The PSS should
help the team understand the person, what the person wants and needs, and how best to support
him/her to live the life he/she desires.
With the focus person’s permi ssion, information is also obtained from others with whom the person
interacts. These supports may not be able to attend the PSS meeting but can contribute information
prior to the meeting via the SC/TCM/TC
. This information is gathered over the phone and documented
in planning notes along with the date the conversation took place. The SC/TCM /TC is responsible for
sharing this information at the planning meeting.
Person Centered Thinking Skills© (PCT) developed by The Learning Community will be used during
the planning meeting to gather information. The Person Centered Thinking skills provide a structure
for gathering information during a conversation rather than simply having a question/answer session.
With the SC/TCM/TC
acting as the facilitator and the person acting as co-facilitator of the planning
meeting, the team must work together to obtain all the information that goes in the PSS.
*******Always remember to ask “why,” especially when people give yes/no answers. “Why”
provides an important avenue of exploring topics further. *******
Person Centered Thinking Skills© (PCT) are used as a way to gather information during the PSS
meeting. The skills can also be useful throughout a person’s certification year to gather and organize
information. The PCT Skills include:
DMH IDD Plan of Services and Supports guidance
• The Relationship Map©
• Important To and For©
• Working and Not working©
• 4+1 Questions©
• Communication Chart©
• Good Day/Bad Day©
• Routines and Rituals©
• 2 Minute Drill©
• The Donut©
• Matching Profile©
• Learning Log©
The SC/TCM/TC and all providers are responsible for taking notes during the planning meeting. Notes
can be written on flip chart paper, the PCT Skills© forms or regular paper depending on what is
comfortable for the person and team. SCs/TCMs/TCs are not required to provide copies of their notes/
PCT Skills© forms to providers. Providers must have their own notes/ PCT Skills© forms to be able to
develop Activity Support Plans for the outcomes they are responsible for implementing. Notes/ PCT
Skills© forms will be used by the BIDD to monitor PSSs and Activity Support Plans.
Completing the PSS
The following instructions and examples should be used as a guide to completing a PSS. The
examples do not encompass all items required in each section. These examples must not be
used in writing a future PSS. Instructions are organized in the sequence in which they appear in the
PSS document. Once the PSS is approved by BIDD, everyone on the team will receive a complete
copy of the plan – including the Essential Information.
Part I: Essential Information
This part of the PSS should be completed by the Support Coordinator/Targeted Case
Manager/Transition Coordinator
prior to the PSS meeting. The information should be obtained
through a conversation(s) with the person/legal representative/family either via phone or in person.
The Essential Information can also be completed with staff if they are the ones most likely to have any
of the current information. Certain items can be completed prior to the planning meeting but must be
reviewed with the person’s team at the beginning of the meeting. At the beginning of the PSS
meeting, the following items must be reviewed:
• Medications
• Back-up and Emergency Plans
• Risk assessment
• Employment
• Behavior Supports (If a person has a Behavior Support Plan, it must be reviewed
and documented in the notes/ PCT Skills forms and be attached to the PSS.)
• Contact Information - Complete the identification information for the person and
his/her family members. The person’s address must be entered in the Personal Profile
section of LTSS.
• In the Family Contact Information, include any family members that will not be listed in
the “Natural Supports” section. The Emergency Contact is to be entered in the
Personal Profile section of LTSS.
• ID/DD Waiver/IDD Community Support Program Supports
Depending upon the program, this section includes ID/DD Waiver Supports or IDD
Community Support Program Supports as well as those not funded by either program.
Write the person’s name at the
top of each Skill or note page.
SCs/TCM/TCs must submit
their notes/ PCT Skills© forms
to BIDD as attachments to the
PSS. Providers must maintain
theirs in the person’s record for
BIDD review.
DMH IDD Plan of Services and Supports guidance
This section should not be generic definitions of services or include
medical/institutional terminology. It must be specific to the person and contain
enough information and justification to support the services a person is
approved to receive – the why, when and how. The information listed below must be
included in the PSS.
ID/DD Waiver Supports IDD Community Support Program Supports
• List the services/supports provided through
the ID/DD Waiver along with all the
necessary contact information for each
agency (email address is required) Use the
email address of the staff member who is
most likely the appropriate staff to receive
alerts from LTSS
• Indicate the frequency of the
service/support (hours per day, month or
year)
• Describe in detail: WHEN the person uses
the service; HOW the person utilizes the
service; and WHY the person needs the
service/support.
• Include a set schedule if there is one or the
times services are usually provided
• If the service is Home and Community
Supports, indicate if a family member is
providing the service, their relationship to
the focus person, and how many hours per
month they provide
• All direct support professionals (DSPs)
must be reflected on the Relationship Map
• List the services/supports provided
through the IDD CSP along with all the
necessary contact information for each
agency (email address is required)
• Indicate the frequency of the
service/support (hours per day, month or
year)
• Describe in detail: WHEN the person
uses the service; HOW the person
utilizes the service; and WHY the person
needs the service/support.
• Include a set schedule if there is one or
the times services are usually provided
• All direct support professionals (DSPs)
must be reflected on the Relationship
Map
Non-Waiver Agency Supports Non-IDD CSP Program Supports
• List the agencies that provide
services/supports to the person through
avenues other than the ID/DD Waiver
along with all the necessary contact
information for each agency
• Provide a brief summary of how, when and
why the support is used
• Examples of non-Waiver agency supports
are Vocational Rehabilitation, Physical
Therapy, Community Support Services,
Counseling, etc. All supports listed here
must also be reflected on the Relationship
Map.
• List the agencies that provide
services/supports to the person through
avenues other than the IDD CSP along
with all the necessary contact information
for each agency
• Provide a brief summary of how, when
and why the support is used
• Examples of IDD CSP agency supports
are Vocational Rehabilitation, Physical
Therapy, Counseling, etc. All supports
listed here must be reflected on the
Relationship Map.
DMH IDD Plan of Services and Supports guidance
• Natural Supports
List the people who provide unpaid supports to the focus person.
Include family, friends, neighbors, people who support the person in the
community and anyone else the person wishes to include. This could include
those that provide support through a church, job or a volunteer program.
Include names (first and last) of the natural support rather than “family” or
“friends” since this section will pre-populate the Shared Planning section in
LTSS.
Indicate the natural support’s relationship to the person, their phone number
and how and when they provide support to the person. (This must include how
often the natural support sees or speaks with the person and what they do
together. If the phone number is unavailable, enter 000-000-0000. **
All natural supports listed here must be reflected on the Relationship Map.
People listed in the center section of the Relationship Map should be reflected
in the PSS. If they do not support the person regularly or never but the person
wants them on the map, document this information somewhere on the
Relationship Map page.
• Medical Information
List the physician(s) who provide services/supports to the focus person and
their specialty area such as general practitioner, dentist, neurologist,
ophthalmologist, etc.
Provide the physician’s contact information.
All medical agency services/supports listed here must be reflected on the
Relationship Map.
Medications
List all of the current medications the person is taking including over-the-
counter medicines.
For each medication, indicate the dosage and frequency the person is
taking, the physician who prescribed the medication and the reason for
taking it. (www.rxlist.com
is a good resource for understanding
medications and their usage)
If it is an over-the-counter medication, indicate why they need it or the
condition for which it is taken.
Indicate if the medicine is used as a psychotropic medication
List any chronic health or physical conditions the person has. Chronic health
or physical conditions are ongoing conditions that the person has lived
with and will continue to live with for the foreseeable future. (Ex: diabetes,
cerebral palsy, hypertension, epilepsy, etc.) Also indicate any diagnoses that
are not listed in the evaluation section.
DMH IDD Plan of Services and Supports guidance
The history of health problems/issues addresses any illnesses the person
experienced in the past but that are not affecting their health and welfare
presently. Include any surgeries or procedures the person has undergone that
may affect his/her current situation. (Ex: stroke, heart attack, cancer, removal of
organs, no seizures experienced in 5 years, etc.) Also indicate any historical
diagnoses that are not listed in the evaluation section.
Current limitations on physical activities are usually supported by a doctor’s
note. The SC/TCM/TC
is to upload the note into the attachments section of the
PSS module under “Other.” It may be that a person can only lift a certain
amount of weight due to a hurt back or are temporarily restricted from certain
activities due to medical issues. (This section does not include Cerebral Palsy,
wheelchair, walker or crutches, etc.)
If the person was ever admitted to a facility (Ex: ICF/IID, Nursing Facility,
Rehabilitation Facility, Behavioral Health Facility, etc.) indicate when, where
and why they were admitted and the circumstances surrounding discharge.
List the dates of the most recent physical and dental exams.
List anything the person may be allergic to and indicate how he/she reacts to
the allergen.
• Medical and Mental Health Support Needs
If the person has experienced any physical complaints or other medical issues
during the past year, provide a summary of the issue(s) and the outcome. This
is where the SC/TCM/TC
can list anything that may have come about as a
result of a physical exam during the past year.
List any special medical items necessary for the person to live comfortably.
Indicate the equipment or treatment and when, why and how it is used and who
is responsible. (Examples: Baclofen pump, G-tube, Peg-tube, oxygen,
disposable adult briefs, ventilator, blue pads, Epi-pen, etc.) (Example: Mary is
allergic to bees. She keeps an Epi-pen with her at all times.)
If the person is receiving Mental Health support services, provide a description
of the services/support, when and why the support is needed and how it
benefits the person.
• Communication and Equipment/Technology
Indicate the person’s method of communication. (Do they use words or
gestures to speak?)
Describe supports needed for communication (what communication devices,
sign language, etc.)
Describe any adaptive equipment or assistive technology supports the person
uses and why. (Examples: wheel chair, lifts, hospital bed, hearing aids, walker,
bath chair, adaptive forks or knives)
DMH IDD Plan of Services and Supports guidance
Indicate how is the equipment maintained and who is responsible.
Describe is the back-up plan for power outages if medical equipment is used.
• Risk Assessment
The Support Coordinator /Targeted Case Manager/Transition Coordinator completes
the Risk Assessment Tool with the focus person, his/her family or legal representative,
and providers before the meeting. It will be reviewed at the meeting and all pertinent
information will be included in the PSS. List the date(s) the Risk Assessment Tool was
completed, any identified risks and the strategies for avoiding identified risks
(Resolution) for each. If the person has no identified risks, write “none” in this section
and on the Risk Assessment Tool and upload it to LTSS.
• Back-Up and Emergency Plans
Indicate what will happen if the provider does not show up – this includes all
services that go to the person’s home, not just in-home services.
Indicate the actions to take if the day program, work or other activity is canceled
or closed.
Indicate the actions to take when disasters occur – this refers not only to natural
disasters but also to emergencies, issues with housing, staff not being
available, issues with evacuation, etc.
These plans must include the name and phone number of who the person is to
call.
Plan for future living arrangements – where will a person live in the future or
where will they go if something happens to their home or people they live with.
• Family and Current Living Arrangements
Indicate the current living arrangement for the focus person (at home with
parents, at home with siblings, in a supervised living setting, in an apartment
with/without a roommate, etc.).
State with whom the person lives, and the age, occupation and health condition
of everyone living in the home. Provide information about the level of support
each individual living in the home provides to the person.
Include ALL family listed on the Relationship Map and the amount of support
they provide to the person (Example: Aunt Mary lives in Chicago and sees Sue
twice a year.)
If the person resides in a group home, indicate the roommates’ first names.
If the person resides alone or in a group home, indicate the extent of the
support/interaction he/she has with family as well as the information above.
DMH IDD Plan of Services and Supports guidance
• Education
Indicate the current school, if applicable. List the name of the last school
attended (if known). Indicate if he/she received a certificate of completion or a
diploma and the date (an estimate of May 31st and the year of graduation is
appropriate). If a person is under the age of 21 and not in school, indicate in
the notes the reason(s) why.
Employment and Volunteer Activities
If the person currently has a job, indicate where he/she is employed, when
he/she began, the days and hours he/she works, and provide a summary of the
work duties. If the person’s schedule varies, the SC/TCM/TC can choose the
days and times the person generally works. ** Estimate the begin date if
necessary. Indicate such in the notes.
If the person was previously employed, indicate where he/she worked as well
as the end date and the reason he/she is no longer employed at that location.
Estimate dates and days, if not known, and indicate such in the notes.
If a person is not employed, indicate why in the “Duties” column. Employment
MUST be addressed at all meetings for people ages eighteen (18) and older
and be documented in the PCT Skills/Notes.
If the person volunteers somewhere in the community, indicate where, the
begin date, the days and hours he/she volunteers and what duties are
performed while volunteering. List as many places as applicable. If exact begin
dates are not known or if the schedule varies, estimate in this section and
indicate such in the notes.
If the person volunteered in the past, provide the necessary information, if
available. Estimate dates and days, if not known, and indicate such in the
notes.
If the person has never volunteered, please indicate such in the notes.
• Previous and Current Behavior Supports
This section includes any and all information regarding current or past actions
that
providers would need to know to support the person.
If the person is currently or has previously received services to assist in
correcting inappropriate actions, indicate what the actions are/were, when they
occur or occurred and what was done or is being done to eliminate or change
the actions, if necessary.
If the person has a Behavior Support Plan in place, indicate there is a plan
being implemented and upload a copy of the plan with the PSS.
If the person currently does things out of the ordinary but they do not need a
Behavior Support Plan, list those actions and specifics, if known.
DMH IDD Plan of Services and Supports guidance
• Serious Incidents During the Past Year
Write a summary of any serious incidents that occurred during the past certification
year. Include information regarding the incident(s) that occurred and how the
incident(s) was resolved or the outcome(s) of the incident(s). Indicate if the PSS was
changed as a result of the incident.
• Evaluation Information
Record the person’s current ICAP score and level, the date the assessment
was conducted, and who conducted it.
Indicate the date of the most recent Psychological Evaluation and who
conducted the evaluation.
List the diagnoses given as a result of the evaluation.
If there are any diagnoses on Axis I or III, ask which, if any, are still relevant
and list them in the Chronic Medical Conditions section, History of Health
Problems/Issues section, or Medical Needs section, depending on the nature of
the diagnosis.
• Essential Information Completed By
The SC/TCM/TC completes this section by indicating the person/legal
representative/family that provided the information, his/her name, and the date
completed. The SC/TCM/TC can indicate in the Notes who else may have provided
information for completion of the Essential Information. This person should be listed in
the section “Contributors Not at Meeting” if they are not at the actual meeting.
The Planning Meeting
The Support Coordinator/Targeted Case Manager /Transition Coordinator is responsible for
facilitating the planning meeting. Good facilitation is crucial to complete the Personal Profile. The
Personal Profile must be reflective of the person and the supports needed to make sure he/she lives
the best life possible. The more information that is elicited during the planning meeting, the stronger
the plan will be to support the person. This will entail asking questions to draw information out of the
person/team rather than asking yes/no questions. In some cases subjects or ideas may need to be
challenged or teased out to determine a way to change something or make something new and
different happen that is important to or for the focus person. If optimistic discontent is not created,
change will not occur.
The key to a good person centered plan is asking “why” when gathering information and
understanding the “why” when reviewing the PSS.
Remember the plan belongs to the person and is about what they want for their life rather than
what the family and providers think is best for them. Plan WITH the person rather than FOR
the person.
The plan must always be current and reflect what is happening in the person’s life. The person
must be aware of the process for requesting changes and updates to their PSS throughout the
year and not just at the annual planning meeting in order for the document to always be
DMH IDD Plan of Services and Supports guidance
current. Requests for change should be made to the Support Coordinator/Targeted Case
Manager. The person/legal representative must make the request. Providers can inform the
Support Coordinator/Targeted Case Manager of issues that may be occurring, but the request
for additional services must come from the person/legal representative. The process must be
explained during the planning meeting so all team members are aware of the process.
The Personal Profile is written in the present tense rather than describing what has happened
in the past or what may happen in the future.
Using people’s first names in a PSS makes the plan more person centered. It is their plan and
they know the people supporting them and their relationship to the support person.
The PSS must be written in plain language so that it is easily understood by the person and
everyone else on their team. Medical or institutional terminology must be avoided.
Pay attention to behaviors as well as words. People often speak louder with actions than with
words. Sometimes people tell us what they think we want to hear rather than how they really
feel or what they really think. By reading a person’s behaviors, these things can be figured out.
The Person Centered Thinking Skills© provide a guide for gathering information through a
regular conversation rather than a question/answer session. People are more likely to
contribute information if they feel comfortable and are not being pressured with answering
questions. Make sure everyone at the meeting is included in all aspects of the conversation.
All information included in the Personal Profile section must come directly from the notes or
Person Centered Thinking Skills forms written during the meeting; however not all information
gathered will always go into the Personal Profile. Some information may not be appropriate to
include in the person’s PSS.
Examples: negative things about the person stated at the meeting;
discussions at the meeting that may have not been positive or were hot
topics; information gathered/offered that may not be important to know or do,
etc. However, these things should be reflected in your notes so that you
know they were discussed and can follow up on them at a more appropriate
time.
Information should be recorded as it is expressed during the meeting. When the SC/TCM/TC
writes the Personal Profile, he/she organizes the information and determines where it belongs
in the PSS. If information is expressed in a negative manner, the SC/TCM/TC should use the
“Reframing Reputations” Skill© when writing the information in the PSS. Negatives must be re-
worded in the PSS to make them factual, yet not stereotypical or clinical. (Example: “Amy is
attention seeking.” Could be “Amy wants alone time with staff.”)
The SC/TCM/TC is responsible for organizing the information discussed during the planning
process and developing the PSS. The PSS should not be a copy of the PCT Skills©/notes
taken during the meeting. Information is gathered using the skills but it does not necessarily
belong under that section of the PSS. It may be more appropriate in another section of the
PSS.
Example: Bad Day Skill© – a person says “last minute changes” can cause
them to have a bad day. If something has an effect on a person and how
they act, that is information that could go under the Important TO or
Important FOR section of the PSS. Same with Dislikes – if a person dislikes
something, why and what happens? Is this something that is Important To or
For them?
DMH IDD Plan of Services and Supports guidance
Information in the Personal Profile must be in the form of a sentence. (Example: “Spot is
important to Mary because he is her constant companion:” not just “Spot.”)
For people who do not use words to speak, write what a support person may think the focus
person would say or do. (Example: “Suzy says she thinks Mary would say playing with Spot is
working for her.”)
Once a PSS is developed and implemented, the SC/TCM (not the Transition Coordinator)
is
responsible for keeping the PSS document current and ensuring all team members have the
most recent information.
If/when changes or revisions are made to the PSS during the certification year, all team
members must agree and will then receive an updated copy of the PSS from the SC/TCM.
Throughout the planning process, it is recognized that sometimes difficult choices may
have to be made. Teams are encouraged to be creative in overcoming obstacles such
as limited funding, isolated geographical locations and limited community resources in
order to support the person in meeting their desired outcomes.
