Free Collaborative Systems of Care (CSOC) Quarterly Reporting Information Guide - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-22688 (Rev. 07/2008)

STATE OF WISCONSIN Completion of this form meets the requirements of Chapter 46.56, Section 14(c) of the Wis. Stats.

COLLABORATIVE SYSTEMS OF CARE (CSOC) QUARTERLY REPORTING INFORMATION GUIDE
Personally identifiable information is collected for monitoring the development of CSOC projects. All information gathered is confidential. Use this form for reference only. The type of data outlined in this form is collected quarterly using a Microsoft Access database and sent electronically via e-mail to the State. For more information or technical assistance, contact one of the following individuals in the Bureau of Prevention, Treatment and Recovery: Tim Connor--608-261-6744 or George Hulick--608-266-0907. Instructions: Quarterly report is due no later than the 30 of the month following the end of the reporting period.
th

Name ­ Child (Last, First, Middle Initial)

Date of Birth

Name ­ Case Manager

Status this Quarter Quarterly Report Period Year: __________ Funding Source Enrolled 1st Quarter (January ­ March) 3rd Quarter (July ­ September) 01 = MA 03 = Private Insurance 05 = Parents Discharged 2nd Quarter (April ­ June) 4th Quarter (October ­ December) 02 = SSI 04 = Katie Beckett 06 = Other: Please complete the following Mental Health DSM IV Diagnosis information and Child Adolescent Functioning Scale (CAFAS) information. CHILD ADOLESCENT FUNCTIONING DSM IV DIAGNOSIS ASSESSMENT SCALE Axis Axis I Role Performance: Community Behavior Toward Others Axis II Moods/Emotions Axis III Axis IV Social Stressors Axis V GAF at Intake Name ­ Author of Diagnosis On Medication at start date of services? Yes No Date Diagnosed If yes, specify medication(s) and daily dosage: Yes No 1 2 3 4 5 6 Self-Harmful Behavior Substance Use Thinking Youth Score Caregiver Resources: Material Needs Caregiver Resources: Family/Social Support Caregiver Resources Score: Notes/Comments Date Administered Name ­ Administered By Notes/Comments Number Name of Diagnosis Role Performance: School/Work Role Performance: Home

(1 = mild, 6 = severe)

F-22688

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Service Costs
Instructions: Record all costs associated with maintaining the child in the community for a one-month period.

Service Code *

Service Description

Vendor (Service Provider)

Units Projected

Unit Description **

Unit Cost

Total Cost

Paid for By ***

Total: * Service Codes
MEDICAL SERVICES
5000 Assessments Outpatient 5010 Assessments Inpatient 5020 Medication Trial Inpatient 5030 Medication Trial Outpatient 5050 Psychiatric Reviews/Medication Checks 5099 Other Medical Services

MENTAL HEALTH SERVICES
5100 Individual Therapy 5101 Individual AODA Therapy 5110 Family Therapy 5120 Group Therapy 5121 Group AODA Therapy 5130 Special Therapy 5140 Crisis Intervention 5050 Crisis Counseling 5160 In-Home Treatment 5170 Day Treatment 5180 Evaluation Services 5200 Therapeutic Community Support Services 5201 Reintegration Treatment Services 5210 Reintegration Treatment Services 5220 Consultation with Other Professionals 5221 Child and Family Team Meeting/Planning 5230 Crisis Case Planning 5240 Behavior Management Services 5229 Other Mental Health Services

PLACEMENT SERVICES
5300 Crisis Home/Beds 5310 Treatment Foster Care 5320 Therapeutic Group Home 5330 Partial Hospitalization 5340 Residential Treatment/Child Caring Institutional Placement 5350 Psychiatric Hospitalization 5360 Assessment Home 5370 Foster Day Care 5380 Shelter Care 5390 Foster Home Care 5400 Group Home Care 5499 Other Placement Services

SOCIAL/RECREATIONAL COSTS
5527 Membership Costs 5528 Recreational Equipment Costs 5529 Social Activities Cost 5520 Recreational Reimbursement Costs 5550 Supported Independent Living 5560 Supported Work Environments 5570 Transportation 5580 Discretionary Funds 5590 Other Case Aide Services 9999 Non-Covered Services

