DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-20855 (Rev. 08/2008)
HSRS MENTAL HEALTH MODULE
MODULE TYPE 9
1 Worker ID 3b First Name 3c Middle Name 7 Client Characteristics W = White
STATE OF WISCONSIN SOS Desk (608) 266-9198 Completion of this form meets the requirements of the State / County contract specified under the Wisconsin Statutes. S. 46.031(2g) 2 Client ID 3d Suffix 8 MA Number 4 Birthdate (mm/dd/yyyy) 5 Sex F M
REGISTRATION - Screen M1 - New, Update, Error Correct or Inquiry
Episode Key 3a Last Name 6a Hispanic / Latino Y = Yes N = No
6b Race (Check up to 5) A = Asian B = Black or African American P = Native Hawaiian or Pacific Islander I = American Indian or Alaska Native 9b Commitment Status Review Date 16b No. Living With Client 10 BRC Target Population 17 Veteran Status Yes No
MENTAL HEALTH INFORMATION
9a Legal/Commitment Status 15 Social Support 11 Presenting Problem (client perspective) 18 Referral Source 12 Diagnostic Impression Primary 20 Family ID Axis III 13 County of Residence 14 Episode Closing Date
16a No. of Minor Children
19 Case Review Date
21 Local Data
SERVICES - Screen M2 - New, Update, Error Correct or Inquiry
Prog. No. (U) 22 SPC/Subprogram 23 SPC Start Date 24 Provider Number Units 25 Days 26 Other 27 SPC End Date 28 SPC End Reason 29 Delivery Date mm yyyy 30 SPC Review Date mm yyyy
CONSUMER STATUS - Screen M4 Required when BRC Target Population in Field 10 is Coded H or L.
31 BRC Target Population Update 32 Psychosocial and Environmental Stressors 33 Global Assessment of Functioning (Specific two digit number) 34 Health Status 35 Health Care Appointment Health Vision Dental 36 Suicide Risk
37 Residential Arrangement
38 Daily Activity
39 Employment
40 Employment Level
41 Legal/Commitment Status Update
42 Criminal Justice System
43 Financial Supports
OPTIONAL DATA - Screen 18 (Module Key:
Street Address City State Zip Code County Telephone
Shaded areas are optional.
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