All information included in the PSS must be written in complete sentences and include
“WHY” – For example, someone says attending the day program is important to
him/her. WHY is it important to him/her? Is it because they see their friends there?
Part II: Personal Profile
The Personal Profile is the core of the person’s plan and contains the most vital information – an
image of the person and the supports needed to make sure he/she lives his/her best life possible.
Good facilitation and participation of all team members is crucial to completing the Personal
Profile.
A. Introduction: Great Things about ______
The Introduction is written with positive, person-first language to introduce the focus person. It
emphasizes the positive qualities identified by the person and others that know him/her best. Written
correctly, the Introduction should capture the person’s spirit and provide a clear impression of the
person’s admirable qualities and present his/her “positive reputation.” It should be worded as if you
were introducing the person to someone new.
Example: Mary has a dynamic personality. She has a great sense of humor
and loves to make people laugh. Mary is very passionate about things that
are important to her such as her dog Spot. She is a loyal friend. Mary loves
a challenge and will not give up until she has done what she set out to do.
B. Hopes and Dreams
This section describes the hopes and dreams of the focus person at this time in their life. The PSS
must reflect the true hopes and dreams of the person and not just what the team believes is
obtainable. No hope or dream should go unacknowledged or be dismissed just because team
members believe it is unattainable. These must be the person’s hopes and dreams. Hopes and
dreams should not be tied to health or welfare.
Ask the questions:
What would he/she like to accomplish?
Where does he/she want to go?
What does he/she hope to have one day?
What would he/she like to learn to do?
Example: Mary wants to live in an apartment with her best friends,
DMH IDD Plan of Services and Supports guidance
Kimberly and Susan. Mary hopes that one day she will get the
chance to go to Washington and meet the president.
C. Important TO and Important FOR
Recognizing what is important TO and important FOR a person is the fundamental Person Centered
Thinking Skill©. When planning with a person, focus on what is important to the person as well as
what is important for them (health and safety). The goal is to balance what is important to/for the
person so that they can live a good life.
IMPORTANT TO:
These are things in life that are special to the person. This section must include things, when present
(or if applicable), that are likely to contribute to a good day, or when absent, are likely to contribute to
a bad day. The following areas MUST be addressed:
Relationships
Things to do and have
Community Integration (places to go)
Rhythm and pace of life
Rituals and Routines
Status or control over one’s life (choices, decisions, options)
Anything else the person wishes to include
Tips:
• Do not include items the team thinks are or should be important to the
person. This is just what the person thinks.
• Remember there is a difference between what someone “likes” and what is
“important to” the person. “Likes” can be included in the section “Things
People Need to Know and Do to Support the Person and Keep Them
Healthy and Safe” or “Strengths.”
IMPORTANT FOR:
These are things that are necessary in a person’s life to ensure their health and welfare. The following
areas MUST be addressed but not limited to:
Things pertaining to issues of health (prevention, treatment, diet, exercise,
physical health, mental health, etc.)
Issues of safety
Support needs
Medical conditions
What is necessary to help the person be a valued and contributing member
of their community
Examples:
Important to Mary Important for Mary
It’s important to spend time with best
friends, Kimberly and Susan, to laugh and
have fun.
Spending time with Abby, Sam, and her
friends is important for Mary so she has
good relationships and supports
Spot (puppy) is important to Mary because
he is her constant companion.
It is important for Mary not to be rushed so
she doesn’t forget things and become
upset.
It’s important to Mary to choose where she
and Suzy (HCS provider) eat lunch and
Being with Suzy is important for Mary.
With Suzy, she gets to go do things
DMH IDD Plan of Services and Supports guidance
Important to Mary Important for Mary
shop so she has some say in what she
does.
without her parents.
It’s important to Mary to not be rushed; she
will forget things and become upset.
Taking care of Spot is important for Mary.
It gives her a sense of responsibility and
she takes it very seriously
D. Working/Not Working
This section provides a snapshot of what is currently working and not working in a person’s life from
multiple perspectives. Things that may occur in the future or that need to be prevented are not
recorded here. All team members must look through the lenses of the focus person and not just their
own. Each service must have its own section and the information working and not working must be
relevant to that service/support being provided. Topics addressed MUST include but are not limited to:
Living arrangement (where and with whom)
Relationships (family, friends, providers, anyone else)
What the person does for fun
Where they like to go and what they like to do in the community
How the person spends his/her days (include school, day program, job,
volunteering, retirement activities, etc.)
The amount of control the person has over life choices (Example: churches,
activities, clothes, time they go to bed at night, etc.)
Any plans developed to support the person in addition to the PSS, when applicable.
(Example: a Behavior Support Plan, doctor ordered diet, any plans written for
restrictions/limitations.)
Addressing ALL
of the items indicated above from each team member’s perspective allows the team
to think through how to support the person rather than jumping straight to the “fix” for the person.
The “Not Working” section shows different perspectives which leads to questions as to why something
is occurring. In these cases, the information may show up here and in the “Questions/Things to Figure
Out” section.
Examples: The examples listed below do not encompass all items required to be addressed.
• Perspectives:
Person’s perspective – list things the person says are working and not working
in his or her life as related to ALL areas listed above. If the person cannot use
words to speak, the team may all contribute. Indicate who says what they think
Mary would say is working/not working from her perspective.
Mary’s perspective
Working Not Working
Mary thinks taking care of Spot is working.
She likes playing with him and feeding
him.
Not being able to decide what she
wants to eat for lunch at the day
program is not working for Mary. She
doesn’t like some of the food they
serve.
Spending time doing fun things with Suzy
like getting nails done, going to eat
Mexican food, and walking at the park is
working for Mary.
Having to sit next to Steve at the day
program is not working. He gets on her
nerves with his loud mouth.
Mary is happy learning to play games on Suzy not being around enough isn’t
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Mary’s perspective
Working Not Working
the computer. She thinks this is working
well.
working for Mary. She misses Suzy
when she is gone and thinks they don’t
get to spend enough time together.
Family’s perspective - list things family members see as working and not
working for the person regarding the topics listed above. Family members must
look through the lenses of the person as well as their own. Ideas/subjects
should not be listed in a negative fashion, nor should they violate the person’s
rights.
Abby (mom) and Sam’s (dad) perspective
Working Not Working
Suzy spending time with Mary and taking
her places she wants to go is working.
Not having enough HCS hours to do
more things with Suzy on the weekends
is not working.
It is working that Mary gets to do new
activities and experience new things at the
day program.
The weight Mary has gained from
eating too many sweets is not working.
It is not good for her health and
wellbeing.
Mary being able to do things for herself
like getting ready to go to the day program
is working out well.
Mary not having a job in the community
so she can be around more people and
make money isn’t working.
Provider’s perspective - list things the provider(s) see as working and not
working for the person regarding the support(s) they are providing. Providers
must look through the lenses of the person as well as their own. Each
service/support should have a separate working/not working perspective.
Ideas/subjects should not be listed in a negative fashion, nor should they violate
the rights of the person. The provider should say “why” something is not
working.
XYZ Agency; HCS; Suzy’s perspective
Working Not Working
It is working that Mary takes good care of
Spot. She loves him so much.
Not enough HCS hours to do more
things with Mary isn’t working.
Mary and I having fun together laughing
and singing in the car is working well for
her and me.
It’s not working that Mary doesn’t have
more opportunities to make new friends.
The schedule Abby and I have worked out
for me to support Mary works well for
everyone.
Mary always asking to go get ice cream
isn’t working. Her mother says she has
gained a lot of weight. I don’t like telling
her no though.
XYZ Agency; DSA; Dan’s perspective
Working Not Working
Mary learning to use the computer to play
games is working well. She is very good
on the computer.
Mary wanting to do everything in the
kitchen and not allowing others to have
a chance isn’t really working.
It is working that Mary keeps the day It’s not working that Mary doesn’t want
DMH IDD Plan of Services and Supports guidance
XYZ Agency; DSA; Dan’s perspective
Working Not Working
program calendar up to date. She always
knows what is going on.
to get off the van when returning from
community activities.
Mary eating lunch with her best friends
Kimberly and Susan works well for her.
Sitting next to Steve during certain
activities doesn’t seem to be working for
Mary. He gets on her nerves.
E. Things People Need to Know (and do) to Support the Person and Keep Them Healthy
and Safe
This section includes information/instructions others need to know and do to support the
person. The information should not focus on services but rather on a description of the person
and supports necessary for them to have a good life. It should be detailed and specific and be
written so it is easy to understand and clearly explains how to provide supports. Any
information can be recorded in this section including, but not limited to, inappropriate actions,
means of communication, routines, likes, dislikes, coping strategies, relationships, fears or
concerns and what to do about them, movement and mobility, seizures, medications, feeding
rituals or instructions, treatments and interventions, special considerations, etc. Think about it
from a provider’s perspective and what they would need to know and do to support someone
they just met. A provider should be able to know what to do for or with someone and
when, how and WHY. This may be the only part of the PSS a DSP reads.
Examples:
Actions that are not appropriate or may cause problems:
Example: John will hit staff or other people in the program when he doesn’t
get his way.
Special considerations that relate directly to the person
Example: Remind Ryan not get in other people’s faces when talking to
them.
Person's fears or concerns
Example: Sam is afraid of the dark. Always make sure the nightlight is on
before turning out his light at bedtime.
Movement and mobility - include any approaches, supplies or devices that are
used to accomplish movement and mobility; movement patterns and/or habits
Example: Lizzie uses a power wheelchair to get around. The chair needs to
be charged every night. When she goes to the mall, Walmart or out to eat,
Lizzie takes her manual wheelchair and needs to be pushed.
Routines - include routines for the morning, bathing, evening, etc.
Example: Dottie has a bed bath every other morning and a shower the other
days. Dottie does not like having her face wet so staff use a special shower
chair that reclines to keep the water out of her face.
F. Strengths
This section focuses on what the person can do for him/herself or can do with assistance.
Indicate the person’s abilities to perform specific activities. This should be a description of the
person rather than a list of their positive qualities. The description reflects the person’s abilities
and likes. Use complete sentences.
Example: Mary has the ability to control her emotions. She likes to make her
own decisions. Mary manages her money with the assistance of Sam. She
will let you know when she doesn’t like something or isn’t excited about
doing something. Mary uses the microwave to cook popcorn when she
DMH IDD Plan of Services and Supports guidance
watches movies. She gets herself ready for the day program in the morning
and does her nighttime routine on her own. She loves to ride her bike
around the neighborhood.
G. Referrals
Describe any referrals necessary for the person. Indicate who will make the referral and by
when. (Examples: VR, MH, therapy, etc.)
H. Questions/Things to figure out
This section is a place to record things the team does not know about the person and/or
questions left unanswered at the end of the planning meeting. More times than not, the team
will not know all the necessary information or the answers to all questions.
Where are we missing information?
What do we need to know more about?
What do we need to figure out to make something happen or how to better support
the person?
Always include who will be responsible for following through with getting more
information regarding the issue or what they will do. Also include the timeline. If a
staff person is responsible, then this information will also go in the person’s Activity
Support Plan for that specific service.
Example: Mary wants to swim more often. Where is a place that has a pool
that can accommodate a person who uses a wheelchair? – Shelly from DSA
will look into this
Part III - Person-Centeredness
All services and supports provided must be person centered. People with disabilities have rights that
cannot be violated and must be protected. Each person must be given choices regarding the services
and supports they need to live a good life. Each of the following must be addressed in the PSS and
there must be a statement associated with each answer:
Information on what services are available must be presented to the person/legal
representative/family in an understandable manner in order for them to make an informed
decision on which service(s) they wish to utilize. Explain each applicable service and how it is
used.
Information on all certified providers must be presented to the person/legal
representative/family in an understandable manner in order for them to make an informed
decision on which provider(s) to utilize.
Information regarding different living environments/arrangements must be presented to the
person/legal representative/family in an understandable manner in order to choose the best
living environment/arrangement for the person. Some people living at home with families may
not know there are other options. People already living in the community need to know there
are other places to live if they are not happy where they are.
If the person chooses to live in a group setting, there must be documentation that they were
given a choice of roommates.
Unless the person is a minor (under the age of 18) or has a legal guardian/representative (with
legal documentation), they should be given control over their personal resources.
Example: access to money, access to health and wellness, emotional support,
spirituality, social supports, etc. If a person’s family assists them with making
DMH IDD Plan of Services and Supports guidance
choices or budgeting their money, please indicate this information.
Documentation must be maintained indicating the person is given a choice of activities in
their day program and home settings. Examples must be provided of what the person
chooses to do.
Example: arts and crafts, where to go eat, where to go look for a job; where to
shop, etc.
Any limitations or restrictions must be addressed. Limitations and/or restrictions limit a person’s
movement, daily activities, choices, access, or functions. Placing limitations and/or restrictions on
a person often results in the person losing an object or not getting to do something they enjoy.
Positive reinforcement is not present when restrictions are in place. If a person has a limit or
restriction, there must be a plan in place supporting the necessity of the restriction/limitation and
how it is to be used. A copy of the plan must be attached to the PSS. The plan must include the
specific circumstances it will be used in, the fading techniques of the plan and the consent of the
person/legal representative to implement the plan. If there is a doctor’s note supporting a special
diet or other health items, a copy of the medical or a doctor’s note must be attached to the PSS.
Examples of limitations/restrictions: visitors not allowed; having items taken
away for certain reasons; food choices not allowed; being limited to a special
diet; being told when to eat or sleep.
Part IV – Signatures
Everyone at the PSS planning meeting must sign the Signature Page to indicate they participated in
developing the PSS. Each team member’s signature indicates a promise being made to the
focus person to work on making their life better by supporting their outcomes. The signature
page also serves to hold those team members accountable for implementing their part of the PSS. If
someone did not attend the planning meeting but still contributed information via the SC/TCM/TC
,
their name and relationship to the person must be indicated in the appropriate section along with the
date the information was provided to the SC/TCM/TC. The SC/TCM/TC signs the document last
indicating they are responsible for monitoring the implementation of the PSS. The signature page
must be uploaded into the LTSS system along with the Skills/Notes from the planning meeting in the
attachments section of the PSS module.
The Support Coordinator/Targeted Case Manager sends a copy of the signature page to providers
who attended the meeting.
Part V - Shared Planning
The Shared Planning section of the Plan of Services and Supports indicates specific outcomes a
person wishes to achieve in order to lead the life they desire. Outcomes are developed by the
person and his/her team based on what is important TO them according to the information
collected and written in the Personal Profile section of the PSS. The person may want to change
an aspect of his/her life, learn to do something new, or continue doing something that is currently
working in their life.
Outcomes are not directed by the services/supports a person receives but rather by the life
they wish to live. Outcomes direct the services and supports to be provided. Outcomes are not
services a person receives or specific details written on how to support them. They are
general statements about living life.
• Outcomes must be measurable:
Can you see it?
Can you count it?
DMH IDD Plan of Services and Supports guidance
• The Support Coordinator/Targeted Case Manager/Transition Coordinator may choose to
use the “Person Centered PSS Outcome Worksheet” to record ideas or recommendations
for outcomes as agreed upon at the meeting. The form is optional.
• All outcomes must be written using the following formula:
Name + action verb + what/where + so that/in order to = expected results
The “Desired Outcomes” is where each outcome idea developed during the meeting is recorded.
The SC/TCM/TC writes the outcomes after the meeting based on the ideas discussed
during the meeting.
The “Provider Services” column indicates who is responsible for completing activities related to
each outcome. This may include more than one provider and/or service. Natural supports can
also be responsible for supporting outcomes. If a natural support is going to support an
outcome their name will be pre-populated from the Natural Supports section of the PSS in the
LTSS system.
The "How Often" column indicates how often activities will be completed while working towards
the outcome. The timeframe must indicate if the activity will be completed daily, weekly or
monthly. If activities are to be completed weekly or monthly, the number of times of
participation/support must be included. The start and end dates will be pre-populated by the LTSS
system to reflect the dates of the person’s current certification year.
Examples:
Outcome Desired Outcomes Provider
Services
How
Often
Start
Date
End
Date
1
Mary participates in arts and crafts
in order to make things to give to
her family and friends.
XYZ Agency/HCS,
DSA
3 x
per
week
10/1/15 9/30/16
2
Mary attends church so that she can
worship God and see her friends in
Sunday School.
XYZ Agency, HCS
XYZ Agency, DSA
Abby and Sam
2 x
per
week
10/1/15 9/30/16
3
Mary feeds and walks Spot in order
to ensure he is healthy and well
cared for.
XYZ Agency, HCS
Abby and Sam
Daily 10/1/15 9/30/16
4
Mary eats out, shops, gets her nails
done and does other things in order
to enjoy herself and be a part of her
community.
XYZ Agency, HCS
XYZ Agency, DSA
Abby
4 x
per
week
10/1/15 9/30/16
The Plan of Services and Supports should always be a complete, current snapshot of a person’s life.
Everyone’s life changes all the time. The people who receive supports are no different. Health
changes, friends come and go, jobs change, life changing events happen. The plan should always be
updated to reflect those changes in order to know the person and what is currently happening in
his/her life.
Planning with a person using Person Centered Thinking Skills© and practices allows you to dig
deeper, ask more questions, and find out more about a person than ever before.
Always ask
“WHY”?? Plans and outcomes are truly individualized. People we support will begin communicating
with us and letting us help he/she live the life they want. Only when people see change do they
believe it.
DMH IDD Plan of Services and Supports guidance
Revisions to the Plan of Services and Supports
The PSS is a fluid document that is meant to be revised throughout the year as a person’s situation
changes. Revisions can be made to any section of the PSS. Providers can also ask for changes to a
PSS regarding the Shared Planning Section. An outcome may be accomplished or a new outcome
may need to be added. Additionally, they may have information regarding an item in the Essential
Information Section that may need to be updated. The person/legal representative must agree to all
changes either in writing, or via a witness hearing the request. Everyone who attended the most
recent in-person PSS meeting must get a copy of the revised PSS.
Due to changing needs, there could be instances when all members of the team must come together
during the person’s certification year to review/revise the PSS. For example, a person could have a
change in medical condition and new services must be requested, the Personal Profile must be
updated and the Shared Planning must be revised. Other examples could include someone moving
from their family home to Supervised Living. A new PSS meeting would need to be held to involve the
new provider and new outcomes may need to be developed. The revised PSS and signature page
would be sent to everyone who attended the meeting.