SUPERVISION SERVICES
5530 Community Supervision 5540 Intensive Supervision 5541 Education Costs

CASE AIDE SERVICES
5521 Teacher's Aide 5522 Parent Aide 5523 Supervision 5524 Mentoring 5525 Recreation 5526 Life Coach

OTHER SERVICES
5410 Respite Services 5500 Case Management 5501Case Management-Treatment Foster Care 5502 Training Expenses

CORRECTIONAL PLACEMENTS
5420 Detention 5430 Corrections Per Month Total Amount CY = County PR = Program FA = Family (1st Party)

** Unit Descriptions
Per Hour Per Day Per Week

***Paid for By Codes
PS = Public School System FR = Free MC = Medicaid ST = State PI = Private Insurance NA = Not Applicable

F-22688

Page 3

Service Costs
Instructions: Record all costs associated with maintaining the child in the community for a one-month period.

Service Code *

Service Description

Vendor (Service Provider)

Units Projected

Unit Description **

Unit Cost

Total Cost

Paid for By ***

Total: * Service Codes
MEDICAL SERVICES
5000 Assessments Outpatient 5010 Assessments Inpatient 5020 Medication Trial Inpatient 5030 Medication Trial Outpatient 5050 Psychiatric Reviews/Medication Checks 5099 Other Medical Services

MENTAL HEALTH SERVICES
5100 Individual Therapy 5101 Individual AODA Therapy 5110 Family Therapy 5120 Group Therapy 5121 Group AODA Therapy 5130 Special Therapy 5140 Crisis Intervention 5050 Crisis Counseling 5160 In-Home Treatment 5170 Day Treatment 5180 Evaluation Services 5200 Therapeutic Community Support Services 5201 Reintegration Treatment Services 5210 Reintegration Treatment Services 5220 Consultation with Other Professionals 5221 Child and Family Team Meeting/Planning 5230 Crisis Case Planning 5240 Behavior Management Services 5229 Other Mental Health Services

PLACEMENT SERVICES
5300 Crisis Home/Beds 5310 Treatment Foster Care 5320 Therapeutic Group Home 5330 Partial Hospitalization 5340 Residential Treatment/Child Caring Institutional Placement 5350 Psychiatric Hospitalization 5360 Assessment Home 5370 Foster Day Care 5380 Shelter Care 5390 Foster Home Care 5400 Group Home Care 5499 Other Placement Services

SOCIAL/RECREATIONAL COSTS
5527 Membership Costs 5528 Recreational Equipment Costs 5529 Social Activities Cost 5520 Recreational Reimbursement Costs 5550 Supported Independent Living 5560 Supported Work Environments 5570 Transportation 5580 Discretionary Funds 5590 Other Case Aide Services 9999 Non-Covered Services

SUPERVISION SERVICES
5530 Community Supervision 5540 Intensive Supervision 5541 Education Costs

CASE AIDE SERVICES
5521 Teacher's Aide 5522 Parent Aide 5523 Supervision 5524 Mentoring 5525 Recreation 5526 Life Coach

OTHER SERVICES
5410 Respite Services 5500 Case Management 5501Case Management-Treatment Foster Care 5502 Training Expenses

CORRECTIONAL PLACEMENTS
5420 Detention 5430 Corrections Per Month Total Amount CY = County PR = Program FA = Family (1st Party)

** Unit Descriptions
Per Hour Per Day Per Week

***Paid for By Codes
PS = Public School System FR = Free MC = Medicaid ST = State PI = Private Insurance NA = Not Applicable

F-22688

Page 4

Service Costs
Instructions: Record all costs associated with maintaining the child in the community for a one-month period.

