HUMAN SERVICES ASSOCIATES, INC.
Family Service Planning Team & Title XXI Intervention
CHILDREN’S MENTAL HEALTH OUTCOME/CFARS FORM
*Client Name:
Last
First
Middle
[PRINT NAME]
Section 1 : If purpose of evaluation is 4-Administative discharge complete areas with paper/pencil picture only.
**Provider Initial Evaluation Date from MH Outcome Form at Admission:
***HSA Initial Evaluation Date from MH Form at Admission:
1. *Social Security#:
2. *Contractor ID:
3.*Provider Purpose of Evaluation:
1- Admission to agency
2- 3 month Interval
3- Discharge from Agency
(Select a choice, then complete the sections
associated with that choice)
-
4.*Evaluation Date:
MM
4- Administrative Discharge (Complete areas with
paper/pencil picture only )
5-Immediate Discharge
1- Admission to agency
2- 3 month Interval
3- Discharge from Agency
3.(a) *HSA Purpose of Evaluation:
/
DD
/
59-3174674
4- Administrative Discharge (Complete areas
with paper/pencil picture only )
5-Immediate Discharge
5. *Provider ID:
5(a).*HSA Provider ID:
YYYY
59-3174674
Section 2 :
6. *Provider Site ID:
6(a) .*HSA Site ID:
8. *Mental Health
Diagnosis:
7. Client ID:
(799.9) = Unknown Cause
For ICD-9 code enter the first three digits from DSM-IV Code (i.e. Major depression disorder,
recurrent – DSM-IV (296.30) / ICD-9 (296)
9. Substance Abuse
(799.9) = Unknown Cause
For ICD-9 code enter the first three digits from DSM-IV Code (i.e. Major depression disorder,
recurrent – DSM-IV (296.30) / ICD-9 (296)
Diagnosis
10. **CFARS
Rater ID: Note:
Full Rater ID is
required
_
Rater Education Specialty
Rater FMHI Certification #
Definition for first two digits:
01 – Non-Degree Trained Technician
02 – AA Degree Trained Technician
03 – BA/BS
04 – MA/MS
05 – MA/MS Licensed Practitioner
06 – PhD/PsyD/EdD – Licensed
Psychologist
07 – MD/DO – Board Certified
CFARs Section: Note: If completing at the 3 or 9 month interval choose “5- None of the Above” on Question 1.
1.* Purpose of CFARS Evaluation:
2. *Substance Abuse History:
1- Admission to Agency
2- 6 month Interval
3- Discharge from Agency
0-No
1-Yes
4- Administrative Discharge
5- None of the Above
(Abused Drugs or Alcohol in the last 6 months)
3. *Problem Severity Rating Scales: Assign a severity Rating Number to each Section to describe the consumer’s problems or assets during the last
3 weeks. Mark an “X” through this section if completing this form at the 3 or 9-month interval
1
No
Problem
2
Less
Than Slight
3
Slight
Problem
4
Slight to
Moderate
a. Depression:
e. Cognitive Performance:
b. Anxiety:
f. Medical/Physical:
c. Hyper Activity:
g. Traumatic Stress:
d. Thought Process:
h. Substance Abuse:
HSA Form #4: Children MH Outcome/CFARS
Page 1 of 4
5
Moderate
Problem
6
Moderate
to Severe
i. Interpersonal
Relationships:
j. Home Setting
Behavior
k. ADL
Functioning:
l. Socio-Legal:
7
Severe
Problem
8
Severe to
Extreme
9
Extreme
Problem
m. Select:
Work/School:
n. Danger to Self:
o. Danger to
Others:
p. Security
Management
Effective: 7/01/2010 Revised 4/11/2007, 5/29/2008, 7/30/2008,
3/18/2010,6/17/10, 06/25/10
HUMAN SERVICES ASSOCIATES, INC.
Family Service Planning Team & Title XXI Intervention
Client Name
[PRINT]
Section 2 Cont.