Recertification Plans of Services and Supports
For recertification Plans of Services and Supports, the SC/TCM may take a copy of the current PSS to
the PSS meeting. It can be used as the basis of the conversation. All elements of the Essential
Information should be kept current throughout the year. Before the PSS meeting, the Support
Coordinator/TCM can review the elements with the person/legal representative/service providers to
ensure they are up-to-date. However, the following elements of the Essential Information must be
reviewed at the PSS meeting to ensure they are, indeed, current:
Medical Information
Medications
Back-up and Emergency Plans
The Risk Assessment
Employment
Behavior Supports (if applicable)
Any restrictions
The Skills to be used at each meeting will vary from person to person. The SC/TCM must use their
judgement to determine which Skills may be necessary to gather additional information. Any new
Skills and all notes taken at the PSS meeting must be submitted to BIDD with the recertification PSS.
The Relationship Map is the only required Skill to be used. It is to be updated, as needed, and be
submitted with the PSS.
All sections of the Part II: The Personal Profile should be reviewed to ensure all sections are accurate
and current. All questions in the Person Centeredness Section must be addressed. The Shared
Planning Section is to be updated/changed according to information gathered during the PSS
meeting. Everyone who attends the recertification PSS meeting must get a copy of the revised PSS
and the signature page.
Providers should bring copies of their Activity Support Plans to the meeting to review, also. The
provider has 30 days from receipt of the PSS to complete revisions the Activity Support Plan. It must
be submitted to the SC/TCM by the 15th of the month following the month it is developed.
The Plan of Services and Supports Instructions include person centered concepts, principles and materials used
with permission from The Learning Community for Person Centered Practices. Find out more at
www.learningcommunity.us. Support Development Associates, Inc. also contributed to development of the PCT
Skills©.
DMH Plan of Services and Supports form
Plan of Services and Supports Status: Program Type: ID/DD
Overview
Active: Created Date:
PSS Type: Initial/Recertification/Change Effective Date:
Service Type End Date:
Comments:
Part I - Essential Information
Contact Information
Legal First Name: Medicaid #
Legal Last Name: Initial Certification Date:
Legal Middle Name: Home Phone:
Preferred Name: Cell Phone:
Date of Birth: Email:
Address: Support Coordinator/TCM
Family Contact
First Name: Phone:
Last Name: Fax:
Middle Name: Email:
Contact Type: Address:
First Name: Phone:
Last Name: Fax:
Middle Name: Email:
Contact Type: Address:
First Name: Phone:
Last Name: Fax:
Middle Name: Email:
Contact Type: Address:
DMH Plan of Services and Supports form Page 2 of 9
Name: Medicaid #: Certification Date:
ID/DD Waiver Supports
Service Information
Service Type: PSS Service:
Frequency Type: Units per month:
Hours per Month: Rate:
Minutes: Costs:
How/When Support is Used:
Provider Information
Provider Name: Provider Number:
Contact Name: Phone:
Address: Email address
Service Information
Service Type: PSS Service:
Frequency Type: Units per month:
Hours per Month: Rate:
Minutes: Costs:
How/When Support is Used:
Provider Information
Provider Name: Provider Number:
Contact Name: Phone:
Address: Email address
PSS Costs
Annual Waiver Plan Services Total:
Annual 1915(i) Services Total:
Total PSS Budget:
Non – Waiver Agency Supports
Agency Contact Name Phone Number: Non-Waiver Agency
Support
How/When Support Provided
DMH Plan of Services and Supports form Page 3 of 9
Name: Medicaid #: Certification Date:
Natural Supports
Are there natural supports? Yes/No
Support Person Relationship Support Role Phone Number
Medical Information
Physician Specialty Address Phone
Medications
Medications required?
Medication: Physician: Dosage Frequency Reason(s)
Prescribed
Psychotropic
Y/N
Recent Physical and Health Conditions
Recent Physical Complaints and/or Health Conditions
Chronic health conditions? Yes
No
Description:
History of health problems/issues? Yes
No Description:
Current limitations or restrictions
on physical activities?
Yes
No
Description:
Any serious illnesses and/or
hospitalizations in the past year
including ER visits?
Yes No
Description:
Admissions to ICF/IID, Mental
Health Facilities, Rehabilitation
Facilities or other inpatient care?
Yes No
Description:
(when,
where, why)
Latest Exam Dates
Date of my last physical exam:
Date of my last dental exam:
Estimated/approximate date? Estimated/Approximate date?
Examination Results
Examination Results
DMH Plan of Services and Supports form Page 4 of 9
Name: Medicaid #: Certification Date:
Allergies:
Reactions:
Medical Support Needs and Mental Health Support Needs
Medical Support Needs Mental Health Support Needs
.
Communication, Adaptive Equipment, Assistive Technology and/or Modifications
Method(s) of communication:
Describe supports needed for communication (if any):
Describe any adaptive equipment or assistive
technology supports used:
How is equipment maintained? Who is responsible?
What is the back-up plan for power outages if medical
equipment is used?
Describe any environmental modifications necessary:
Risk Assessment
Date Created:
Risk:
Resolution
Back-up and Emergency Plans
Steps to take if the provider does not show up:
Steps to take if the day program/work or other activity
is canceled, closes or you have to
leave for some other reason:
Steps to take when a natural disaster occurs:
Plan for future living arrangements if something were
to happen to the primary caregiver:
DMH Plan of Services and Supports form Page 5 of 9
Name: Medicaid #: Certification Date:
Family and Current Living Arrangements
Education
Current School Year
Last School
Attended:
Year
Type of
Diploma/Certificate:
Year:
Employment History
Was {name} ever
employed? Yes No
Reason why
{name} isn’t
working:
Volunteer Activities
Did {name} ever
volunteer? Yes No
Behavior Supports
Previous and Current Behavior Supports:
Serious Incidents During the Past Year
Evaluation Information
Current ICAP Date: Current ICAP Score
Who Completed the ICAP Current ICAP Service Level
Previous ICAP Date Previous ICAP Score
Who Completed the ICAP? Previous ICAP Service Level
Psychological
Date:
Examiner Name: Examiner Agency:
Primary DSM Code
Secondary DSM Code(s)
Essential Information completed by:
Person: Legal Guardian:
Support Coordinator/Credentials: Additional
Contributors:
Date Reviewed:
DMH Plan of Services and Supports form Page 6 of 9
Name: Medicaid #: Certification Date:
Part II – Personal Profile
Great Things About {name}
Hopes and Dreams
Important To/For
Important TO Important FOR
Working/Not Working
Perspectives
Things that work Things That Do Not work
__________’s Perspective:
___________’s Perspective:
Family’s Perspective
Family’s Perspective
Family’s Perspective
Family’s Perspective
Provider’s Perspective
Provider’s Perspective
Provider’s Perspective
Provider’s Perspective
DMH Plan of Services and Supports form Page 7 of 9
Name: Medicaid #: Certification Date:
Need to Know & Strengths
Things People Need to Know to Support {name} and Keep Him/Her Healthy and
Safe
{Name} ‘s Strengths
Questions/Things to Figure Out
Question Person Responsible
Are any referrals needed?
Yes No Explain:
DMH Plan of Services and Supports form Page 8 of 9
Name: Medicaid #: Certification Date:
Part III – Person Centeredness
Choice, Control, Restrictions/Limitations
Were you given a choice of
service(s)?
Yes
No Please describe:
Were you given a choice of
provider(s)?
Yes
No Please describe:
Were you given a choice of
living setting(s)?
Yes
No Please describe:
Were you given a choice of
roommate(s)?
Yes No
Please describe:
Do you have control of your
personal resources?
Yes
No Please describe:
Are you given a choice of
activities in your living
setting? (including where you want
to go in the community)
Yes
No Please describe:
Are you given a choice of
activities in your day program
setting?
(including where you want
to go in the community)
Yes
No Please describe:
Do you have any restrictions
or limitations set by staff?
(including visitors and food)
Yes No
Please describe:
DMH Plan of Services and Supports form Page 9 of 9
Name: Medicaid #: Certification Date:
Contributors Not at Meeting
Support Person Relationship Date contributed
Signatures
Type Name Services Signature Name Signature Date
Part IV - Shared Planning
Desired Outcome Supports How Often Start Date End Date
DMH IDD Activity Support Plan
IDD Waiver Activity Support Plan
Purpose
The purpose of the Activity Support Plan (ASP) is to document activities and strategies/support
instructions to be completed in order for a person to work towards reaching their desired
outcomes as documented in the Plan of Services and Supports. Staff should be able to read a
person’s ASP and know exactly how to provide services and supports to that person.
General
An ASP is required for each service a person receives. Providers are responsible for developing
the ASP with the person and legal/representative after the development of the Plan of Services
and Supports (PSS). The ASP is tailored to the outcomes developed during a person’s PSS
meeting. Each service will have a separate ASP regardless of whether or not the same provider is
providing more than one service.
The Support Coordinator/Targeted Case Manager must ensure all ASPs are consistent and
include activities that were identified to meet the outcomes developed during the PSS meeting. If
the Support Coordinator/Targeted Case Manager finds the ASP does not reflect what was
discussed at the PSS meeting, he/she can return it to the provider for revision.
Outcome Statement
Providers write the outcome statements from the Shared Planning section of the PSS that pertain
to the service/support they provide. Different services may have more or less outcomes on the
ASP than others. Outcomes may be on more than one ASP if both services can provide support in
reaching the outcome.
Person’s Support Activities
List the support activities a person will participate in to assist him/her in meeting his/her stated
outcomes. Activities are things that can be seen and counted. They include some sort of action
word, relate to the desired outcome being addressed and are appropriate to the service/support
being provided. There may be multiple support activities for each outcome.
Strategies/Support Instructions
The Strategies/Support Instructions describe how supports will be provided based on the person’s
choices and preferences. The strategies/support instructions will provide detailed directions for
staff to follow when completing support activities with the person. The strategies/support
instructions may include what the person likes to do, the type of support needed, specific
directions for staff to follow, teaching steps, what is needed for success.
and where the evidence
of progress is being recorded. The information must be very detailed and specific to each person
and each outcome.
How Often/By When
The ASP includes how often activities will be conducted/completed as decided upon during the
PSS Development meeting. In order to track progress and collect data, each outcome must be
DMH IDD Activity Support Plan
completed/done a certain number of days per week or days per month. If an outcome is
addressed daily, the number of times per day does not need to be indicated.
Once the provider receives the approved PSS, they develop the Activity Support Plan with the
person/legal representative within 30 days of certification date.
Timelines
For ID/DD Waiver and IDD CSP providers, Activity Support Plans must be developed with the
person/legal guardian (if applicable) within thirty (30) days of receipt of the person’s PSS. The
ASP is to be submitted to the appropriate Support Coordinator/Targeted Case Manager by the
15th of the month following development. It must be reviewed and/or revised at least annually, as
changes are needed or whenever the person wishes to revise it.
Other IDD services – The Activity Support Plan is to be developed with the person/legal guardian
(if applicable) within 30 days of the date of the PSS and be in the person’s record no later than the
10th of the month following development. It must be reviewed and/or revised at least annually, as
changes are needed or whenever the person wishes to revise it.
The Support Coordinator must ensure all ASPs are consistent and include activities that were
identified to meet the outcomes developed during the PSS meeting. If the Support Coordinator
does not feel the ASP reflects what was discussed in the PSS meeting, he/she can send it back
and request clarification. The ASP must be reviewed and/or revised at least annually, as changes
are needed or whenever the person wishes to revise it.
Copies of ASPs must be available to staff at all times.
Questions/Things to Figure Out
List questions/ideas/things discussed in the PSS meeting that need to be addressed but cannot
be decided upon at the meeting or that require research or additional information to figure out.
There must be a person responsible assigned to address each item. There must also be
timelines for accomplishing the activity.
Signatures
The ASP is developed with the person/legal representative and signed at the time of
development/review. Staff developing the plan with the person/legal representative sign (including
credentials) and date the plan.
IDD Waiver Activity Support Plan
Name: Medicaid #: Agency: Service:
DMH IDD Activity Support Plan
(Use as much space as necessary)
Outcome Statement List the support activities for each
desired outcome
Support Instructions
Describe how supports need to be tailored
to the person’s preferences and profile
How often or
by when?
IDD Waiver Activity Support Plan
Name: Medicaid #: Agency: Service:
DMH IDD Activity Support Plan
Questions/Things to Figure Out
(use as many lines as necessary)
1.
Person
Responsible: By when:
2.
Person
Responsible: By when:
Signatures
Person: Date:
Legal
Representative: Date:
Provider
Signature/Credentials: Date:
DMH IDD Service Note
IDD Service Notes
Purpose
IDD Service Notes are used to document activities that take place during the provision of services.
Documentation must be detailed and specific to each person’s Activity Support Plan. Staff
activities toward the provision of services must also be documented. A single form can be used
for one (1) or two (2) days, depending on the amount of information; use as many pages as
necessary to adequately document the information each day/time services are provided. For
example, if a person goes out to participate in a community activity, two (2) notes may be
necessary for that day: one (1) for program site activities and one (1) for community activities.
General
Indicate the person’s name, Medicaid number (or other ID number if the person does not receive
Medicaid), the name of the service and the name of the agency providing the service. Document
the date of service, the time it begins (using a.m./p.m.), the time it ends (using a.m./p.m.), and the
total time spent providing services. Staff providing the service must sign indicating his/her
credentials and date the form.
IDD Service Notes replace Activity Notes. IDD Service Notes are required for the following IDD
services:
• Behavior Support (Each time services are provided. A separate form for detailed observation may be
used if desired.)
• Community Respite (Each time services are provided.)
• Day Habilitation (Daily)
• Day Services-Adult (Daily)
• Early Intervention (Each time services are provided.)
• Home and Community Supports (Each time services are provided.)
• In Home Respite (Each time services are provided)
• Host Homes (Daily)
• Job Discovery (Each time services are provided.)
• Prevocational Services (Daily)
• Supervised Living (Daily - There must be a Service Note for each shift.)
• Supported Employment (Each time services are provided.)
• Shared Supported Living (Daily)
• Supported Living (Each time services are provided.)
• Work Activity (Daily)
IDD Service Notes must reflect who, what, when, where, how and why for activities each day/ time
services are provided. The following must be specifically addressed:
• Activities in which the person chose to participate
• When and where all activities occurred (at the program site, in the community[list the specific location
of the activity], in the home)
• How and why activities were completed (this relates activities back to the person’s
Activity Support Plan)
• What worked well about the activity(ies) and what the person liked
• What did not work well about the activity(ies) and what the person did not like
• Strategies or instructions staff followed during the provision of services
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DMH IDD Service Note
• Progress toward meeting stated outcomes
IDD Service Notes must also be used to document the following:
• When supports are not provided according to the Activity Support Plan
• Why a person chose not to participate in an activity
• Unusual events/circumstances
• Why a person is absent on any given day
• Phone calls or interaction with family or other providers/entities on behalf of the person
Service notes can be written or typed. Use as much space as necessary to completely document
all activities.
Timelines
IDD Service Notes must be completed the day services are provided and be in the person’s
record no later than the 10th day of the month following the month service are provided.
IDD Service Note
Name: Medicaid #:
Service: Agency:
DMH IDD Service Note form
Date: Begin Time: End Time: Total Time: Location(s):
Person’s Activities Staff’s Activities
(Who, What, When, Where, How, Why)
Staff Signature/
Credentials
Date: Begin Time: End Time: Total Time: Location(s):
Person’s Activities Staff’s Activities
(Who, What, When, Where, How, Why)
Staff Signature/
Credentials
DMH IDD Strikethrough 2016 IDD Weekly Service Note guidance
IDD Weekly Service Note
Purpose
IDD Service Notes are used to document activities that take place during the provision of
services. Documentation must be detailed and specific to each person’s Activity Support
Plan. Staff activities toward the provision of services must also be documented.
General
Indicate the person’s name, Medicaid number (or other ID number if the person does not
receive Medicaid), the name of the service and the name of the agency providing the service.
Document the date of service, the time it begins (using a.m./p.m.), the time it ends (using
a.m./p.m.), and the total time spent providing services. Staff providing the service must sign
indicating his/her credentials and date the form.
IDD Weekly Service Notes are required for the following IDD services:
• Community Respite (Each time services are provided.)
• Day Habilitation (Daily)
• Day Services Adult (Daily)
• Prevocational Services (Daily)
• Work Activity (Daily)
IDD Weekly Service Notes must reflect who, what, when, where, how and why for activities
each week services are provided. The following must be specifically addressed:
• Activities in which the person chose to participate
• Where all activities occurred (at the program site, in the community[list the specific location of the
activity], in the home)
• How and why activities were completed (this relates activities back to the person’s Activity
Support Plan)
• What worked well about the activity(ies) and what the person liked
• What did not work well about the activity(ies) and what the person did not like
• Staff followed during the provision of services
• Progress toward meeting stated outcomes
IDD Weekly Service Notes must also be used to document the following:
• When supports are not provided according to the Activity Support Plan
• Why a person chose not to participate in an activity
• Unusual events/circumstances
• Why a person is absent on any given day
• Phone calls or interaction with family or other providers/entities on behalf of the person
Service notes can be written or typed. Use as much space as necessary to completely
document all activities.
Timelines
IDD Weekly Service Notes must be completed the week services are provided and be in the
DMH IDD Strikethrough 2016 IDD Weekly Service Note guidance
person’s record no later than the 10th day of the month following the month service are
provided.
Monthly Summary
At the end of the month, a summary of progress or lack of progress toward outcomes must
be documented.
Staff completing the Weekly Progress Note must sign and date the form at the end of the
month.
DMH IDD Strikethrough 2016 IDD Weekly Service Note form
IDD Weekly Service Note
Name ___________________________________________
ID Number _______________________________________
Service __________________________________________
Attendance during month of in the year of
Days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Time
In
Time
Out
Total
Time
Weekly
Dates Summary of Activity
1st Week
Outcomes:
Date: Signature/Credential:
2nd Week
Outcomes:
Date: Signature/Credential:
DMH IDD Strikethrough 2016 IDD Weekly Service Note form
3rd Week Outcomes:
Date: Signature/Credential:
4th Week Outcomes:
Date: Signature/Credential:
5th Week
Outcomes:
Date: Signature/Credential:
Monthly
Summary
Date:
Staff Signature/Credential:
Date: Supervisor Signature/Credential:
DMH Strikethrough 2016 ID-DD Waiver IDD CSP Service Authorization guidance
ID/DD Waiver/IDD CSP Service Authorization
Purpose
To inform a provider what type and amount of ID/DD Waiver and IDD CSP service(s) they are
authorized to provide to an individual and the begin and end dates for the authorization.
The provider receives this form from the Support Coordinator/ Targeted Case Manager.
General
Initially and when updated, the Support Coordinator/ Targeted Case Manager sends the most
current Interdisciplinary Summary and Recommendations Report Social and Psychological
Reports from the Diagnostic and Evaluation Team with the Service Authorization. The Support
Coordinator also sends the most current Medical Evaluation.