Service Code *

Service Description

Vendor (Service Provider)

Units Projected

Unit Description **

Unit Cost

Total Cost

Paid for By ***

Total: * Service Codes
MEDICAL SERVICES
5000 Assessments Outpatient 5010 Assessments Inpatient 5020 Medication Trial Inpatient 5030 Medication Trial Outpatient 5050 Psychiatric Reviews/Medication Checks 5099 Other Medical Services

MENTAL HEALTH SERVICES
5100 Individual Therapy 5101 Individual AODA Therapy 5110 Family Therapy 5120 Group Therapy 5121 Group AODA Therapy 5130 Special Therapy 5140 Crisis Intervention 5050 Crisis Counseling 5160 In-Home Treatment 5170 Day Treatment 5180 Evaluation Services 5200 Therapeutic Community Support Services 5201 Reintegration Treatment Services 5210 Reintegration Treatment Services 5220 Consultation with Other Professionals 5221 Child and Family Team Meeting/Planning 5230 Crisis Case Planning 5240 Behavior Management Services 5229 Other Mental Health Services

PLACEMENT SERVICES
5300 Crisis Home/Beds 5310 Treatment Foster Care 5320 Therapeutic Group Home 5330 Partial Hospitalization 5340 Residential Treatment/Child Caring Institutional Placement 5350 Psychiatric Hospitalization 5360 Assessment Home 5370 Foster Day Care 5380 Shelter Care 5390 Foster Home Care 5400 Group Home Care 5499 Other Placement Services

SOCIAL/RECREATIONAL COSTS
5527 Membership Costs 5528 Recreational Equipment Costs 5529 Social Activities Cost 5520 Recreational Reimbursement Costs 5550 Supported Independent Living 5560 Supported Work Environments 5570 Transportation 5580 Discretionary Funds 5590 Other Case Aide Services 9999 Non-Covered Services

SUPERVISION SERVICES
5530 Community Supervision 5540 Intensive Supervision 5541 Education Costs

CASE AIDE SERVICES
5521 Teacher's Aide 5522 Parent Aide 5523 Supervision 5524 Mentoring 5525 Recreation 5526 Life Coach

OTHER SERVICES
5410 Respite Services 5500 Case Management 5501Case Management-Treatment Foster Care 5502 Training Expenses

CORRECTIONAL PLACEMENTS
5420 Detention 5430 Corrections Per Month Total Amount CY = County PR = Program FA = Family (1st Party)

** Unit Descriptions
Per Hour Per Day Per Week

***Paid for By Codes
PS = Public School System FR = Free MC = Medicaid ST = State PI = Private Insurance NA = Not Applicable

F-22688

Page 5

CONTACT WITH POLICE AND/OR JUVENILE JUSTICE
(Only report offenses in the past six months) Month/Year Type of Violation Taken into Custody? Yes Yes Yes Yes Yes Yes DISPOSITION CODES: 01 Supervision 02 Fine 03 Restitution 04 Secure Detention 05 Non-Secure Detention 06 Hospitalization 07 CCI 08 Group Home 09 Foster Home No No No No No No Adjudicated? Yes Yes Yes Yes Yes Yes No No No No No No 13 No Contact Disposition (Use Codes Below)

10 Community Service 11 Pending 12 Informal Arrangements

RESTRICTIVENESS OF LIVING ENVIRONMENT
Living Location Dates (List Start & End Dates) Start Date End Date Only report living locations within this quarter Level of Restrictiveness (Use corresponding codes at right) Jail Living Environment and Level of Restrictiveness 9.8 9.0 9.0 8.9 8.4 7.8 7.5 7.2 6.5 6.0 5.7 5.7 5.1
Individual Emergency Shelter Home Specialized Foster Care Regular Foster Care Supervised Independent Living Home of Family Friend Home of Adoptive Parent Home of Relative School Dormitory Home of Natural Parent (Child) Home of Natural Parent (18 yrs) Independent Living with Friend Independent Living on Own

Living Location (See choices at right)

Correctional Center State Mental Hospital County Detention Center Intensive Treatment Unit AODA Inpatient Rehab Inpatient Hospital Wilderness Camp 24-hr Year Round Residential Treatment Center Group Emergency Shelter Residential Job Corps Center Group Home Treatment Family Foster Home

4.9 4.6 3.8 3.6 2.6 2.6 2.5 2.0 2.0 1.9 1.4 0.5

NOTE: Adopted from Hawkins, R.P.; Almelda, M.C.; Fabry, B.; & Reltz, A.C. (1991) Hospital & Community Psychiatry.