Free Case-Focused Case Management Education (CME) - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-21168 (08/2008)

STATE OF WISCONSIN

CASE-FOCUSED CASE MANAGEMENT EDUCATION
Completion of this form is voluntary. The information is being collected as part of a pilot project being conducted by the Bureau of Mental Health and Substance Abuse Services of the Department of Health Services and the Mental Health and Education Resource Center at the University of Wisconsin-Madison to provide a case-focused continuing education program for Wisconsin mental health professionals. PERSONAL INFORMATION Name ­ Participant (Last) Your name as you would like it to appear on the CME/CEU Certificate (if different than above) Contact Address (Street) Telephone Number ­ Home

(First)

(MI)

Apt. / Unit #

City

State

Zip Code

WI
Telephone Number ­ Alternate Title / Medical Specialty

(

)

(

)

E-mail Address Please share comments or concerns about your continuing education needs, history, and preferences

EMPLOYER INFORMATION (Optional) Name ­ Employer Department Contact Address (Street) Telephone Number ­ Work Fax Number City Employer Webpage URL State Zip Code

WI ( ) ( )

Specialty Licensure/Credentials Earned OTHER PROFESSIONALS ACTIVELY WORKING WITH CHILD / ADOLESCENT (Please check all that apply) School Psychologists--how many? Clinical Psychologists--how many? Counseling Psychologists--how many? Rehabilitation Psychologists--how many? Licensed Foster Parents--how many? Social Workers--how many? Other Caseworkers--how many? Other Mental Health Professionals--how many? Behavioral Neurologists--how many? Pediatricians--how many? Psychiatrists--how many? Judges--how many? Attorneys--how many? Pastor / Rabbi--how many? Other Counselors--how many? Please describe

Other Professionals--how many?

Please describe

F-21168

Page 2

CHILD / ADOLESCENT CASE INFORMATION (NOTE: Please do not include any personally identifiable patient information) Current Primary Diagnosis (If no formal diagnosis, provide working diagnosis and/or detail below) Male Female Age years old Concurrent Comorbid Diagnoses

Current Medications and Dosing Information Drug (Brand) Dosage/Administration

Active Symptoms and Concerns

Yes Yes Yes For Office Use:

No No No

Current or past history of substance abuse/misuse? Current or past history of juvenile justice involvement? Are you willing to provide case records with personally identifiable information redacted?