Timelines
No service can begin before the start date on the Service Authorization. Before any services
can begin, the provider must review the
Interdisciplinary Summary and Recommendations
Report Social, Medical and Psychological Reports from the Diagnostic and Evaluation Team
and document the review in a Contact Summary the Service Notes in the individual’s record.
The Support Coordinator/ Targeted Case Manager
must issue the Service Authorization(s) to
the providers chosen by the individual and listed on the Plan of Care Services and Support
within five (5) days of receipt of the approved certification/change(s) from the BIDD.
1. Initial Certification/Readmission – The Support Coordinator/ Targeted Case Manager will
issue Service Authorization(s) within five (5) days of receipt of the approved initial
certification/readmission request.
2. Changes – If, during the individual’s certification year, there is a change in the
type/amount of service a person receives, the Support Coordinator
/ Targeted Case
Manager will send the provider an updated Service Authorization indicating there are
changes within five (5) days of receipt of the Plan of Care Services and Supports from
the BIDD. The Service Authorization will have the new type(s) and/or amount(s) of
services being authorized along with the end date of the previously authorized types(s)
and/or amount(s) of service.
3. Recertification – Annually, within five (5) days of receiving an individual’s approved
recertification, the Support Coordinator/ Targeted Case Manager issues a new Service
Authorization to the provider(s) reflecting the services and the amount(s) of service(s) the
agency is authorized to provide. The effective date of the Service Authorization will be
the individual’s certification begin date and the end date will be the certification lock-in
end date.
If the Support Coordinator / Targeted Case Manager
does not receive a signed copy of the
DMH Strikethrough 2016 ID-DD Waiver IDD CSP Service Authorization guidance
Service Authorization from an agency within ten (10) days, the Support Coordinator/ Targeted
Case Manager will ask the individual if he/she would like to be referred to another provider. At
that time, the Support Coordinator / Targeted Case Manager sends the agency a Service
Authorization with an end date for the service(s).
Another Service Authorization is issued for the next agency chosen. The start date for that
agency must be no sooner than the end date of the previous Service Authorization.
Start and End Dates
All service amounts/frequencies will have an authorized start and end date. Service
Authorizations are valid only for the dates listed on the form. The end date cannot exceed the
person’s current certification lock-in end date, regardless of the authorized start date.
1. Authorized Start Date
a. The date of the individual’s certification, regardless of type
b. Date changes to the Plan of Care Services and Supports
are approved by BIDD
2. End Date
a. Initial/readmission/recertification – The certification lock-in end date
b. Changes – The day the BIDD approves changes to the Plan of Care Services and
Supports
c. When a service is terminated
If at any time a person chooses to change providers of in home services
, the Service
Authorization will be effective on the 1st day of the month following the request unless the
Support Coordinator can obtain documentation of the amount of services provided thus far in
the month. (ex: Change in provider is requested July 12th; the Service Authorization will have
an effective date of August 1st and the end date will be the individual’s certification lock -in end
date).
Exceptions:
a. Suspected abuse or neglect or other situations in which the individual’s health and
welfare are at risk
b. The individual is not receiving/has not received the particular service during the
month in which the change in provider is requested.
Signature of Authorized Agency Representative
An authorized agency representative must sign and date the form to verify the information is
accurate and return a copy to the appropriate Support Coordinator/ Targeted Case Manager
BEFORE services can begin.
The Support Coordinator/ Targeted Case Manager must sign and date the form when received
from the agency.
DMH Strikethrough 2016 ID-DD Waiver CSP Waiver Service Authorization form
ID/DD Waiver
Service Authorization
To: From:
Name of Agency Support Coordination Department
Re:
Individual’s Name IDD Waiver Support Coordinator
Medicaid Number IDD Waiver Support Coordinator Phone/e-mail
Individual’s Address and Phone Number
Change in type(s)/amount(s) of service
Procedure
Code
Service
Amount Frequency Authorized
Start Date End Date
--- ---
--- ---
--- ---
--- ---
--- ---
--- ---
--- ---
ID/DD Waiver Support Coordinator Comments/Information
Can the agency provide the service(s) requested? Yes No
Agency Comments
Signature of Authorized Agency Representative Date
To Be Completed by Support Coordinator
Date Received from Agency Support Coordinator Signature
DMH ID/DD Waiver HCS Service Agreement
ID/DD Waiver Home and Community Supports
Service Agreement
Purpose
The Home and Community Supports (HCS) Service Agreement outlines the allowable activities,
rules and procedures regarding the provision of the service. The agreement indicates supports
and/or activities that can and cannot be provided by staff when services are rendered.
General
The provider is responsible for reviewing the form with the person/legal representative. Both the
staff person and person/legal representative must sign form to indicate agreement to adhere to
the requirements in order to receive services.
Timelines
The provider reviews the Home and Community Supports Service Agreement with the
person/legal representative prior to or at the time the provider begins providing services and at
least annually thereafter, at the same time the Activity Support Plan is completed
. A signed
document must be maintained in the person’s record and the person/legal representative must
be given a copy to keep.
ID/DD Waiver HCS Service Agreement
ID/DD Waiver Home and Community Supports
Service Agreement
Name: Medicaid Number:
1. Home and Community Supports (HCS) will meet the support needs identified in the Plan of Services
and Supports and Activity Support Plan. Only the amount of Home and Community Supports authorized
in the Plan of Services and Supports will be provided. If a change in the amount is needed, the Support
Coordinator must be contacted.
2. HCS can be provided in the home and/or in the community and either with or without a parent/legal
representative present, depending upon identified support needs.
3. HCS staff cannot be responsible for caring for others who may be in the home. HCS staff is only
responsible for the person who is enrolled in the ID/DD Waiver. Also, the HCS staff person is not
responsible for caring for pets.
4. HCS cannot be provided at a staff person’s home.
5. If a scheduled HCS visit must be canceled (e.g. because of a doctor’s appointment, illness, going out of
town, etc.), the provider must be notified as soon in advance of the cancellation as possible. Three (3)
cancellations for which no notice is given will result in a review of the Plan of Services and Supports to
determine if Home and Community Supports are still necessary and appropriate.
6. HCS may be terminated according to the provisions in the ID/DD Waiver Enrollment Agreement.
7. If a decision is made to terminate HCS, notification will be sent as soon as possible. The Support
Coordinator will assist in locating other service options, if available. There are established procedures
for filing an appeal of the decision. The services will not change until the outcome of the appeal is
determined. If termination of services is due to the environment or persons in the environment posing a
risk to the HCS staff person, services might continue pending the outcome of the appeal.
8. Should any problems arise regarding the provision of HCS, the Support Coordinator is to be notified
immediately.
9. HCS cannot be provided on an overnight basis outside of the legal residence.
10. HCS staff cannot provide medical treatment of any sort, as defined in the Mississippi Nurse Practice Act
Rules and Regulations.
11. Home and Community Supports staff cannot accompany a minor child on a medical visit without the
parent/legal representative.
HCS staff cannot provide services to someone who is in a hospital or any other facility being reimbursed
by Medicaid, Medicare or private insurance.
12. Home and Community Supports cannot be provided in a school setting.
13. Home and Community Supports providers cannot do personal errands or have interactions with their
family and friends during the provision of services.
The above information has been reviewed and the circumstances under which Home and Community
Supports can be provided are understood.
Person/Legal Representative Signature Agency Representative Signature/ Credentials
Date Date
DMH ID/DD Waiver IHR Service Agreement
ID/DD Waiver In-Home Respite
Service Agreement
Purpose
The In-Home Respite Service Agreement outlines the allowable activities, rules and procedures
regarding the provision of the service. The agreement indicates supports and/or activities that
can and cannot be provided by staff when services are rendered.
General
The provider is responsible for reviewing the form with the person/legal representative. Both the
staff person and person/legal representative must sign form to indicate agreement to adhere to
the requirements in order to receive services.
Timelines
The provider reviews the In-Home Respite Service Agreement with the person/legal
representative prior to or at the time the provider begins providing services and at least annually
thereafter, at the same time the Activity Support Plan is completed. A signed document must be
maintained in the person’s record and the person/legal representative must be given a copy to
keep.
ID/DD Waiver In-Home Respite Service Agreement
ID/DD Waiver In-Home Respite Service Agreement
Name: Medicaid Number:
1. In-Home Respite will meet the support needs identified in the Plan of Services and Supports and
Activity Support Plan. Only the amount of In-Home Respite authorized in the Plan of Services and
Supports will be provided. If a change in the amount is needed, the Support Coordinator must be
contacted.
2. In-Home Respite is to be provided in the home. The provider can take the person on short (1-2 hour)
community outings to get out of the house for a short period, but community participation cannot be the
purpose of the service.
3. In-Home Respite staff cannot be responsible for caring for others who may be in the home. In-Home
Respite staff is only responsible for the person who is enrolled in the ID/DD Waiver. Also, the In-Home
Nursing Respite staff person is not responsible for caring for pets.
4. If a scheduled In-Home Respite visit must be canceled (e.g. because of a doctor’s appointment, illness,
going out of town, etc.), the provider must be notified as soon in advance of the cancellation as
possible. Three (3) cancellations for which no notice is given will result in a review of the Plan of
Services and Supports to determine if In-Home Respite is still necessary and appropriate.
5. In-Home Respite may be terminated according to the provisions in the ID/DD Waiver Enrollment
Agreement.
6. If a decision is made to terminate In-Home Respite, notification will be sent as soon as possible. The
Support Coordinator will assist in locating other service options, if available. There are established
procedures for filing an appeal of the decision. The services will not change until the outcome of the
appeal is determined. If termination of services is due to the environment or persons in the environment
posing a risk to the In-Home Respite staff person, services might continue pending the outcome of the
appeal.
7. Should any problems arise regarding the provision of In-Home Respite, the Support Coordinator is to be
notified immediately.
8. In-Home Respite staff cannot provide medical treatment of any sort, as defined in the Mississippi Nurse
Practice Act Rules and Regulations.
9. In-Home Respite staff cannot accompany anyone on a medical visit.
10. A relative may only provide up to 172 hours of In-Home Respite per month.
11. In-Home Respite providers cannot do personal errands or have interactions with their family and friends
during the provision of services.
The above information has been reviewed and the circumstances under which In-Home Respite can
be provided are understood.
Person/Legal Representative Signature Agency Representative
Signature/Credentials
Date Date
DMH Strikethrough 2016 ID-DD Waiver IHNR Service Agreement guidance
ID/DD Waiver In-Home Nursing Respite Service Agreement
Purpose
The In-Home Nursing Respite Service Agreement outlines the allowable activities, rules and
procedures regarding the provision of the service. The agreement indicates supports and/or
activities that can and cannot be provided by staff when services are rendered.
General
The provider is responsible for reviewing the form with the person/legal representative. Both
the staff person and person/legal representative must sign form to indicate agreement to
adhere to the requirements in order to receive services.
Timelines
The provider reviews the In-Home Nursing Respite Service Agreement with the person/legal
representative prior to or at the time the provider begins providing services and at least annually
thereafter, at the same time the Activity Support Plan is completed. A signed document must
be maintained in the person’s record and the person/legal representative must be given a copy
to keep.
DMH ID/DD Waiver IHNR Service Agreement form
ID/DD Waiver In-Home Nursing Respite
Service Agreement
Name: Medicaid Number:
Agency:
1. In-Home Nursing Respite (IHNR) services will meet the support needs identified in the Plan of Services and
Supports and Activity Support Plan. Only the amount of In-Home Nursing Respite authorized in the Plan of
Services and Supports will be provided. The Support Coordinator must be contacted if a change in the amount is
needed.
2. IHNR is provided by either a Licensed Practical Nurse (LPN) or Registered Nurse (RN). The service is intended to
be temporary (short-term) and provide periodic relief to the primary caregiver.
3. IHNR is provided in the family home either with or without a parent/legal guardian present, depending upon
identified support needs.
4. IHNR services cannot be provided in the nurse’s or any of his/her relatives’ homes.
5. Nurses are NOT responsible for caring for others who may be in the home. The nurse is only responsible for the
person who is enrolled in the ID/DD Waiver. Also, the nurse is not responsible for caring for pets.
6. If a scheduled time for IHNR must be canceled (e.g. because of a doctor’s appointment, illness, going out of town,
etc.) the nurse must be notified as soon in advance of the cancellation as possible. Three (3) cancellations for
which no notice is given will result in a review of the Plan of Services and Supports to determine if IHNR services
are still necessary and appropriate.
7. It is understood that the IHNR staff person will complete all forms necessary to document the provision of IHNR. I
or my parent/legal representative will be asked to initial the Service Note each time IHNR services are provided to
verify that the provider provided the amount of service indicated. It is understood that signing false or fraudulent
documentation is against the law.
8. If a decision is made to terminate IHNR services because of failure to adhere to the ID/DD Waiver Enrollment
Agreement or the IHNR Service Agreement, notification will be sent as soon as possible. The Support
Coordinator will assist in locating other service options, if available. There are established procedures for filing an
appeal and those will be provided. The services will not change until the outcome of any appeal is determined. If
the environment or persons in the environment pose a risk to the IHNR staff person, the he/she/the agency does
not have to continue providing services.
9. Should any problems arise regarding the provision of IHNR, notify the Support Coordinator immediately to avoid
possible interruption of services.
10. Medical treatment provided by nurses must be completed according to the Mississippi Nurse Practice Act Rules
and Regulations. Any questions regarding nurses and their scope of practice must be addressed directly to the
Mississippi Board of Nursing.
11. Documentation from a physician stating nursing services are medically necessary must be obtained before IHNR
services can be approved.
12. Behavior Support is the only ID/DD Waiver service that may be provided and billed for during the provision of
IHNR.
The above information has been reviewed and the circumstances under which In-Home Nursing Respite
Services can be provided are understood.
Person/Legal Representative Signature Agency Representative Signature/Credentials
Date Date
DMH IDD Waiver IHNR Service Note guidance
IDD Waiver In-Home Nursing Respite Service Note
Purpose
The provider must document on the In-Home Nursing Respite Service Note time spent in
service provision with the person receiving supports. In-Home Nursing Respite Service
Notes must reflect activities and strategies written in the Activity Support Plan.
General
Nurses are governed by the Mississippi Board of Nursing and the Mississippi Nurse
Practice Act and Rules and Regulations. For purposes of the ID/DD Waiver, the In-Home
Nursing Respite Service Note must have information sufficient enough to justify the time
spent providing the service. The In-Home Nursing Respite Service Note must identify the
time services began, the time they ended (indicating a.m./p.m.) and the total amount of
time spent providing services. The person/legal representative must sign the note
verifying the services documented were provided during the times indicated.
In-Home Nursing Respite Service Notes must be completed during service provision. The
nurse completing the In-Home Nursing Respite Service Note signs and dates it at the
completion of the shift.
Timelines
In-Home Nursing Respite Service Notes must be in the person’s record no later than the 10th
day of the month following the month they were completed.
DMH IDD Waiver IHNR Service Note form
IDD Waiver In-Home
Nursing Respite
Service Note
Name
Agency
ID Number
Page of
Provider’s Signature/Credentials Date
(m/d/yr)
Time In
(am/pm)
Time
Out
(am/pm)
Total Time Person/Legal
Representative’s
Signature
Notes
DMH Strikethrough 2016 IDD Employment Profile guidance
IDD Employment Profile
Purpose
The IDD Employment Profile is used for people who have not had or who do not wish to
participate in Job Discovery. The IDD Employment Profile is used to determine a person’s skills,
interests and preferences as they relate to a career path or field of employment. This
information serves as the basis of job searching for the person.
General
Information gathered is used to determine the best job fit for someone. The Employment
Specialist/Job Coach is to use this information when assisting a person in locating a job.
The information can be relayed to potential employers in order to help facilitate obtaining
a job in which the person can be satisfied and successful.
If a person is referred to a Supported Employment provider already has a job, this form
would not need to be completed. It would be completed at such time as when the person
desires a new job or is terminated from his/her current job.
Information to Be Gathered
Address each area with the person and/or someone who knows him/her best if he/she does not
speak using words. This information can be gathered by the Program Supervisor or a Direct
Support Staff person.
Timelines
The IDD Employment Profile is to be completed within thirty (30) days of enrollment in a
Supported Employment program and is to be updated if a person loses/changes jobs. The
purpose of the update is to ensure any changes in the information are reflected. For instance, a
person may find after working for several months that he/she likes a more interactive work
environment than when he/she first started or he/she may gain skills that would need to be
reflected when looking for another job. The IDD Employment Profile must be in the person’s
record by the 10
th of the month following the month in which it is completed.
ID/DD Waiver/IDD Community Support Program
The IDD Employment Profile must be submitted to the person’s ID/DD Waiver Support
Coordinator or IDD Community Support Program Targeted Case Manager by the 15th of the
month following the month it is completed. The information gathered from the IDD Employment
Profile may be used to update the Plan of Services and Supports and generate new outcome(s)
for the person. A Team Meeting may be necessary and provider staff will be required to attend.
DMH IDD Employment Profile form
IDD
Employment Profile
Name:
ID Number:
Date:
Provider Agency:
Availability:
☐ Weekdays ☐ Evenings ☐ Full time (40 hours/week)
☐ Weekends ☐ Part-time (at least 20 hrs/week) ☐ Less than part-time (less than 20 hrs/week)
Transportation:
☐ Needs transportation ☐ Needs assistance/training to access public transportation
☐
Can access public
transportation ☐ Family/neighbor/friend/co-worker will transport
Financial Situation:
☐ Income must not affect benefits ☐ Financial ramifications not an obstacle
☐ Is concerned/would like more information about increased income effect on SSI/SSDI
Time awareness:
☐ Cannot tell time ☐ Understands break and lunch
☐ Can tell exact time ☐ Can tell time to the hour
☐ Must have digital clock/watch to tell time ☐ Can tell time with analog clock/watch
Lifting ability:
☐ 0-5 lbs. ☐ 10-20 lbs.
