Form 208
CLIENT DATA FORM
Client Code:___________________________
Client Name: ________________________________________________________________________________
1st Contact Date:________ / ________ / ________
Programs:
001-Outpatient
002-FLC
003--First Day
005—Board & Care
007--Cape May
009-SCILS
010--SBYS-Pleasantville
Status:
011-SafeHarbor
012-YCM Atlantic
013--Family Preservation
015--SBYS-EHTHS
016-EHT Family Success Ctr
018 P’ville Family Success Ctr
019Kinship Legal Guardianship
C. Enrollee IC
021-Trained Volunteer
027-YCM Cumberland
028--OC ARRA
030--Rainbow Place
031-HEDS
032-SBYS PLP - Child Care
034-Kinship Wraparound
E. Active IC
Therapist: ______________________
Case Manager: ______________________
Primary (Axis 1) DX (DSMIV) ______________________
Secondary DX ______________________ (include V71.09 if N/A)
Clinical Supervisor: ______________________
Physical DX______________________ (include 00000 if N/A)
Axis 4______________________
Psychotropic Meds: ______________________Y/N
Veteran Status______________________Y/N
Soc. Sec. Elig. (circle 1)
A. Determined Eligible
B. Potentially Eligible
C. Probably Not Eligible
D. Determined Ineligible
036--Juvenile Sex Offenders
039--SAIF – Case Mgt
045--SAIF – General Assis.
048-Cultural Competence Trng.
055-HEDS-JDAI
057-Crime Prevention
060--JJRFL
Residential Arrangement (circle 1)
A. Private Residence
B. Cooperative Living Situation
(No MH Svcs)
C. Foster Family Care
D. Homeless/On Street
E. Community Residential Prog.
(with MH Svcs)
F. Boarding Home/RHCF
G. Nursing Home/SNF/ICF
H. Residential Subst. Abuse Prog.
J. DDD/MR Residence
K. DYFS Residential Trtmt. Ctr.
Education Level (in years) ________ ________
(If student, grade)
Axis 5______________________
L. Children's Group Home/
Teaching Family Program
M. Homeless Shelter
N. Other Residential Program
O. State Psychiatric Hospital
P. County Psychiatric Hospital
R. CCIS Inpatient
S. Other Psychiatric Inpatient
T. State Correctional Facility
V. Detention Center
W. Other Institutional Setting
X. Unknown
Education Type (circle 1)
A. Regular/Vocational Education
B. Special Education
Handicapping Condition (circle up to 5)
A. Ambulatory/Orthopedic
D. Developmental Disability/MR
B. Auditory
E. Neurologically Impaired
C. Communication
F. Medical
C. Post High School Education
D. Not in School
G. Visual
H. Emotionally Disturbed
(Ed. Classifi. Only)
J. Perceptually Impaired
(Ed. Classifi. Only)
K. None
C. No, Other Foreign Language
D. No, American Sign Lang.
English Speaking (circle 1)
A. English Speaking
B. No, Spanish Speaking
Living Circumstance (circle 1)
A. Alone/Independent
B. With Relatives/Family
Level of Functioning at time of admission ______________________
C. Other
Past Service History (circle up to 5)
A. Alcohol Treatment Program
B. Drug Treatment Program
C. Community Corrections Prog.
D. Correctional Facility
E. Detention Center
F. Probation
G. DDD
H. DYFS
J. Family Crisis Interv. Unit
K. Child Study Team Evaluation
L. Group Home with MH Services
M. Specialized Foster Care
N. Public Welfare
O. Other Social Service Agency
P. State Psychiatric Hosp.
R. County Psychiatric Hosp.
S. CCIS Inpatient
T. Other Psychiatric Inpatient
Program/Service Needs: (Circle up to 5)