1 - Salary
2 – WAGES/TANF
11. * Primary Source of Income:
12. *Psychiatric Disability Income:
0-No
1-Yes
3 - Retirement/Pension/SSI
4 - Disability
13. *Service to Exceed or has Exceeded 12 Months
15. *Admission Type:
7 – Unknown
0-No
1-Yes
Non-Adjudicated Children
Adjudicated Children
14.*Dependency/
Criminal Status:
5 - Other
6 - None
01 – Delinquent – In physical custody
02 - Delinquent – not in physical custody
03 - Dependent, in physical custody
04 - Dependent, not in physical custody
05 - Dependent & Delinquent, in physical custody
06 - Dependent & Delinquent, not in physical custody
07 – CINS, not in physical custody
1 - Voluntary Competent
2 – Voluntary Incompetent
08 - Other DCF program status
09 - Under custody & supervision of
family/guardian
Incompetent to Proceed
27 - Incompetent to Proceed–Ages 0-17
28- Incompetent to Proceed – Ages 18-20
3 - Involuntary Competent
4 - Involuntary Incompetent
Performance Measures
16. *Days Spent in the Community in Last 30 Days:
17. *Rx? Is client taking atypical antipsychotic medication in past 90 days:
0-No
18. *Total School Days Available (last 30 days):
NOTE: Max. Number is 22 due to weekends
19. *School Days Attended (last 30 days):
20. *Current CGAS Rating:
21. *Committed to DJJ (last 90 days):
NOTE: Max. number is 22 due to weekends
(Must have an entry between 01 and 99)
0-No
1-Yes
22. *Risk Factor: (No MH diagnosis, but risk factors for Emotion Disturbance)
23. *Residential Status:
24. *Marital Status:
25. * Employment Status:
01 - Independent – alone
02- Independent – shares costs with relatives
03 - Independent – shares costs with non-relatives
04 - Dependent – not sharing costs with relatives
05 - Dependent – not sharing costs with non-relatives
06 – Regular Assisted Living Facility
1-Single
4-Divorced
2-Married
5-Separated
3-Widowed
6-Unreported
10 – Active military, overseas
20 – Active military, USA
30 – Full Time
31-Employed in Family Run Business
40 – Part Time
26. *County of Residence:
27.*Highest Education:
1-Yes
0-No
07 - Foster Care/Home
08 - Group Home
09 - Homeless
10 - Hospital
11 - Nursing Home
12 - Supported Housing
1-Yes
13 - Correctional Facility
14 - DJJ Facility
17-Limited Licensed Assisted
Living Facility
99 - Not Available or Unknown
7-Registered Domestic Partner
8-Legally Separated
50 – Leave of Absence
60 – Retired
70 – Terminated (unemployed)
81 – Homemaker
82 – Student
83 – Disabled
84 – Criminal Inmate
85 – Other Inmate
86-Not Authorized to work
(illegal alien and some children)
(88 - Homeless, 99 - Out of State)
20 - No Schooling
21 - Nursery Schooling to 4th Grade
22 - 5th to 6th Grade
23 - 7th to 8th Grade
24 - 9th Grade
25 - 10th Grade
HSA Form #4: Children MH Outcome/CFARS
26 - 11th Grade
27 - 12th Grade, No Diploma
28 - High School Graduate-Diploma
29 - 1 or > year College, No Degree
30 - Associate’s Degree (AA, AS,
etc.)
Page 2 of 4
32 - Master’s Degree (MA, MS, MSW,
etc.)
33 - Prof. Degree (MD, DDS, JD, etc.)
34 - Doc. Degree (PhD, EDD, etc.)
35 - Special School
36 -Vocational School
Effective: 7/01/2010 Revised 4/11/2007, 5/29/2008, 7/30/2008,
3/18/2010,6/17/10, 06/25/10
HUMAN SERVICES ASSOCIATES, INC.