☐ 20+ lbs. ☐ Cannot lift
Endurance (hours per day):
☐ 2-4 hrs, many breaks ☐ 2-4 hrs, few breaks
☐ 5-8 hrs, many breaks ☐ 5-8 hrs, few breaks
Preferred work area (check all that apply):
☐ Small area/one room ☐ Several rooms
☐ Building-wide ☐ Building and grounds
Mobility:
☐ Walks without assistance ☐ Requires adaptations/assistance to walk/stand
☐ Uses a wheelchair/must be pushed ☐ Uses a wheelchair/can self-navigate
Supervision (check all that apply):
☐ Requires one-on-one supervision/all times ☐ Can be unsupervised for 30 minutes
☐ Can be unsupervised for 60 minutes ☐ Does not require immediate supervision
☐ Prefers to work alone ☐ Likes to be a part of a team of 3 or less
☐ Likes to work in larger groups
Adapt to change/ability to follow rules:
☐ Accepts change ☐
Is confused by changeDoes
not adapt to change ☐ Does not like change
☐ Prefers routine tasks ☐ Prefers variety of tasks ☐ Flexible
☐ Follows variety of rules ☐ Must have assistance to follow rules
Multitask (check all that apply):
☐ Can complete 1-3 tasks in sequence
independently ☐ Can complete 1-3 tasks in sequence with assistance
☐ Can complete 4-6 tasks in sequence
independently ☐ Can complete 4-6 tasks in sequence with assistance
☐ Can complete more than 7 tasks independently ☐ Can complete more than 7 tasks with assistance
Self-initiation:
☐ Always requires prompting to move to next step ☐ Will ask for next step 25% of the time
☐ Will ask for next step 25%-50% of the time ☐ Will ask for next step more than 50% of the time
Benefits desired (check all that apply):
☐ None ☐ Vacation ☐ Vision
DMH IDD Employment Profile form
IDD
Employment Profile
Name:
ID Number:
Date:
Provider Agency:
☐ Medical ☐ Dental
Interactions/Preferred Work Environment (check all that apply):
☐ Friendly, talkative co-workers ☐ Prefers few interactions with co-workers
☐ Helps others (co-workers, customers) ☐ Prefers busy, high demand work site
☐ Receives satisfaction from completing tasks ☐ Prefers very quiet work site
☐ Prefers a relaxed work site ☐ Requires recognition for a job well done
☐ Would like to advance in the company
Person has expressed interest in:
Things done to earn money in the past:
Short term jobs(less than 90 days):
Describe any interactions/services from MDRS (include dates and activities)
Volunteer or internship experiences:
Describe favorite employment experience (if applicable):
Describe work skills the person already has:
How does the person get around in the community:
DMH IDD Employment Profile form
IDD
Employment Profile
Name:
ID Number:
Date:
Provider Agency:
What are the person’s hobbies and interests:
What are the person’s preferred conditions (non- negotiations) for employment at this time:
What are the person’s potential contributions to offer to employers:
Staff signature/credentials
DMH ID/DD Waiver Job Discovery Profile guidance
ID/DD Waiver Job Discovery Profile
Purpose
The Job Discovery Profile is developed as a result of the Job Discovery Process and contains
information that provides a full and accurate picture of the person.
General
The Job Discovery Profile should be written in positive, person-first language that portrays the
person in the best light possible. While a specific form is not required, all elements listed below
must be addressed.
Part I
Identification information (birthdate, gender, address, phone number(s), Medicaid Number, Social Security
Number, place of residence, name of parent/legal representative, address and phone number, if different than the
person’s, marital status, additional agencies involved with the person and what they provide and/or agencies
involved with the family and what they provide. The PSS can be used to gather some of this information.)
Living Arrangements
a. Family members involved in the person’s life, including extended family in the local area
b. Names, ages and employment (if applicable) of the people living in the home/residence (if
applicable)
c. Residential history
d. Description of neighborhood
e. Location of neighborhood in the community
f. Transportation used by person, family, staff
g. General commercial areas (shopping , industry, services) near the home
Education and Specialized Training History
a. School, dates of attendance, degree/Certificate of Completion/Occupational Diploma,
reason if not completed
b. Vocational training, internships, special trainings, sheltered workshops, other day
programs, dates, locations, name of entity, special skills developed, level of interest in
these activities
c. Work History (list most recent first), business, dates, job title, pay, responsibilities,
reason(s) for leaving
Part II
Person and Family
a. Brief summary
b. Typical routine
c. Family (or staff, as appropriate) supports
d. Family (staff) and person’s needs for daily routine support
e. Physical and health related issues
DMH ID/DD Waiver Job Discovery Profile guidance
Educational Experiences
a. Overall educational experiences
b. Academic services
c. Community recreation activities/participation
d. Vocational experiences and activities
Employment and Related Activities
a. Informal work performed at home for others
b. Formal chores and responsibilities
c. Entrepreneurial activities
d. Internships, structured work experiences, sheltered work, other day programs,
volunteering
e. Wage employment
f. General areas of previous work interest
Life Activities and Experiences
a. Friends and social groups
b. Personal activities including hobbies, done at home
c. Family/friend activities, including hobbies, done at home
d. Personal activities, including hobbies, done in the community
e. Family/friend activities, including hobbies, done in the community
f. Specific events and activities that are of crucial importance
Skills, Interests and Conditions in Life Activities
a. Domestic/home skills
b. Community participation skills
c. Recreation/leisure skills
d. Academic skills
e. Physical fitness skills
f. Arts and Talents
g. Communication skills
h. Social skills
i. Mobility skills
j. Sensory skills (sight, hearing, smell, touch)
k. Vocational skills
l. Personal care needs
Connections for Employment
a. Potential connectors in family (or staff, as appropriate)
b. Potential connectors among friends, neighbors, and work colleagues
c. Potential connection sites in community relationships
d. Potential connections through clubs, organizations, or groups (such as church or school)
e. List of local employers (determined by proximity, relationships, interest areas, etc.)
DMH ID/DD Waiver Job Discovery Profile guidance
Part III
Conditions for Success
a. General conditions for participant
b. General conditions for family (or staff, as appropriate)
c. Conditions for task performance
d. Instructional strategies
e. Environmental conditions
f. Supervisory strategies
g. Supports needed for successful task performance
h. Conditions to be avoided
Interests Toward an Aspect of the Job Market
a. General personal interest
b. General family interests (or staff, as appropriate)
c. Activities participant engages in without being expected to do so
d. General areas of current work interest
e. Specific areas of past work experience
Contributions
a. Strongest positive personality characteristics
b. Most reliable strengths regarding performance
c. Best current and potential skills to offer to potential employers
d. Credential training, certifications, and recognized skills
e. Possible sources for recommendations
f. Resources/financial assets
Challenges
a. Areas potentially needing matching to employment sites
b. Areas potentially needing negotiation with local employers
c. Physical/health restrictions
d. Habits and routines
e. Challenges related to disability – need for accommodation and disclosure
f. Financial issues
g. Transportation issues
Potential Employer List
List businesses, addresses and types of each business.
Signatures
The Job Discovery Profile must be signed and dated by the person/legal representative, Job
Discovery staff, and his/her program director.
Timelines
The Job Discovery Profile is to be completed no more than three (3) months from the date of the
person’s referral to the Job Discovery agency. It is to be in the record by the 10
th of the month
following the month it is completed. Submit to the Support Coordinator by the 15th of the month
following the month it is developed.
DMH ID/DD Waiver Request for BS/CS Services guidance
Request for ID/DD Waiver Behavior Support
and/or Crisis Support Services
Purpose
The form must be completed when a person requests a Behavior Support Evaluation or Crisis
Support. The form is submitted by the ID/DD Waiver Support Coordinator with input from the
person, family, providers, and the chosen Behavior Support or Crisis Support provider.
General
Indicate the service being requested, the person’s diagnoses, medications, targeted behaviors,
the frequency of behaviors and the last occurrence and the environment(s) where the behavior(s)
occurred. The form must reflect whether or not the person has received the service in the past. If
the answer is yes, the previous provider and dates services were provided must be indicated.
The request for each service must be tailored to the service and the justification must support the
definition of the service as indicated in the DMH Operational Standards
.
Timelines
If a person is admitted to Crisis Support services prior to the service being approved on his/her
Plan of Services and Supports, the Support Coordinator has five (5) days to submit a request to
BIDD for approval. Behavior Support services cannot be provided prior to BIDD approval.
The Support Coordinator submits the form electronically to the BIDD.
DMH IDD Waiver Request for BS/CS form
ID/DD Waiver Request for Behavior Support
and/or Crisis Support
Name:
Date:
Medicaid #: Regional Program:
Support
Coordinator: SC Phone Number:
Service(s)
Requested:
Provider Requested:
Diagnoses:
Current
Medications:
Target
Behavior(s):
Frequency of
behavior(s):
Date of last
occurrence of
behavior(s):
Environment(s)
where behavior(s)
occur:
Desired
goal/outcome of
service:
Has the person received the service(s) before? Yes No
If so, list dates and provider(s)
and reason(s) services are
provided outcomes/goals
achieved:
Source(s) of Information:
Support Coordinator Signature/Credentials Date
BIDD Staff Approval
DMH ID/DD Waiver Medical Verification for BS and CS Services guidance
Medical Verification for ID/DD Waiver
Behavior Support and Crisis Intervention Services
Purpose
A physical evaluation must be conducted by a licensed physician or nurse practitioner to rule out
any underlying medical conditions that may be causing the behavior(s) to occur (for example, an
abscessed tooth, ulcer, ear ache etc.).
General
ID/DD Waiver Behavior Support
This form is to be completed during the Behavior Support evaluation process. During the
Behavior Support Consultant’s initial meeting with the person/legal representative and service
provider(s), if applicable, the rationale for the form is explained. The person/legal
representative/service provider is responsible for ensuring the form is completed by a physician
or nurse practitioner. The physical evaluation cannot be more than ninety (90) days old at the
time Behavior Support Services begin.
ID/DD Waiver Crisis Intervention
A person must see a physician/nurse practitioner as soon as feasible after
the provision initiation of ID/D
D Waiver Crisis Intervention Services to determine if there are any
physical/medication factors that may be contributing to the crisis behaviors. The ID/DD Waiver
Crisis Intervention Services provider is responsible for working with the person/legal
representative and/or other service providers to have the form completed as soon as possible,
but not to exceed ten (10) days after the
provision initiation of ID/DD Waiver Crisis Intervention
Services.
Timelines
The ID/DD Waiver Behavior Support/ID/DD Waiver Crisis Intervention provider must maintain a
copy of this form in the person’s record. It must be placed in there no later than the 10th of the
month following the month it is signed by the physician/nurse practitioner. A copy must be
forwarded to the Support Coordinator no later than the 15th of the month following the month it is
completed.
Formatted: Strikethrough
Formatted: Underline
Formatted: Underline
Formatted: Strikethrough
DMH ID/DD Waiver Medical Verification for BS/CI Services form
Medical Verification for ID/DD Waiver
Behavior Support and Crisis Intervention Services
Person’s Name:
Healthcare
Provider’s Name: Office Phone:
Healthcare
Provider’s Address:
Proposed Behavior Support/Crisis Intervention Service:
Healthcare Provider: Please initial to indicate your agreement or disagreement with each of
the items listed below. If you are in disagreement with any of the statements, please
summarize on the reverse side of this form your reasons for disagreeing, as well as your
recommendations and/or treatment plans.
Agree Disagree
There is no medical reason that this person cannot participate in the
proposed Behavior Support/Crisis Intervention Services.
This person presents no symptoms of physical illness that should
receive medical treatment prior to starting/continuing Behavior
Support/Crisis Intervention services.
This person presents no symptoms of mental illness that should receive
medical treatment prior to starting Behavior Support/Crisis Intervention
services.
There are no special medical precautions to follow during the
implementation of Behavior Support/Crisis Intervention services.
Based Upon My Knowledge of This Person:
He/she can participate in the proposed Behavior Support/Crisis Intervention services.
He/she requires medical treatment that must be successfully completed prior to
starting Behavior Support/Crisis Intervention services.
He/she cannot participate in the proposed Behavior Support/Crisis Intervention
services for medical reasons.
Signature of Healthcare Provider/Credentials Date
DMH ID/DD Waiver Functional Behavior Assessment guidance
ID/D/DD Waiver Functional Behavior Assessment
Purpose
To assess where the behavior(s) occurs, any antecedent(s) of the behavior(s), consequences(s)
of the behavior(s), factor(s) that may be maintaining the behavior(s), frequency of the
behavior(s), and how the behavior(s) impacts the person’s environment and life.
General
This assessment is completed by the Behavior Support Consultant using interviews with the
person, family, others, and direct observation. Observation of youth can occur in the school
setting, but actual Behavior Support Services cannot occur be provided in the school and be
billed to Medicaid.
All components must be addressed.
The Recommendations sections contains information indicating if the Behavior Support
Consultant recommends a Behavior Support Plan is warranted, staff training only is warranted, or
no Behavior Support Services are needed. It also indicates information regarding any referrals
that may need to be made or other recommendations that can assist the person/family.
Timelines
The Functional Behavior Assessment must be completed within ninety (90) days
of BIDD approval for Behavior Support Services of for the Functional Behavior Assessment.
Submission of Documentation
The ID/DD Waiver Functional Behavior Assessment must be submitted to the Support
Coordinator along with the Behavior Support Plan and Justification for Behavior Support Services
within ten (10) days of completion of the Behavior Support Plan.
The Support Coordinator then
submits all documentation to BIDD for review.
If the ID/DD Waiver Functional Behavior Assessment indicates a Behavior Support Plan is not
warranted, but training of staff and other individuals who interact with the person is, indicate such
on the Justification for Behavior Support Services.
If the ID/DD Waiver Functional Behavior Assessment indicates neither a Behavior Support Plan
nor training is necessary, submit the completed ID/DD Waiver Functional Behavior Assessment
to the appropriate Support Coordinator within ten (10) days of completion, along with a narrative
indicating that Behavior Support Services were not warranted as per the assessment.
DMH ID/DD Waiver Functional Behavior Assessment form 1 of 6
ID/DD Waiver Functional
Behavior Assessment
Name:
Assessment
Date(s):
ID Number:
DOB: Sex: M F
Respondents(s): Behavior Consultant/Credentials/Agency:
I. Description of Behavior(s)
A. What are the behavior(s) of concern? For each, define the topography (how it is performed),
frequency (how often it occurs per day, week, or month), duration (how long it lasts when it
occurs), and intensity (the magnitude of the behavior - low, medium, high - and if it causes harm).
Behavior and Topography: Frequency Duration Intensity
Behavior and Topography: Frequency Duration Intensity
Behavior and Topography: Frequency Duration Intensity
Behavior and Topography: Frequency Duration Intensity
B. Which of the behaviors described above occur together (e.g., occur at the same time; occur in a
predictable chain; occur in response to the same situation)?
II. Ecological Events That May Affect the Behavior(s)
A. What medications is the person taking (if any), and how do you believe these may affect his/her
behaviors?
B. What medical complications (if any) does the person experience that may affect his/her behavior
(e.g., asthma, allergies, rashes, sinus infections, seizures, etc.)?
DMH ID/DD Waiver Functional Behavior Assessment form 2 of 6
C. Describe the sleep cycles of the person and the extent to which these cycles affect his/her
behavior.
D. Describe the eating routines and diet of the person and the extent to which these routines may
affect his/her behavior.
E. Briefly list below the person’s typical daily schedule of activities:
6:00 am 3:00 pm
7:00 am 4:00 pm
8:00 am 5:00 pm
9:00 am 6:00 pm
10:00 am 7:00 pm
11:00 am 8:00 pm
12:00 pm 9:00 pm
1:00 pm 10:00 pm
2:00 pm 11:00 pm
F. Describe the extent to which you believe the activities that occur during the day are predictabl
for the person. (e.g., when to get up, eat dinner, shower, go to school/work, etc.)?
G. About how often does the person get to make choices about activities, reinforcers, etc.? In what
areas does the person get to make choices (e.g., food, clothing, social companions, leisure
activities, etc.)?
H. Describe the variety of activities performed on a typical day (exercise, community activities, etc.)
I. How many other people are in the setting (work/school/home)? Do you believe that the density
of people or interactions with other persons affect the targeted behaviors?
J. If the person is attending a day program, what is the staffing pattern? To what extent do you
believe the number of staff, training of staff, quality of social contacts with staff, etc., affect the
targeted behaviors?
K. If not attending a day program, describe some typical interactions of the person with others in the
home or other environments.
DMH ID/DD Waiver Functional Behavior Assessment form 3 of 6
L. Are the tasks/activities presented during the day boring or unpleasant for the person, or do they
lead to results that are preferred or valued?
M. If the person attends a day program, what outcomes are monitored regularly by staff (frequency
of behaviors, skills learned, activity patterns)?
N. If the person does not attend a day program, how do people in the home or other environments
monitor outcomes?
III. Events and Situations that Predict Occurrences of the Behavior(s)
A. Time of Day: When is the behavior(s) most likely and least likely to occur?
Most Likely Least Likely
B. Setting: Where is the behavior most likely and least likely to occur?
Most Likely Least Likely
C. Control: With whom is the behavior most likely and least likely to occur?
Most Likely Least Likely
D. What activity is most likely and least likely to produce the behavior(s)?
Most Likely Least Likely
E. Are there particular situations, events, etc., that are not listed previously that “set off” the
behavior(s) that cause concern (particular demands, interruptions, transitions, delays, being
ignored, etc.)?
F. What would be the one thing you could do that would be most likely to make the undesirable
behavior(s) occur?
IV. Function of the Undesirable Behavior(s)
A. Review each of the behaviors listed in Part I and define the function(s) you believe the behavior
serves for the person (i.e., what does he/she get and/or avoid by doing the behavior?).
Behavior:
What does he/she get? What does he/she avoid?
Behavior:
What does he/she get? What does he/she avoid?
DMH ID/DD Waiver Functional Behavior Assessment form 4 of 6
Behavior:
What does he/she get? What does he/she avoid?
Behavior:
What does he/she get?
What does he/she avoid?
B. Describe the person’s most typical response to the following situations:
1. Is the above behavior(s) more likely less likely unaffected if you present him/her
with a difficult task?
2. Is the above behavior(s) more likely less likely unaffected if you interrupt a
desired event (eating ice cream, watching TV, etc.)?
3. Is the above behavior(s) more likely less likely unaffected if you deliver a “stern”
request/command/reprimand?
4. Is the above behavior(s) more likely less likely unaffected if you are present but
do not interact with him/her?
5. Is the above behavior(s) more likely less likely unaffected if the routine is
changed?
6. Is the above behavior(s) more likely less likely unaffected if something the
person wants is present but he/she cannot get to it (i.e., a desired object that is out of
reach)?
7. Is the above behavior(s) more likely less likely unaffected if he/she is alone?
V. Efficiency of the Undesirable Behavior(s)
A. What amount of physical effort is involved in the behavior(s) (e.g., prolonged intense tantrums -
vs- simple verbal outbursts, etc.)?
B. Does engaging in the behavior(s) result in a “payoff” (getting attention, avoiding work) every
time? Almost every time? Once in a while?
C. How much of a delay is there between the time the person engages in the behavior(s) and gets
the “payoff”? Is it immediate, a few seconds, or longer?
DMH ID/DD Waiver Functional Behavior Assessment form 5 of 6
VI. Primary Method(s) Used by the Person to Communicate
A. What are the general expressive communication strategies used by or available to the person in
the following situations?