A. Crisis Stabilization/Emergency Svcs.
B. CCIS Inpatient
C. Other Psychiatric Inpatient
D. Client Advocacy
E. Daily Living Skills
F. Medication Monitoring/Education
G. Partial Care
H. Psychological/Psychiatric
Evaluation Only
J. Psychotherapy/Counseling
K. Self-Help Services
L. Service Coordination/Linkage
Presenting Problems (circle up to 5)
A. Alcohol Abuse
B. Anxiety
C. Assaultive Behavior
D. Bizarre Behavior
E. Compulsive Gambling
F. Daily Living Problems
G. Depression/Mood Disorder
H. Destructive to Property
V. Clinical Case Management/
Youth Case Management
W. Outpatient/Counseling
X. Partial Care
1. Residential Care
2. Emergency/Mobile Outreach/
Treatment Team
3. Liaison Services
4. Systems Advocacy
5. Self Help Serv.
6. None
M. Community Residential Program (with MH Svcs)
N. Crisis Housing
O. Outreach/In-Home Services
P. Residential Support Services
R. Respite Care
S. Pre-Vocational Services
T. Transitional/Supported Employment
V. Child Study Team Evaluation
W. DDD
X. DYFS
1. Information and Referral
2. Other
J. Developmental Disability
K. Drug Abuse
L. Eating Disorder
M. Economic Stress
N. Fire Setting/Ideation
O. Homicidal Behavior/Threat
P. Legal/Justice Involvement
R. Marital/Family Problem
S. Medical/Somatic Complaints
T. No Social Support Resources
V. Organic Mental Disorder
W. Physical Abuse/Assault Victim
X. Physical Neglect
1. Runaway Behavior
2. School Problems
3. Sexual Abuse/Rape Victim
4. Sexual Abuser
5. Social/Interpersonal (other than family)
6. Suicide Attempt
7. Suicide Threat
8.Thought Disorder
9. Other
Primary Presenting Problem (from above) ______________________
Current Service Involvement (circle up to 5)
A. Alcohol Treatment Program
K. Child Study Team Evaluation
B. Drug Treatment Program
L. Group Home with MH Services
C. Community Corrections Prog.
M. Specialized Foster Care
D. Correctional Facility
N. Public Welfare
E. Detention Center
O. Other Social Service Agency
F. Probation
P. State Psychiatric Hosp.
G. DDD
R. County Psychiatric Hosp.
H. DYFS
S. CCIS Inpatient
J. Family Crisis Interv. Unit
T. Other Psychiatric Inpatient
V. Clinical Case Management/
Youth Case Management
W. Outpatient/Counseling
X. Partial Care
1. Residential Care
2. Emergency/Mobile Outreach/
Treatment Team
3. Liaison Services
4. Systems Advocacy
Non-MH Needs (circle up to 5)
A. Alcohol Abuse Services
B. Correctional
C. Drug Abuse Services
D. Education
J. Medical/Health Related
K. Pastoral
L. Recreation
M. Transportation
E. Employment
F. Financial
G. Housing
H. Legal/Justice
5. Self Help Serv.
6. None
N. Other
P. None
Ethnic Group:
A. American/Indian/Alaskan Native
B. Asian/Pacific Islander
C. Black, Not of Hispanic Origin
D. Hispanic
E. White, Not of Hispanic Origin
Location
5 EHT - Main Office
1 Egg Harbor Twp Comm Cntr
A Absecon
2 Pleasantville Fam Ctr
Sub-Contract
A–
B–
C–
D–
Adolescent OP
Court
Open Access Clinic
Drug & Alcohol Adolescent
CP – Child Physical Abuse
SC – Child Sexual Abuse
AM – Adult Molested as Child
DV - Domestic Violence
FM – Family Member
I – Intensive OP
J – Juvenile Sex Offenders
L – Jail Diversion
S SBS
O – None
RO - Robbery
EA – Elder Abuse
AS - Assault
OT – Other (Specify)
SH – Survivors of Homicide Victims _______________________
VC – Violent Crime
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Name
Client Code
Identified Client
_________________________________________
____ ____ ____ ____ ____ ____
Mother
_________________________________________
____ ____ ____ ____ ____ ____
Father
_________________________________________
____ ____ ____ ____ ____ ____
Other
_________________________________________
____ ____ ____ ____ ____ ____
_________________________________________
____ ____ ____ ____ ____ ____
_________________________________________
____ ____ ____ ____ ____ ____
_________________________________________
____ ____ ____ ____ ____ ____
_________________________________________
____ ____ ____ ____ ____ ____
CODES
Employment Status – A.