Family Service Planning Team & Title XXI Intervention
Client Name
[PRINT]
Section 3
28. ** IDENTIFY DISABILITY FACTORS:
a.*Developmental Disability:
b.*Physical Disability:
c.*Non-ambulatory (bedridden, wheelchair):
d. *Visually Impaired
e.*Hearing Impaired
f. *Person’s English Language understanding and speaking are severely limited
g. *ADL Function: (Difficulty performing independently in day-to-day living)
88888 – Homeless
29. *Zip Code:
0-No
0-No
0-No
0-No
0-No
0-No
0-No
1-Yes
1-Yes
1-Yes
1-Yes
1-Yes
1-Yes
1-Yes
99999 – Unknown
1 - Shows evidence of recent severe stressful event and problems with coping
2 - Displays symptomatology placing person at risk of more restrictive intervention if
untreated
3 – Both (1 & 2)
4 – None
1 - Temporary Cash Assistance
2 - Diversion Family Program
3 - Not a TANF Client
30. *Mental Health Problem:
31. *TANF Status:
32. *Family Size:
Number living in home (1-9)
$
33. *Annual Personal Income (00-99):
9 = 9 or more
(99) – Unknown
(98) - Income over $98,000
[Last 12 months]
34.*Primary
Referral Source:
01 - Individual (Self-Referral)
02 - SA Care Provider
03 - MH Care Provider
04 - Juvenile Justice
05 - County Public Health Unit
06 - School (Education)
07 - Employer /EAP
08 - Other social
service/health/Community Ref.
09 - TASC
10 - Probation/Parolee
11 - DUI/DWI
12 - Pretrial
13 - Prison/Jail
14 - Other court order/legal entity
16 - CINS/FINS
17 - ARF
18 - Outreach Program
19 – DCF/ADM
20 - Community Hospital
21 - State Hospital
35. *Baker Act: (Meets criteria for admission to Baker Act facility)
0-No
22 - Physician/Dr
23 - Law enforcement
24 - Fam Safe: Foster
Care
25 - Fam Safe: Prof.
Services
99 - None of the
Above
1-Yes
0-No
36. *Did client receive medication through Indigent Psychiatric Medication Program in the past 90 days?
37. *Is client taking any medication through Patient Assistance Program in the past 90 days? (e.g.
Zyprexa, Risperdol, Seroquel, Geodon, Clozaril, etc.)
38.* SAMH Contract #:
GHG19 (T21)
40.*Provider NPI #:
1356532584
41. *Veteran of US
Armed Services?
0-
No
1-
0-No
1-Yes
1-Yes
1407813405
39.*Contractor NPI #
1407813405
40(a). HSA Provider NPI #:
Yes
01- No attendance in the past month
02- 1-3 Times in past month
42.* Social Connectedness
03- 4-7 times in past month
04- 8-15 times in past month
43.*Number of Times Client was arrested in the past 30 days
(0-9) Use 9 if arrested more than 9 times:
44.*Was the client suspended and/or expelled within the
1last 30 days?
2-
0506-
Suspended
Expelled
16-30 Times in past month
Some attendance in past month,
but frequency unknown.
34-
Suspended and Expelled
Not Applicable
HSA Representative:
[PRINT NAME]
[PRINT NAME]
HSA Representative Signature:
HSA Form #4: Children MH Outcome/CFARS
Date:
Page 3 of 4
Effective: 7/01/2010 Revised 4/11/2007, 5/29/2008, 7/30/2008,
3/18/2010,6/17/10, 06/25/10
HUMAN SERVICES ASSOCIATES, INC.
Family Service Planning Team & Title XXI Intervention
Children’s MH Outcomes/CFARS Form Schedule
~
~
~
~
Upon admission or initiation - MH Outcomes and CFARS
6 months – MH Outcomes and CFARS
12 Months – MH Outcomes and CFARS
Discharge – MH Outcomes and CFARS
~ 3 months – MH Outcomes Section Only
~ 9 Months – MH Outcomes Section Only
NOTE: Use above scheduled intervals until the client is discharged.
HSA Form #4: Children MH Outcome/CFARS
Page 4 of 4
Effective: 7/01/2010 Revised 4/11/2007, 5/29/2008, 7/30/2008,
3/18/2010,6/17/10, 06/25/10