Request
attention
Request
Help
Request
preferred
food/objects/
activities
Show you
something
or a place
Indicate
physical
pain
Indicate
confusion
Protest/
reject
situation
Complex speech
Multiple words
One word utterances
Complex signing
Simple signs
Echolalia
Pointing
Leading
Grab/Reach
Increased movement
Moves away
Moves closer
Fixed gaze
Facial expressions
Aggression
Self-injury
Eye movements
Augmentative
communication
B. With regard to receptive communication:
1. Does the person follow requests or instructions? If so approximately how many?
2. Is the person able to imitate physical models for various tasks or activities?
3. Does the person respond to signed or gestural requests or instructions?
4. How does the person indicate yes or no?
DMH ID/DD Waiver Functional Behavior Assessment form 6 of 6
VII. Events, Actions, and Objects Perceived as Positive by the Person?
A. In general, what are the things (events/activities/objects/people) that appear to be reinforcing or
enjoyable for the person?
VIII. “Functional” Alternative” Behaviors Known by the Person?
A. What socially appropriate behaviors/skills does the person perform that may be ways of achieving
the same function(s) as the behavior(s) of concern?
B. What things can you do to improve the likelihood that a teaching session will occur smoothly?
C. What things can you do that would interfere with or disrupt a teaching session?
IX. History of the Undesirable Behavior(s) and Programs that Have Been
Attempted
Behavior
How long has this
been a problem? Programs Effect
1.
2.
3.
4.
X. Summary/ Recommendations
Based on the Functional Behavior Assessment, the following action(s)/behavior(s) were discovered:
Behavior Function Location
The results of the assessment(s) reflect that the action(s)/behavior(s)
demonstrated by the person pose a risk to the health and welfare of the
person and/or others.
Yes No
DMH ID/DD Waiver Functional Behavior Assessment form 7 of 6
If a risk(s) exist, list them below:
Behavior Risk to Self Risk to Others
Recommendations:
Behavior Support Consultant/Credentials Date
DMH ID/DD Waiver Behavior Support Plan guidance
ID/DD Waiver Behavior Support Plan
Purpose
The Behavior Support Plan is developed by the Behavior Consultant based on the
assessment(s) used to evaluate the person’s actions or behavior(s).
General
All areas indicated on the Behavior Support Plan must be addressed:
• Background information
• Summary of the Functional Behavior Assessment
• Tracking and reduction strategies
• Objectives
• Staff instructions for implementing the plan
Signatures
The following signatures must be obtained by the provider the Behavior Support
Consultant after completion and review of the Behavior Support Plan:
The parent/legal representative, if appropriate, and the person receiving services,
indicating they agree with the contents of the Behavior Support Plan and consent for its
implementation,
The Behavior Consultant agreeing to implement the plan as written and to notify the
person/family/legal representative before making any changes or modifications,
The Behavior Support Specialist (when applicable) agreeing to implement the plan and
collect data to report to the Behavior Support Consultant as indicated in the plan,
The Director or Supervisor of the program the person attends (if the Behavior Support
Plan is to be implemented in such a setting), indicating he/she agrees with the content of
the Behavior Support Plan and will provide support as necessary. Also, he/she is
agreeing to allow appropriate staff to be trained by the Behavior Support Consultant
and/or a Behavior Support Specialist to ensure the plan continues to be successful after
the Consultant/Specialist has ceased providing services.
Timelines
The Behavior Support Plan must be completed within thirty (30) days of completion of the
Functional Behavior Assessment.
A copy of the Behavior Support Plan, along with the Functional Behavior Assessment and
Justification for Behavior Support Services, must be submitted to the Support Coordinator
within ten (10) days of completion of the Behavior Support Plan. The Support Coordinator
will submit the documentation to BIDD for review. The Behavior Support Plan must be
approved before services can begin. The Behavior Support Plan must be reviewed at least
quarterly.
A copy must be in the person’s record no later than the 10
th day of the month following the
month it is approved by BIDD.
DMH ID/DD Waiver Behavior Support Plan Page 1 of 5
ID/DD Waiver Behavior Support Plan
Name:
Behavior
Consultant:
Medicaid #: Agency:
Address:
Contact
Number:
Phone
Number:
Background
Reason for
Referral:
History:
Psychiatric
Diagnoses:
Summary of Functional Behavior Assessment
Target Identification
Methods:
Description of
Assessment Procedures:
Target Behavior(s) and
Definitions:
Behavior(s) Definitions
DMH ID/DD Waiver Behavior Support Plan Page 2 of 5
Behavioral Findings:
Behavioral Description Antecedents Consequences
Relevant Findings from
Physiological
Issues/Illness/Injury
Assessment:
Relevant Findings from
Environmental and
Setting Assessment:
Relevant Findings from
Communicative
Functions:
Hypothesis and Summary
of Behavior Function(s):
Baseline Data:
Replacement Behaviors
Identified:
Tracking and Reduction
Behavior
Reduction:
Baseline Data:
Intervention
Expectation:
Replacement/
Alternative
Behavior:
Review Criteria:
DMH ID/DD Waiver Behavior Support Plan Page 3 of 5
Behavior
Reduction:
Baseline Data:
Intervention
Expectation:
Replacement/
Alternative
Behavior:
Review Criteria:
Behavior
Reduction:
Baseline Data:
Intervention
Expectation:
Replacement/
Alternative
Behavior:
Review Criteria:
DMH ID/DD Waiver Behavior Support Plan Page 4 of 5
Objective(s)
1.
2.
3.
4.
Staff Instructions
Preventive Measures:
Replacement
Behavior/Alternative Skill
Training:
Consequence Strategies:
Procedural Safeguards:
Medication Side Effects of
Concern:
DMH ID/DD Waiver Behavior Support Plan Page 5 of 5
Agreements and Signatures
I agree with the content of this Plan and give consent for its implementation. I have received
a copy of the plan. I understand the behavior management techniques that will be used with
this program. I may terminate the program at any time.
Person: Date:
Person/Legal
Representative:
Date:
I agree to implement the Plan as described. If any modifications are necessary, I will contact
the person/family before making any changes. I will ensure staff is trained before terminating
my services.
Behavior Support
Consultant:
Date:
I agree to the contents of this Plan and will support the Consultant/Interventionist as needed
to ensure implementation of the Plan. Appropriate staff will receive training to ensure the
Plan continues, as needed, after the Consultant/Interventionist terminates services.
Program Director:
Date:
Behavior
Consultant/Credential Date:
BIDD Use Only
Approved Denied
Signature of BIDD Staff Signature of BIDD Staff
DMH ID/DD Waiver Justification for Behavior Support Services guidance
ID/DD Waiver Justification for
Behavior Support Services
Purpose
The provider uses the ID/DD Waiver Justification for Behavior Support Services to justify
the type and amount of Behavior Support Services needed.
General
Based upon the Functional Behavior Assessment and Behavior Support Plan, indicate
the amount of Behavior Support Services needed to change/modify targeted behaviors or
whether or not only staff training is needed to change/modify targeted behaviors.
Timelines
The Justification for Behavior Support Services is submitted along with the Functional Behavior
Assessment and Behavior Support Plan to the appropriate Support Coordinator within ten (10)
days of completion initiation
of the Behavior Support Plan. It must be maintained in the person’s
record. The SC then submits all documentation to BIDD for review.
DMH ID/DD Waiver Justification for Behavior Support Services form
ID/DD Waiver Justification for Behavior Support Services
Name: Medicaid Number:
Agency:
Based upon the Functional Behavior Assessment completed it is recommended
that Behavior Support services are warranted. (date)
It is anticipated that approximately hours for months will be required to implement
the Behavior Support Plan.
OR
Based upon the Functional Behavior Assessment completed, it is recommended
(date)
that direct Behavior Support services are not warranted but there is a need for staff training
It is anticipated that approximately hours will be required to adequately train staff to manage
identified behaviors.
Behavior Support Consultant
Signature/Credentials
Date
BIDD Signature Date
DMH Strikethrough 2016 ID-DD Waiver Behavior Support Quarterly Review Report guidance
ID/DD Waiver Behavior Support
Quarterly Review Report
Purpose
The Behavior Consultant must complete a Behavior Support Quarterly Review Report for each
quarter services are provided. The report reflects the supports provided and the amount of
progress made during that particular quarter.
General
Based on data gathered during each quarter, the Behavior Consultant composes a report that
reflects medication changes, target behavior(s), information about Behavior Support Plan
implementation, and narrative information about baseline data or data from the previous
Quarterly Review Report as well as narrative information about the current quarter’s data.
The report includes next steps to be taken in implementation of the Behavior Support Plan. Next
steps could include actions such as continuing with the Behavior Support Plan as it is written or
modifying it to meet any changing needs. Modifications can be made to the intervention,
intervention techniques, target behaviors, training needs, timelines, etc.
The Behavior Support Quarterly Review Report must be signed and dated by the Behavior
Consultant and be filed in the person’s record by the 10
th of every month. BIDD staff will review
the Quarterly Reports onsite.
Timelines
The Quarterly Review Report is to be completed at the end of each three (3) months of service to
the person. It is to be submitted to the Support Coordinator by the 15
th of the month following the
month it is completed.
DMH ID/DD Waiver Behavior Support Quarterly Review Report form
ID/DD Waiver Behavior Support
Quarterly Review Report
Name: Date of Report:
Medicaid Number:
Behavior Consultant:
Behavior Specialist:
Support Coordinator:
Behavior Support Plan Approved:
Describe any changes in
behavior, medication
(include prescribing
doctor) and/or diagnosis:
Explain reasons for
changes:
Target Behaviors:
Locations of Behavior Support Plan implementation:
□ Home
□ Day Program
□ Community
□ Place of Employment
Behavior Support Plan structure:
□ Modeling
□ Reinforcement/Consequences
□ Training for staff/family
□ One-on-one supervision
□ Redirection & blocking
□ Verbal Prompting
□ Environmental accommodations
□ Other:
Describe baseline data or data collected for previous review as well as a narrative of the previous review:
DMH ID/DD Waiver Behavior Support Quarterly Review Report form
ID/DD Waiver Behavior Support
Quarterly Review Report
Name: Date of Report:
Medicaid Number:
Include a narrative of the current quarter’s data.
Next Steps:
Behavior Consultant Signature /Credentials Date
DMH ID/DD Waiver Request for Additional BS Hours
ID/DD Waiver Request for Additional
Behavior Support Services
Purpose
When additional Behavior Support Services are deemed necessary by the Behavior Consultant,
a Request for Additional Behavior Support Services form must be submitted to BIDD for
approval.
General
The Behavior Consultant indicates the amount of service needed, the target behaviors, the
number of Behavior Support service hours that have been used thus far, how they were used
and includes justification for the additional hours being requested. The desired goal(s) or
outcome(s) must be included.
The form and the most recent Quarterly Review Report are submitted to the appropriate Support
Coordinator for submission to the BIDD for review.
DMH ID/DD Waiver Request for Additional BS Hours 1
ID/DD Waiver Request for Additional
Behavior Support Services
(Use as many pages as necessary and attach most recent Quarterly Review Report)
Name: Date:
Medicaid #: Agency:
Behavior Consultant: Phone Number:
# Additional Hours
Requested:
# Hours utilized to
date:
Target
behavior(s):
Justification for
additional
services:
(why hours are
needed and how
they will be used)
Desired
goals/outcomes:
BIDD USE ONLY
Approved Disapproved
DMH ID/DD Waiver Request for Additional Crisis Support Hours
ID/DD Waiver Request for Additional
Crisis Support Services
Purpose
Crisis Support Services can be provided for up to thirty (30) days per a person’s certification
year. If When additional Crisis Support Services are deemed necessary by the Program
Supervisor, a Request for Additional Crisis Services form must be submitted for approval.
General
The Program Supervisor indicates the additional number of days needed, the targeted behaviors,
the number of days that have been used thus far, how they were used and includes justification
for the additional days being requested. The desired goal(s) or outcome(s) must be included.
The form and any attached documentation are submitted to the appropriate Support Coordinator
for submission to the BIDD for review. The maximum number of days of Crisis Support someone
may receive without additional approval is thirty (30).
DMH ID/DD Waiver Request for Additional CS Hours
ID/DD Waiver Request for Additional
Crisis Support Services
(use as many pages as necessary)
Name: Date:
Medicaid #: Regional Program:
Program Supervisor: Phone Number:
Additional # Days
Requested:
# Days utilized to
date:
Targeted
behavior(s):
Justification for
additional
services:
(why days are
needed and how
they will be used)
Desired
goals/outcomes:
BIDD ONLY
Approved Disapproved
DMH ID/DD Waiver Request for CI Services
Request for ID/DD Waiver
Crisis Intervention Services
Purpose
The form must be completed when a person requests ID/DD Waiver Crisis Intervention services.
General
Crisis Intervention Services are approved on an individual’s Plan of Services and Supports when
there is a reasonable expectation, based on past occurrences or immediate situational
circumstances in which the individual is at risk of causing physical harm to him/herself, causing
physical harm to others, damaging property, eloping, or being unable to control him/herself in a
manner that allows participation in usual activities of daily life. The provider will be chosen at the
time the service is approved on the Plan of Services and Supports; therefore, if a crisis arises,
the provider can be dispatched immediately.
If a need for Crisis Intervention arises whereby a provider must provide immediate assistance,
but the service is not yet on the Plan of Services and Supports, the provider and Support
Coordinator must work together to gather justification for the need for the service and submit this
form to BIDD for review. The request must be submitted to BIDD within five (5) days of the
initiation of Crisis Intervention services.
Crisis Intervention can be requested for up to seven (7) days or 168 hours. If additional services
are deemed to be necessary, the provider must submit the ID/DD Waiver Request for Additional
Crisis Intervention Services from to the Support Coordinator who will then submit it to BIDD for
review.
The ID/DD Waiver Crisis Intervention Services provider notifies the Support Coordinator that
services have been utilized. The provider completes the form. It must be signed by the Clinical
Supervisor of the ID/DD Waiver Crisis Intervention Services Team.
Timelines
If a person receives Crisis Intervention services prior to the service being approved on their Plan
of Services and Supports, the Support Coordinator has five (5) days from the date services were
provided to work with the provider to get the form completed and submit it to BIDD for approval.
DMH ID/DD Waiver Request for Crisis Intervention Services
ID/DD Waiver Request for
Crisis Intervention Services
Name: Date of Request:
Medicaid Number: Regional Program:
Support Coordinator: Phone Number:
# of Days/Hours Being Requested:
Diagnoses:
Current Medications:
Target Behavior(s):
Frequency of behavior(s): Date of last occurrence of behavior(s):
Environment(s) where behavior(s) occur(red):
Desired goal/outcome of service:
Has the person received the service(s) before? ☐Yes ☐No
If so, list dates, provider(s), outcomes/goals achieved and why service ended:
Source(s) of Information:
Clinical Supervisor/Credentials Date
BIDD ONLY
Approved Disapproved
DMH ID/DD Waiver Crisis Intervention Plan guidance
ID/DD Waiver
Crisis Intervention Plan
Purpose
The ID/DD Waiver Crisis Intervention Plan is developed for people who utilize IDD Waiver Crisis
Intervention Services.
General
A Crisis Intervention Plan is developed for someone for whom the service is on his/her approved
Plan of Care and staff/family know his/her potential crisis(es), as well as for those people who
have experienced a crisis and received ID/DD Waiver Crisis Intervention Services. The person
can either have received the service on an episodic basis or it can be for someone who requires
the service on a 24/7 basis, depending on the nature of the crisis and the person’s individual
circumstances.
The ID/DD Waiver Crisis Intervention Plan is used to provide a plan for use in mitigating and
intervening in a person’s individual crisis situation. There can be multiple types of crises
addressed on a single plan. Describe the person’s relevant history in regard to the presenting
crisis(es) and the known trigger(s) for said crisis(es). The ID/DD Waiver Crisis Intervention Team
and the person/legal representative, Support Coordinator and providers, if applicable, then work
to develop the ID/DD Waiver Crisis Intervention Plan that can be implemented in the home, the
community, a day program or some combination of sites.
In addition to the case record, copies of the ID/DD Waiver Crisis Intervention Plan are to be
maintained in all settings where it may be implemented and the ID/DD Waiver Crisis Intervention
Team is to train all individuals who may have to implement components of the ID/DD Waiver
Crisis Intervention Plan.
The ID/DD Waiver Crisis Intervention Team also provides a Team member’s name and phone
number to contact in case of a crisis which cannot be resolved by implementing the ID/DD
Waiver Crisis Intervention Plan.
It is signed by the person/legal representative, the ID/DD Waiver Crisis Intervention Team
Clinical Supervisor, by ID/DD Waiver Crisis Team staff who is primarily responsible for
implementation, if applicable, a staff of another provider(s) who may have to implement the plan
as well other ID/DD Waiver Crisis Intervention Team staff who may have to implement the ID/DD
Waiver Crisis Intervention Plan.
Timelines
The ID/DD Waiver Crisis Intervention Plan must be developed within five (5) days of the provision
of or referral for ID/DD Waiver Crisis Intervention Services.
Copies of the ID/DD Waiver Crisis Intervention Plan must be sent to all applicable parties no
more than five (5) days following development. It must be in the person’s record no later than the
10th of the month following it is developed. The Crisis Intervention Plan must be submitted to the
Support Coordinator by the 15th of the month following the month it is developed. Formatted: Superscript
Formatted: Underline
DMH ID/DD Waiver Crisis Intervention Plan form
ID/DD Waiver Crisis
Intervention Plan
Name:
Medicaid Number:
Provider Agency:
Crisis Intervention Team Contact: Phone number:
Relevant History and Potential Crisis Situation(s): Current Medications
Known Triggers:
Action Steps for Home
Action Steps for Community Locations
(specify location(s))
Action Steps for Day Programs
Person/Legal Guardian Signature/Date Crisis Intervention Team Clinical Supervisor
Signature/Credentials/Date
Responsible Crisis Intervention Team Staff
Signature/Credentials/Date
Other Provider Signature/Credentials/Date Other Responsible Crisis Intervention Team Staff
Signature/Credentials/Date
Other Responsible Crisis Intervention Team Staff
Signature/Credentials/Date
DMH ID/DD Waiver Crisis Intervention Daily Service Note guidance
ID/DD Waiver
Crisis Intervention Daily Service Note
Purpose
This form is used during the provision 24/7 daily ID/DD Waiver Crisis Intervention Services.
General
The ID/DD Waiver Crisis Intervention Daily Service Note must include analysis of the behaviors
and contributing factors, progress in implementing the ID/DD Waiver Crisis Intervention Plan,
providing direct supervision or support, counseling and training family members and/or staff how
to remediate the current crisis and prevent its reoccurrence.
The form is designed to be a running document that allows staff to document activities/events
that take place during the provision of ID/DD Waiver Crisis Intervention Services on a 24/7 basis.
The time services begin as well as when they end must be documented. Use a.m./p.m. Notes
should run from the time the service actually begins on any given day until 11:59 p.m. Notes for
the next day begin at 12:00 a.m. and end on the day and time the person leaves the service.