B.
C.
D.
E.
F.
G.
Employed--Full-time
Employed--Part-time
Armed Services
Sheltered Employment
Unemployed
Not in Labor Force
Unknown
Referral Source
AA. PIP
AB. Other Emergency/Screening
BA. Emergency- -ACMC
BB. Emergency- -Other
CA. IRIS
CB. Laurel Landing
CC. Other Short Term Care Fac.
CD. Kennedy CCIS
DA. County Psych. Hospital
EA. Ancora
-~
EC. Brisbane Hospital
EB. Other State Psych. Hosp.
FA. ACMC Inpatient Psych.
FB. Other Psych. Hosp.
GA. ACMC Gen.
GB. Shore Memorial
GC. Burd. Tomlin Hosp.
GD. Children’s Seashore House
GE. Kessler Hosp.
GE. Bridgeton Hosp.
GG. Alternatives
GH. Other General Hosp.
HA. Atlantic Mental Health
HB. Cape May Mental Health
HC. Jewish Family Service
HD. Other Mental Health
HE. Atlantic Mental Health Liaison
JA. Seabrook
JB. Maryville
Marital Status -
JC. Other Alcohol
KA. Instit. Human 0ev.
KB. Other Drug Agency
LA. School System
MA. CONTACT
MB. Women’s Abuse
MC. Atlantic County Welfare
MD. Atlantic County Health Dept.
ME. Atlantic County Aging
MF. Homemakers
MG. Red Cross
MR. SR. Sites
MI. GAP
MJ. Family Planning
MK. DVR
ML. Other Soc. Agency
MM. Caring
MN. Cape May Office on Aging
MO. CBVI
NP. Home Health Agency
MO. CART/Child Family Team
MR. CCCS
NA. Nursing Home
OA. Boarding Home
PA. Homeless Shelter
RA. Other Resid. Prog.
SA. Police
SB. Court
SC. Family Court
SD. Jail
A. Married/Living as Married
B. Widowed
C. Divorced
D. Separated
E. Never Married
F. Unknown
Family Status
A.
B.
C.
D.
E.
F.
G.
Intact/2 Parent & Children
Reconstituted (Step Family)
Female Head of Household Divorced
Male Head of Household Divorced
Female Head of Household Separated
Male Head of Household Separated~
Female Head of Household Widowed
Legal Status
A.
B.
C.
D.
E.
F.
G.
No Problem
Case Pending
Probation
Parole
Countermeasures
Other
Not Assessed
Rev. 02/11
SE. Parole
SF. Probation
SG. Prosecutor’s Office
SH. TASC
SJ. Other Crim. Just.
SK. Harborfields
SL. JINS
TA. Manor Woods
VA. Pre Trial Interv.
VB. IDRC.
VC. Juv. Conf. Committee
VD. Attorney
VE. Other Community Correction
WA. Family Crisis
XA. Self
XB. Employer
XC. Yellow Pages/Ads/PR
XD. Veterans Administration
XE. Insurance Company
11. Family or Friend
21. Priv. MH. Prac.
31. Private Psychiatrist
41. Medical Doctor
51. Clergy
61. DYFS
71. DDD
81. Other
H. Male Head of Household Widowed
I. Single Adult(s)
J. Couple/No Children
K. Foster Care
L. Extended Family
M. Female Head of Household (w/Child, Never Married)
N. Male Head of Household (w/Child, Never Married)