There must be notes from all shifts detailing the person’s activities (meal times, leisure activities,
personal hygiene activities, attendance at a day program, etc.) as well as reactions to
implementation of the ID/DD Waiver Crisis Intervention Plan.
Timelines
ID/DD Waiver Crisis Intervention Daily Service Notes must be in the person’s record no later than
the 10th of the month following they month they were completed.
DMH ID/DD Crisis Intervention Daily Service Note form
ID/DD Waiver Crisis Intervention
Daily Service Note
Name
Agency
Medicaid #:
Page of
Staff Signature/Credentials Date
(m/d/yr)
Time In
(am/pm)
Time Out
(am/pm)
Total Time
Notes
DMH ID/DD Waiver Crisis Intervention Log – Episodic guidance
ID/DD Waiver Crisis Intervention Log - Episodic
Purpose
The ID/DD Waiver Crisis Intervention Log – Episodic is used to document the provision of
ID/DD Waiver Crisis Intervention Services as they occur episodically, not in the provision of 24/7
ID/DD Waiver Crisis Intervention Services.
General
Document the name, Medicaid number, time services began, time services ended, and
the total amount of time in service provision. The location(s) where services are provided
must be listed. This could be in the person’s home, in a community location, at a
program site or a combination of more than one (1) site. List the names of the people
involved in the situation and their relationship to the person. If someone else receiving
services is involved, simply list his/her relationship to the person. For example, list
“another person participating in the program” rather than Bob Smith.
Describe in detail the nature of the situation which required ID/DD Waiver Crisis
Intervention services. This could include elopement, damage to property, self, others,
etc. This is the justification for the provision of services.
Describe in detail the action(s) taken to address the situation before the arrival of Crisis
Intervention staff. This includes information about what staf f/family/others did to
intervene in or mitigate the crisis.
Describe action(s) taken by Crisis Intervention staff to resolve the crisis. This could
include counseling, the use of Mandt© techniques, removal from the situation to another
setting, etc.
Describe in detail the final resolution of the crisis. Indicate the person’s condition at the
end of the crisis. Part of the resolution of the crisis may be that the person is removed
from the setting for an extended period of time that may cover one or more days. Also
document if referrals were made to other agencies, which agencies, the reason for
referral and the appointment time, if applicable.
Indicate if the ID/DD Waiver Crisis Intervention Plan was implemented as written or if, as
a result of the current situation, it requires revision. If this is the first time services have
been provided, indicate the need for an the ID/DD Waiver Crisis Intervention Plan
must
be developed within five (5) days.
The staff who provided ID/DD Waiver Crisis Intervention Services sign and date the form
upon completion. Even though there is only one line for staff signature/credentials, if
more than one (1) staff participated in the event, include their signature and credentials
also.
Timelines
The ID/DD Waiver Crisis Intervention Log – Episodic must be completed each time services are
Formatted: Strikethrough
DMH ID/DD Waiver Crisis Intervention Log – Episodic guidance
provided. If it is the first time services are being provided, the Clinical Supervisor must notify
the person’s ID/DD Waiver Support Coordinator to request from BIDD that it be added t o the
person’s ID/DD Waiver Plan of Care/Plan of Services and Supports within five (5) days of the
provision of ID/DD Waiver Crisis Intervention Services. The justification for the need for
services is documented on the ID/DD Waiver Request for Crisis Intervention Services form.
The provider completes the ID/DD Waiver Request for Crisis Intervention Services form and
submits it to the Support Coordinator who will then submit it to BIDD for review by the Behavior
Services Oversight Team.
If this is not the first time the services have been used, the provider completes the ID/DD
Waiver Crisis Intervention Log and submits a copy to the Support Coordinator.
All ID/DD Waiver Crisis Intervention Logs must be in the person’s record no later than the 10
th
of the month following the month they are completed.
Formatted: Strikethrough
DMH ID/DD Waiver Crisis Intervention Log- Episodic form
ID/DD Waiver Crisis
Intervention Log
(Episodic)
Name:
Medicaid Number:
Date Time Began Time Ended Total Time
Location(s) where services provided:
People Involved and Relationship:
Situation Requiring Support
(Use as much space as needed)
Action(s) Prior to Crisis Intervention Staff Arrival
(Use as much space as needed)
Action(s) of Crisis Intervention Staff
(Use as much space as needed)
Resolution
(Use as much space as needed)
Crisis Plan Implemented ☐ Crisis Plan Requires Revision ☐ Crisis Plan Needed ☐
Staff Signature/Credentials Date
Clinical Supervisor Signature/Credentials Date
DMH ID/DD Waiver Request for Additional CI Hours
ID/DD Waiver Request for Additional
Crisis Intervention (24/7) Services
Purpose
When additional Crisis Support Intervention Services on a 24/7 basis are deemed necessary by
the Program Supervisor, a Request for Additional Crisis Intervention Services form must
be completed submitted for approval.
General
The Program Supervisor indicates the additional number of days/hours needed, the targeted
behaviors, the number of days/hours that have been used thus far, how they were used and
includes justification for the additional days/hours being requested. The desired goal(s) or
outcome(s) must be included.
Timelines
The form and any attached documentation are submitted to the appropriate Support Coordinator
for submission to the BIDD for review. The maximum number of days hours of
Crisis Support Intervention someone may receive without additional approval is 168 hours.
DMH ID/DD Waiver Request for Additional CI Hours
ID/DD Waiver Request for Additional
Crisis Intervention Services
Name: Date:
Medicaid #: Agency:
Behavior Consultant: Phone Number:
# Additional hours
requested: OR
# Additional days
requested
# Hours utilized to
date:
# Additional Days utilized
to date:
Target
behavior(s):
Justification for
additional
services:
(why hours/days are
needed and how
they will be used)
Desired
goals/outcomes:
BIDD USE ONLY
Approved Disapproved
Section JI
Substance Abuse
Prevention and
Treatment-
Rehabilitation Use
Disorder Services
Educational Activities/Risk Assessments for
TB/HIV/STD
Substance Abuse Monthly Capacity Management
and Waiting List Report
DMH Strikethrough 2016 SA Educational Activities-Risk Assessments for TB-HIV-STD guidance
Risk Assessment Interview & Educational Activities
for TB/HIV/STDs
Purpose
All individuals receiving substance use treatment services (i.e., Outpatient/Intensive Outpatient
Services, Primary/Transitional Residential Services, Withdrawal Management Services, Opioid
Treatment Services, Recovery Support Services, DUI Diagnostic Assessment Services) must
receive a TB and HIV Risk Assessment Interview as well as educational information on
HIV/AIDS, TB, STDs, and Hepatitis.
Applicability
Under each section, if any of the items do not apply, document as “not applicable.”
Risk Assessment Interview for TB/HIV/STDs Form
The staff should verbally administer the interview questions and mark the individual’s responses
on the Risk Assessment Interview Form. Staff should indicate any additional information in the
comments section. After completion on the Assessment Interview, Staff should sign with
credentials and date the form.
Educational Activities & Risk Assessments for TB/HIV/STDs Form
Educational Activities
Lines 1-4: Record the month/day/year and total amount of time spent on each education topic.
A minimum of one hour of HIV Prevention Education is required for all individuals in treatment at
funded Substance Abuse Block Grant HIV Early Intervention Services programs (SABG HIV-
EIS). Educational activities can be conducted in group and/or individual sessions.
HIV Risk Assessment, Testing, & Counseling
Line 1 Record month/day/ year that the Risk Assessment Interview was completed for the
individual receiving substance use treatment services. Total Time is not applicable for
Line 1 item.
Line 2 Record the month/day/year and total time that the individual received HIV pre-test
counseling. This is applicable to all individuals receiving treatment services, even if
they opt out of HIV testing. For SABG HIV-EIS, a minimum of 30 minutes pre-testing
counseling is required.
Line 3 Record YES if the individual received HIV testing and the month/day/year the
individual was tested. Record NO if the individual receiving services opts-out of
testing. An Opt-Out form must be completed if NO is marked. Indicate the
month/day/year the Opt-Out form was completed and signed by the individual. Total
Time is not applicable for Line 3 items.
Line 4 Record the month/day/year and total time the individual receiving services was
provided post-test counseling. Post-test counseling can only be provided IF testing
was conducted. For SABG HIV-EIS, a minimum of 30 minutes of post-test counseling
is required, with 60 minutes for a reactive HIV test.
DMH Strikethrough 2016 SA Educational Activities-Risk Assessments for TB-HIV-STD guidance
Tuberculosis Risk Assessment, Testing, & Referral
Line 1 Record the month/day/year the Risk Assessment Interview was completed for the
individual receiving primary substance use treatment services.
Check YES if results indicate further action is needed.
Check NO if results of risk assessment do not indicate that further action is warranted.
If an individual is determined to be high risk, the individual cannot be admitted to
treatment until testing confirms the individual does not have TB.
Line 2 If further testing is not required, document as “not applicable.”
If Skin Test is completed, record month/day/year when the skin test was administered
to the individual.
Check YES if further action will be taken after the skin test.
Check NO if results of skin test indicate that no further action appears warranted.
Line 3 If further testing is not required, document as “not applicable.”
If X-ray testing is required, record month/day/year that individual received an X-ray to
determine their TB status.
Check YES if further action will be taken after the X-ray.
Check NO if results of X-ray indicate that no further action appears warranted.
Line 4 If further treatment is not required, document as “not applicable.”
If TB treatment is required, record month/day/year when the individual was referred for
treatment for tuberculosis.
Individual Receiving Services Signature/Date
After receiving all applicable risk assessments/educational activities, the individual receiving
substance use treatment services must sign and date the form where indicated.
Staff Signature/Credentials/Date
After the individual has received all applicable risk assessments/educational activities, the staff
person responsible for verifying the administration of these risk assessments/educational
activities must sign, date, and record their credentials.
DMH Strikethrough 2016 SA Educational Activities-Risk Assessments for TB-HIV-STD form
Risk Assessment
Interview
for TB/HIV/STDs
Name
ID Number
Date
1. Have you ever tested positive, been diagnosed with, or treated for tuberculosis
(TB)? Yes No
2. Has anybody you know or have lived with been diagnosed with or tested positive
for TB in the past year? Yes No
3. a.
Within the last month, have you had any of the following symptoms lasting for
more than 2 weeks? If yes, please check items below. No
Fever Drenching night sweats Coughing up blood
Losing weight Shortness of breath Lumps or swollen glands
Diarrhea lasting more than one week
b. Are you now living with someone with any of the following? No
Coughing up blood Drenching night sweats Active TB
4. Have you ever been told that you have a positive HIV test? (test for the AIDS virus) Yes No
5. Do you have a history of IV drug usage? Yes No
6. Have you used cocaine (I.E., powder, crack...etc.)? Yes No
7. Have you ever engaged in unprotected vaginal, anal or oral sex with multiple
partners and/or anonymous partners? Yes No
8. Have any of your current or previous sex partners used IV drugs or been HIV
positive? Yes No
9. Have you ever been paid to have sex or to exchange sex for food, shelter, etc.? Yes No
10. Have you ever been the victim of sexual assault? Yes No
11. Have you ever used alcohol or drug before or during sex? Yes No
12. Have you been diagnosed with or treated for hepatitis and/or a sexually transmitted
disease? Yes No
13. Have you ever lived on the street or in a shelter? Yes No
14. Have you ever been incarcerated or in jail? Yes No
15. Have you had a blood transfusion prior to 1992? Yes No
16. Were you born between the years 1945 and 1965? Yes No
Comments:
Staff Signature/Credentials Date
DMH Strikethrough 2016 SA Educational Activities-Risk Assessments for TB-HIV-STD form
Educational Activities
& Risk Assessments
for TB/HIV/STDs
Name
ID Number
Educational Activities Date
Completed Total Time
1. HIV/AIDS Information (minimum of 1 hour required for funded
SABG HIV-EIS programs)
(including modes of transmission, universal precautions and other preventative
measures, current treatments and how to access them)
2. Sexually Transmitted Diseases (STDs)
(including modes of transmission, precautions to take against contraction, progression of
diseases, current treatment resources and how to access them)
3. Tuberculosis
(including modes of transmission, current treatment resources and how to access them)
4. Hepatitis
(including modes of transmission, precautions to take against contraction, current
treatments and how to access them)
HIV Risk Assessment, Testing, & Counseling Date
Completed Total Time
1. Completion of Risk Assessment Interview
2. Provided HIV Pre-Test Counseling (minimum of 30 minutes)
3. Provided HIV Testing
Yes
No Opt-out form completed for refusal of testing on:
4. Provided Post-Test Counseling if testing was conducted (minimum
of 30 minutes; 60 minutes for a reactive HIV test)
Tuberculosis Risk Assessment, Testing, & Referral Date
Completed
1. Completion of Tuberculosis Risk Assessment
Do results indicate further action? Yes No
2. Completion of Skin Test
Do results indicate further action? Yes No
3. Completion of X-ray
Do results indicate further action? Yes No
4. Referred for Tuberculosis Treatment
By signing, you acknowledge receipt of the educational information and all risk assessments listed above.
Individual Receiving Services Date Staff Signature/Credentials Date
DMH Strikethrough 2016 SA Monthly Capacity Management and Waiting List Report guidance
Substance Abuse Monthly Capacity Management and Waiting List
Reports
Purpose
All substance abuse programs must give first priority to the acceptance and treatment of pregnant
women. Substance abuse programs must also provide treatment to IV drug users. Written
documentation of placement or assessment and referral of pregnant women and IV drug users
must be maintained and reported to the DMH.
Timeline
To assist with appropriate referrals and placement, all residential programs must report to DMH
when the census of the program exceeds 90% capacity and when the census drops below 90%
capacity. Report should be submitted to the Office of Consumer Support by fax
or the Bureau of
Alcohol and Drug Services by email within 24 hours of crossing the 90% threshold.
Pregnant women must be admitted to a program for treatment within forty-eight (48) hours of an
initial contact. IV drug users must be placed in substance abuse treatment programs within forty -
eight (48) hours of an initial contact. Reports must be submitted to the Office of Consumer
Support by fax or the Bureau of Alcohol and Drug Services by email by the 10
th working day of the
month following the reporting period.
The program must monitor and complete the process of securing the most appropriate program
for pregnant women and IV drug users. If the most appropriate program has not been secured by
the end of a reporting month, the report must be sent to the Office of Consumer Support by fax
or
the Bureau of Alcohol and Drug Services by email indicating where the individual is in the
process. The program must continue to submit the information on the individual each month until
he/she is admitted into the appropriate program.
DMH Strikethrough 2016 SA Monthly Capacity Management form
Substance Abuse Capacity
Management
Timeline within 24 hours
Facility
Name
Date
At 90% capacity
No longer at 90% capacity
Fax or Email to:
Office of Consumer Support
Fax Number: (601)359-9570
Or
Bureau of Alcohol and Drug Services
Email: deeannalechtenberg@dmh.state.ms.us
DMH Strikethrough 2016 SA Emergency Placement Pregnant Women Report form
Emergency Placement for
Pregnant Women
Timeline: within 48 hours of initial
contact
Date
Time of
Contact
Type of
Contact
Facility
Name
Client Information
Name
Address
Telephone Number
Other Contact Information
Fax or Email:
Office of Consumer Support
Fax Number: (601)359-9570
Or
Bureau of Alcohol and Drug Services
Email: deeannalechtenberg@dmh.state.ms.us
Date Submitted to DMH
DMH Strikethrough 2016 SA Emergency Placement IV Drug User Report form
Emergency Placement for
IV Drug Users
Timeline: within 48 hours of initial
contact
Date
Time of
Contact
Type of
Contact
Facility
Name
Client Information
Name
Address
Telephone Number
Other Contact Information
Fax or Email:
Office of Consumer Support
Fax Number: (601)359-9570
Or
Bureau of Alcohol and Drug Services
Email: deeannalechtenberg@dmh.state.ms.us
Date Submitted to DMH
Section JK
Administrative
Information
Disaster Preparedness and Response Guidance
Disaster, Fire, and COOP Drills for all Programs
DMH Plan of Compliance Template
Staff Verification of Training on Abuse or Neglect Reporting
Requirements
DMH Disaster Preparedness and Response Plan Development guidance
DISASTER PREPAREDNESS AND RESPONSE
Guidance for Operational Standards
This document contains guidance to assist your program with compliance with The Mississippi Department of Mental Health
Operational Standards for Disaster Preparedness and Response as well as the Continuity of Operations Plan (COOP). By using
this guidance, you will be more likely to meet the required elements for each standard listed. This guidance is not meant to be
copied and pasted into your Policy and Procedures Manual, but is simply a guide to assist you in meeting the agency’s standards.
Beneath each standard (in bold) you will find guidance that will assist you in meeting the desired outcome of that standard. Some
of the standards require completion of certain tasks. For example, in the introduction to the emergency/disaster response plan
section you must have a plan for each site that is “reviewed by the governing body”. You must have in your plan a statement that
the plan will be reviewed by the governing body, how often, and how you will document this.
If you have specific questions regarding these standards, please contact The Mississippi Department of Mental Health , Office of
Incident Management at 601-359-6652 or send email questions to randy.foster@dmh.state.ms.us.
Rule 13.9.A Providers must develop and maintain an emergency/disaster response plan for each service location/site,
approved by the governing body, for responding to natural disasters, manmade disasters (fi res, bomb
threats, utility failures and other threatening situations, such as workplace violence). The plan should
identify which events are most likely to affect the location/site. For example, the location/site is located
near an airport, railroad, nuc lear power plant, typical path of tornado, earthquake zone, coastal region,
etc. This plan must address at a minimum:
- You must have a plan for each service location/site. Each plan may have many of the same elements as other
sites, but each site is a little bit different and the plan should reflect those differences .
- This plan must be approved by your governing authority; you must have documentation of this in meeting
minutes.
- Each program should have as a part of the plan a response for each type of identified threat
Natural events such as tornado, hurricane, wild fire, etc.
Man-made events such as bomb threats, work place violence, etc.
To accurately assess the hazards that each location/site might be vulnerable to, it is suggested that you complete a H azard
Vulnerability Analysis (HVA) or contact the county to obtain county level HVA info. Please see attachment A for more
information on how to conduct a HVA.
1. Lines of authority and Incident Command
Identify who will be in charge for the whole agency and for each location/site in the event of an emergency/disaster. An
organizational chart would be helpful here in the event that the identified person is not available.
2. Identification of a Disaster Coordinator
Please designate one person that will act as your Disaster Coordinator. This individual will be in charge of making sure
the plan is accurate and up to date, drills are conducted appropriately, and that the agency and each location are prepar ed
to respond.
3. Notification and plan activation
This section must contain what triggers activation of the plan, who officially activates the plan, and once the plan has
been activated how staff and individuals who receive services are notified of the event. Part of this section should be
notification to DMH, and local emergency personnel that need to be notified based on the nature of the event (Fire,
Police, DEQ, Emergency Management, etc.).
4. Coordination of planning and response activities with local and state emergency management authoriti es
Your agency and programs must coordinate with the local emergency response agencies. Typically, these are the local
Fire Department, local Police Department, and local Emergency Management Agency. There may be other response
agencies, such as non-profit agencies or other state/local agencies, which you may benefit from coordinating with as
well. Each of these agencies may benefit from having a copy of your emergency/disaster response plan for review,
comment and reference.
DMH Disaster Preparedness and Response Plan Development guidance
5. Assurances that staff will be available to respond during an emergency/disaster
You must have sufficient staff to continue the essential functions of the agency. You should identify how you will
ensure that the needed staff is available to handle those responsibilities. This section should also address how your
agency will ensure that staff is available to respond to community needs during an event.
6. Communication with individuals receiving services, staff, governing authorities, and accrediting and/or licensing
entities
Outline how you will notify individuals receiving services, staff, your governing authorities, and your accrediting and/or
certifying entities that an event has occurred, your plan has been activated, and to what extent and for how long your
services will be affected.
7. Accounting for all persons involved (staff and individuals receiving services)
When the event occurs and directly affects your program, outline how you will make sure all of those present at the time
of the event, both staff and individuals receiving services, are safe and accounted for. This could be done with
attendance logs, lists of those staff that may be traveling, or other means of accounting for every one. There must be a
method to account for each individual.
8. Conditions for evacuation
Outline conditions that would cause you to evacuate your facility. A fire would be an example, but there are others as
well such as power failure, sewage and/or water failure, foreseen unsafe conditions (hurricane, etc.) , gas leaks (must
comply with EMA directives regarding evacuation for gas leaks) and others. You should address all of those here.
9. Procedures for evacuation
Outline procedures for evacuation. Here you should identify the different types of evacuation as well. For example, the
evacuation of your location for a fire is a different type of evacuation than leaving the location and area due to weather or
chemical exposure. This section should also address the plan if the decision is made to shelter in place.
10. Conditions for agency closure
Under what conditions would your agency close? Some reasons might include damage to the facility, prolonged utility
outage, infrastructure failure, and others.
11. Procedures for agency closure
If the conditions have been met for agency closure, what is the procedure? Who has the authority to orde r the agency
closure? Who will be responsible for notification procedures?
12. Schedules of drills for the plan
Drills are required to be held on a schedule to ensure that staff is prepared in the event of an actual emergency/disaster.
This schedule is the minimum requirement; more drills should be conducted if they are deemed necessary. The
minimum schedule of drills should be as follows:
Quarterly fire drills for day programs
Monthly fire drills for residential programs, conducted on a rotating schedule within the following time frames:
7 a.m. to 3 p.m.
3 p.m. to 11 p.m.
11 p.m. to 7 a.m.
Quarterly disaster drills, rotating the nature of the event for the drill based on the e mergency/disaster plan, for
each facility and program.
Annual drill of Continuity of Operations Plan for the agency.
DMH Disaster Preparedness and Response Plan Development guidance
Drills should be unannounced as much as possible to ensure they are as real as possible.
13. The location of all fire extinguishing equipment, carbon monoxide detectors (if gas or any other means of carbon
monoxide emission is used in facility) and alarms/smoke detectors
In your plan you should have a map that shows the location of these items or a written description of the location of these
items. The physical presence of these items in these locations will be checked on site visit.
14. The identified or established method of annual fire equipment inspection
All fire equipment must be inspected on a set schedule, usually annually and by a professional from either the Fire
Department or the equipment company. The method of inspection and documentation of inspection must be outlined
here.
15. Escape routes and procedures that are specific to location/site and the type of disaster(s) for which they apply.
A copy of the escape routes must be in the emergency/disaster response plan for reference. These signs should be posted
in visible locations, oriented to the location in the building, with a route for evacuation specific to that location.
CONTINUITY OF OPERATIONS PLAN REVIEW
*Understand that this Continuity of Operations Plan (COOP) is for the agency as a whole, not for specific
sites/locations. Only 1 COOP is required for the agency. Each site should be provided a copy of the agency’s
COOP.
Rule 13.9.B Providers must develop and maintain a Continuity of Operations Plan, approved by the governing body,
for responding to natural disasters, manmade disasters, fires, bomb threats, utility failures and other
threatening situations, such as workplace violence. This plan must address at a minimum:
The following standards address your Continuity of Operations Plan (COOP). This plan is in place in the event that an
emergency/disaster occurs. This plan ensures that essential functions can continue no matter what type of event occurs.
Your governing body should approve this plan and any changes to it. Please note that the following standards are the
minimum this plan should address.
1. Identification of provider’s essential functions in the event of emergency/ disaster
What are the essential functions of your agency? These are functions that your program’s clients would need even
during an emergency/disaster. Some examples could be medications, individual therapies, residential treatment, or any
other number of services.
2. Identification of necessary staffing to carry out essential functions
List the staff members (not specific names, but positions) that your agency will need to ensure that the essential functions
will continue. List the capacity in which these individuals will serve and backup staff if these individuals are not
available.
3. Delegations of authority
Who has the authority to assign tasks and duties? A COOP organizational chart that shows minimal staff and
responsibilities in the event that the COOP Plan is activated, might be useful here.
4. Alternate work sites in the event of location/site closure
You have identified essential functions and you must identify an alternate location for those functions to continue if your
location/site is not able to provide those functions. These sites must be identified and named with memorandum of
agreements (MOA) or understanding (MOU) in place with the location if needed. It is not sufficient to s imply state that
you will find a location if needed at the time of the event.
DMH Disaster Preparedness and Response Plan Development guidance
5. Identification of vital records and their locations
If you have vital records for staff or individuals served, those are to be identified here along with the location of those
records. Vital records may include case record, personnel records and financial records for agency. T his does not have to
include all records, but should include any records essential to continuing operations.
6. Identification of systems to maintain security of and access to vital records.
How will you maintain the security of these vital records during the event? Buildings may be compromised, the records
may need to be transported to other locations, and the security and confidentiality of those records is important and must
be addressed here. How are your records backed-up and how often does this back-up occur?
Rule 13.9.C Copies of the Emergency/Disaster Response Plans and the Continuity of Operations Plan must be
maintained on-site for each location/site and at the agency’s administrative offices.
You must have copies on site of both the Emergency/Disaster Response Plans and the Continuity of Operations Plan at
each location/site. This ensures that in any event, the staff at every location ha ve access to the needed materials to
follow these plans. These will be checked during the site visit for each program.
Rule 13.9.D Any revisions to the Emergency/Disaster Response Plans and the Continuity of Operations Plan must be
documented and approved by the agency’s governing body. Any revisions must be communicated in
writing to all staff.
Any changes to either plan must be reviewed and approved by the governing body and evidence of this must be
documented in the meeting minutes. You should note in the plan itself that these plans will be reviewed by your
governing body. These minutes will be reviewed by the site visit team. All staff must be notified of any changes to
these plans.
Rule 13.9.E All locations/sites must document, utilizing the standardized DMH form, implementation of the written
plans for emergency/disaster response and continuity of operations. This documentation of
implementation must include, but is not limited to the following:
1. Quarterly fire drills for day programs
For day programs, you must conduct a fire drill in each of the four quarters of the year:
Jan-Mar, Apr-Jun, Jul-Sept, and Oct-Dec.
2. Monthly fire drills for residential programs, conducted on a rotating schedule within the following time
frames:
7 a.m. to 3 p.m.
3 p.m. to 11 p.m.
11 p.m. to 7 a.m.
For residential programs, you must conduct a monthly fire drill rotating between the timeframes listed. For
example: Jan – 7A-7P, Feb 3P-11P, Mar 11P-7A.
This schedule would meet the minimum requireme nts of each shift participating in one drill each quarter. It
may be beneficial for each shift to have a drill each month, but it is not required.
3. Quarterly disaster drills, rotating the nature of the event for the drill based on the emergency/disaster
plan, for each facility and program.
There must be one drill each quarter for those disasters identified in the HVA. These drills should be rotated
to address the types of events most likely to occur based on the HVA.
4. Annual drill of Continuity of Operations Plan for the agency.
On an annual basis (on or before the date of the previous drill), you must conduct a drill for your Continuity
of Operations Plan. You should conduct this drill to test each level of the plan including activating essentia l
DMH Disaster Preparedness and Response Plan Development guidance
staff, movement of vital records, and activating agreement with alternate site location. This drill should be
documented and kept on file for review.
PLEASE SEE ATTACHMENT B FOR FURTHER GUIDANCE ON DRILLS AND MONITORING OF
DRILLS
Rule 13.9.F All supervised living, residential treatment programs, and/or Crisis Stabilization Units must maintain
current emergency/disaster preparedness supplies to support individuals receiving services and staff for a
minimum of seventy-two (72) hours post event. At a minimum, these supplies must include the following:
1. Non-perishable foods
2. Manual can opener
3. Water
4. Flashlights and batteries
5. Plastic sheeting and duct tape
6. Battery powered radio
7. Personal hygiene items.
For supervised living programs and residential substance abuse treatment programs, you must keep on site at a minimum
the items above. Any other items that are viewed as necessary should also be kept on site in the event of an
emergency/disaster. These will be viewed on site by the site visit team. Please be sure to monitor expiration dates as
expired products will be viewed as missing by the site visit team. You must list all items that you plan to keep on site for
such events in the Emergency/Disaster Response Plan. It is up to the program to determine the right amount to provide
these items for the clients on site.
Rule 13.9.G All supervised living, residential treatment programs, and/or Crisis Stabilization Units must have policies
and procedures that can be implemented in the event of an emergency that ensure medication,
prescription and nonprescription, based on the needs of the individuals in the program and guidance of
appropriate medical staff is available for up to seventy-two (72) hours post-event.
Each program must have policies and procedures that state they will not only have seventy-two (72) hour supply of all
prescription and non-prescription medication for each resident, but they must also have appropriate staff available to
administer those medications.
DMH Disaster Preparedness and Response Plan Development guidance
ATTACHMENT A – Hazard Vulnerability Analysis (HVA)
• An HVA is conducted to determine the risks associated with probable or possible disasters or events.
• An HVA identifies the events most likely to affect your organization and the probable impact if they do occur
• Depending on the evaluated level of preparedness, the facility must take necessary steps to ensure they are prepared to
meet the challenges presented by the hazards
There are Four Areas of Concern: Natural, Technological, Human, and Hazmat Events
These should be broken out into each individual type of event (i.e. tornado, fire, etc.)
Items to address for each event type:
• Probability
What is the known risk this will happen
- Low – Rare
- Moderate – Unusual
- High – High Potential or Have Experienced
Use of historical data about previous events can help predict the likelihood
• Response
How long would it take to have an on-scene response
How big will that response be
Historical evaluation of response success
• Human Impact
Potential for staff death or injury
Potential for patient death or injury
• Property Impact
Cost and time to replace/repair
Cost to set up temporary replacement
Time to recover
• Business Impact
Business interruption
Employees and/or patients unable to report to work
Interruption of critical supplies
Financial impact/burden
• Preparedness
Status of current plans (how ready are you for each type of event)
Frequency of drills
Availability of alternate sources for critical supplies/services
• Internal Resources
Types and amount of supplies on hand and will they meet the need
Staff availability
• External Resources
Types of agreements with community agencies
Coordination with local and state agencies
Coordination with nearby health care facilities
Coordination with treatment specific facilities
Community resources
DMH Disaster Preparedness and Response Plan Development guidance
ATTACHEMENT B – Disaster, Fire, and COOP Drill Guidance
Disaster, Fire, and COOP Drills for all Programs
Purpose
Each provider certified by the DMH must maintain an emergency/disaster response plan for each service location/site
for responding to natural disasters and manmade disasters (fires, bomb threats, utility failures and other threatening
situation such as workplace violence). Providers must maintain a Continuity of Operations Plan (COOP) describi ng
how operations will continue in the event of a natural or manmade disaster. Each location/site must document proof
of implementation of these written plans as evidenced by written reports of scheduled and conducted fire, disaster,
and COOP drills.
Timeline
• Disaster drills must be conducted and documented at least quarterly.
▪ Disaster drills must rotate the nature of the event for the drill based on each facility and program’s
emergency/disaster plan.
• Fire drills must be conducted and documented at least monthly for all supervised living and/or residential
programs and quarterly for all day programs.
▪ Fire drills for residential programs must be conducted on a rotating schedule across all three shift
schedules.
• COOP drills must be conducted and documented at least annually.
General Information
Each provider is responsible for developing report formats that will document all aspects of each type of drill in order
to ensure the safety of all persons involved in the drill. Elements to be recorded in each drill report include but are not
limited to:
• Name and location of the program
• Type/nature of the drill
• Date of the drill
• Time the drill began
• Time the drill ended
• Nature of the event (tornado, bomb, hurricane, other) for a disaster drill
• Number of participants
• Names of staff participating
• Assessment of the drill that addresses elements of the emergency/disaster or COOP plan as well as the
behavior of those participating in the drill
• Signature and title of the staff person completing the report
Providers are welcome to contact the Office of Incident Management at 601-359-6652 for technical assistance in the
development of drill reports.
DMH Strikethrough 2016 Fire and Disaster Drills for all Programs guidance
Disaster, Fire, and COOP Drills for all Programs
Purpose
Each provider certified by the DMH must maintain an emergency/disaster response plan for
each service location/site for responding to natural disasters and manmade disasters (fires,
bomb threats, utility failures and other threatening situations such as workplace violence).
Providers must maintain a Continuity of Operations Plan (COOP) describing how operations will
continue in the event of a natural or manmade disaster. Each location/site must document proof
of implementation of these written plans as evidenced by written reports of scheduled and
conducted fire, disaster, and COOP drills.
Timeline
• Disaster drills must be conducted and documented at least quarterly.
▪ Disaster drills must rotate the nature of the event for the drill based on each facility
and program’s emergency/disaster plan.
• Fire drills must be conducted and documented at least monthly for all supervised living
and/or residential programs and quarterly for all day programs.
▪ Fire drills for supervised living residential treatment service must be conducted on
a rotating schedule across all three shift schedules.
• COOP drills must be conducted and documented at least annually.
General Information
Each provider is responsible for developing a report that will document all aspects of each type
of drill in order to ensure the safety of all persons involved in the drill. Elements to be recorded
in each drill report include but are not limited to:
• Name and location of the program
• Type/nature of the drill
• Date of the drill
• Time the drill began
• Time the drill ended
• Nature of the event (tornado, bomb, hurricane, other) for a disaster drill – must rotate
quarterly based on potential hazards
• Number of participants
• Names of staff participating
• Assessment of the drill that addresses elements of the emergency/disaster or COOP plan
as well as the behavior of those participating in the drill
• Signature and title of the staff person completing the report
Providers are welcome to contact the Division of Disaster Preparedness and Response at 601-
359-1288 for technical assistance in the development of drill reports.
DMH Strikethrough 2016 Fire and Disater Drills for all Programs form
Fire and Disaster Drill
Report Form
Program Name_______________________
Date of Drill__________________________
Time of Drill (am/pm)_____________________
Type of
Drill :
Fire (quarterly for day programs, monthly
for residential programs)
Disaster (quarterly for all programs) Type of Disaster:
COOP (annual for all programs)
(Disaster type must rotate each quarter through all applicable disasters)
Exact Start Time of Drill: Exact End Time of Drill:
Amount of Time to Complete Drill :
Number of Participants (not staff) :
Staff Participating in Drill :
Written assessment of general performance on the drill :
(please be specific about actions that took place during the drill)
Signature of Staff Member Preparing Report :
Strikethrough2016 DMH Required Plan of Complaince guidance
Required Plan of Compliance
Purpose
All DMH Certified Providers must submit a Plan of Compliance in response to findings included
in a DMH Written Report of Findings. This template must be utilized by providers.
Timeline
The plan must be completed within the timeframe stated in the DMH Written Report of Findings.
Finding
Reference the DMH Operational Standard included in the DMH Written Report of Findings.
Program/Service
Reference the program or service (if there is not a specific physical location for the program)
included in the DMH Written Report of Findings.
Corrective Action Steps
Outline the action steps the provider will put in place to correct the findings. Do not include
justification.
A request for a waiver of a DMH Operational Standard is not considered a
corrective action step.
Time Line
Include the implementation date and estimated date of completion for each corrective action.
Deficiencies related to Chapters 13, 32 and/or 34 of the DMH Operational Standards must be
corrected within 30 days of the date of this letter.
Plan for Continued Compliance
Outline the plan for how the agency will continue to comply with DMH Operational Standards
and the identified correction action plan(s).
Strikethrough 2016 DMH Required Plan of Complaince Template
Required Plan of Compliance
Plan of Compliance
Please complete all requested information and mail completed
form and supporting documentation to:
Division of Certification
MS Department of Mental Health
239 North Lamar Street, Suite 1101
Jackson, MS 39201
In lieu of mailing the form, you may e-mail the completed
electronic form and supporting documentation to the Division of
Certification. For contact information call #601-359-1288.
Provider Name: Phone:
Provider Contact
Person for follow-up:
Fax:
Email:
Finding
(DMH Standard
Number)
Program/Service/
Record
Corrective Action(s) Time Line Plan for Continued Compliance
Implementation Date:
Projected Completion
Date:
Implementation Date:
Projected Completion
Date:
Implementation Date:
Projected Completion
Date:
Implementation Date:
Projected Completion
Date:
DMH Staff Verification of Training on Abuse or Neglect Reporting guidance
Staff Verification of Training on Suspected Abuse or Neglect
Reporting Requirements
Purpose
All provider staff must be informed of and trained on the procedures for reporting suspicions of
abuse or neglect in accordance with state reporting laws to include but not limited to the
Vulnerable Persons Act and Child Abuse or Neglect Reporting requirements.
Time Line
All provider staff must be informed of and trained on the procedures for reporting suspicions of
abuse or neglect of individuals receiving services in accordance with state reporting laws.
Individuals acknowledge receipt of the information and training during General Orientation
before service delivery. A copy of the verification must be maintained in the staff personnel
record.
Verification form is updated if training is repeated or new training is provided.
Strikethrough 2016 Staff Verification of Training on Abuse or Neglect Reporting Requirements form
Staff Verification of Training on Suspected Abuse or
Neglect Reporting Requirements
I acknowledge that I have been informed of and trained on the procedures for reporting suspicions
of abuse or neglect in accordance with state reporting laws to i nclude but not limited to the
Vulnerable Persons Act and Child Abuse or Neglect Reporting requirements.
I understand that I have a personal responsibility to report suspicions of abuse or neglect in
accordance with state reporting laws.
Staff Signature/ Position or Credentials Witness/ Position or Credentials Date