Free HSRS Mental Health Module Deskcard - Wisconsin

2009 HSRS MENTAL HEALTH
MODULE DESKCARD MODULE TYPE 9 CLIENT CHARACTERISTICS (Field 7)
19 23 25 26 27 28 29 86 02 03 14 04 05 10 12 16 17 39 07 08 32 79 09 36 59 71 50 55 57 18 43 44 45 33 84 37 38 72 80 90 91 92 99 61 62 63 64 69 70 68 74 66 73 Developmental disability - brain trauma Developmental disability - cerebral palsy Developmental disability ­ autism spectrum Developmental disability - mental retardation Developmental disability - epilepsy Developmental disability - other or unknown Family member of developmental disability client Severe emotional disturbance - child / adolescent Mental illness (excluding SPMI) Serious and persistent mental illness (SPMI) Family member of mental health client Alcohol client Drug client Chronic alcoholic Alcohol and other drug client Family member of alcohol and other drug client Intoxicated driver Gambling client Blind / visually impaired Hard of hearing Blind / deaf Deaf Physical disability / mobility impaired Other handicap Unmarried parent Victim of domestic abuse Regular caregiver of dependent person Frail elderly Abused / neglected elder Alzheimer's disease / related dementia Migrant Refugee Cuban / Haitian entrant Corrections / criminal justice system client (adult only) Repeated school truancy Frail medical condition Criminal justice system involvement (alleged or adjudicated) Victim of abuse or neglect (alleged or adjudicated) Homeless Special study code (to be defined as need arises) Hurricane Katrina evacuee Hurricane Rita evacuee None of the above CHIPS - abuse and neglect CHIPS - abuse CHIPS - neglect Family member of abused / neglected child JIPS - status offender Family member of status offender CHIPS - other Family member of CHIPS - other Delinquent Family member of delinquent

LEGAL/COMMITMENT STATUS (Field 9a)
1 2 3 4 5 6 Voluntary Voluntary with settlement agreement Involuntary civil - Chapter 51 Involuntary civil - Chapter 55 Involuntary criminal Guardianship only

89 91 92 94 95

Bad River Indian Reserv Mole Lake Indian Reserv Oneida Indian Reserv Lac Courte Oreilles Indian St Croix Indian Reserv

SOCIAL SUPPORT (Field 15)
(Optional) Family / Marital / Interpersonal Relationships 01 Very frequent contact, positive contact 02 Frequent or more often, usually positive contact 03 Occasional or more often, sometimes positive, sometimes negative 04 Contact is usually negative 05 Little or no social support

BRC TARGET POPULATION (Field 10)
Persons in need of: H Ongoing, high intensity, comprehensive services L Ongoing, low intensity services S Short-term situational services

PRESENTING PROBLEM (Field 11)
01 Marital / family problem 02 Social / interpersonal (other than family problem) 03 Problems coping with daily roles and activities (including job, school, housework, daily grooming, financial management, etc.) 04 Medical / somatic 05 Depressed mood and / or anxious 06 Attempt, threat, or danger of suicide 07 Alcohol 08 Drugs 09 Involvement with criminal justice system 10 Eating disorder 11 Disturbed thoughts 12 Abuse / assault / rape victim 13 Runaway behavior 14 Emergency detention

REFERRAL SOURCE (Field 18)
(Optional) 01 Self 02 Family or friend 03 Law enforcement (except court or correction agency) 04 Court or correction agency 05 School system or education agency 06 Social service agency 07 Inpatient or residential 08 Physician / health care provider 99 Other

STANDARD PROGRAM CATEGORY / SUBPROGRAM (Field 22)
UNITS SPC/SUB STANDARD PROGRAM TO BE CATEGORY NAME REPORTED CODE Inpatient 503 Inpatient Days 503 10 Emergency detention Days 505 DD center / nursing home Days 925 Institution for mental disease Days Residential 202 Adult family home Days 203 Foster home Days 204 Group home Days 205 Shelter care Days 504 Residential care center Days 506 CBRF Days Partial Day 108 Work related services Hours 615 Supported employment Hours 706 Day center services - nonmedical Hours Outpatient 303 Juvenile probation and supervision Hours 507 Counseling / therapeutic resources Hours 507 10 Medication management Hours 507 20 Individual Hours 507 30 Group Hours 507 40 Family (or couple) Hours 507 50 Intensive in-home Hours 507 60 Family support Hours 704 Day treatment - medical Hours Emergency 501 Crisis intervention Hours 503 20 Emergency room - hospital setting Hours

COUNTY OF RESIDENCE (Field 13)
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 84 85 86 87 88 Adams Ashland Barron Bayfield Brown Buffalo Burnett Calumet Chippewa Clark Columbia Crawford Dane Dodge Door Douglas Dunn Eau Claire Florence Fond du Lac Forest Grant Green Green Lake 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 Iowa Iron Jackson Jefferson Juneau Kenosha Kewaunee La Crosse Lafayette Langlade Lincoln Manitowoc Marathon Marinette Marquette Milwaukee Monroe Oconto Oneida Outagamie Ozaukee Pepin Pierce Polk 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 Portage Price Racine Richland Rock Rusk St. Croix Sauk Sawyer Shawano Sheboygan Taylor Trempealeau Vernon Vilas Walworth Washburn Washington Waukesha Waupaca Waushara Winnebago Wood Menominee Out of state

SPECIAL CHILDREN'S SERVICES CATEGORIES

Menominee Indian Res Red Cliff Indian Reserv Stockbridge Munsee Ind Potawatamie Indian Res Lac du Flambeau Indian

CATEGORY / SUBPROGRAM (Field 22) Cont'd
Other 509 Community support Hours 510 Comprehensive community services Days 604 Case management Hours Note: Any other appropriate SPCs associated with mental health services should be reported even though not listed here. The SPCs listed above are those that require units of service reporting.

HEALTH STATUS (Field 34)
1 2 3 4 5 6 7 9 No health condition Stable / capable Stable / incapable Unstable / capable Unstable / incapable New symptoms / capable New symptoms / incapable Unknown

INCARCERATION / INVOLVEMENT WITH CRIMINAL JUSTICE SYSTEM (Field 42)
1 2 3 4 5 6 9 1 2 4 5 6 7 8 9 10 11 12 13 14 15 16 17 99 None On probation Arrest(s) Jailed / imprisoned (includes Huber) On parole Juvenile justice system contact Unknown Paid employment Social Security retirement benefits / pension Disability payments Worker's compensation Food stamps Temporary assistance to needy families (TANF) Trust fund / savings income Alimony / maintenance, child support Unemployment compensation Relatives and / or spouse Rent supplements County cash assistance None Other Supplemental Security Income (SSI) Social Security Disability Income (SSDI) Unknown

SPC CLOSING REASON (Field 28)
01 02 03 04 05 06 07 08 09 10 11 99 Completed service - major improvement Completed service - moderate improvement Completed service - no change Transferred to another community based resource Administratively discontinued service (i.e., noncompliance) Referred Withdrew against staff advice or services not wanted Funding / authorization expired Incarcerated (local jail or prison) Entered nursing home or institutional care (IMD, RCC, etc.) No probable cause Death

HEALTH CARE APPOINTMENT (Field 35)
Health, Vision, Dental 1 Kept appointment or no appointment needed 2 Unable to access needed services 3 Did not keep or refused appointment 9 Unknown

FINANCIAL SUPPORTS (Field 43)

SUICIDE RISK (Field 36)
1 2 3 9 1 2 3 4 5 6 1 2 3 4 5 6 9 1 2 3 4 5 No risk factors Presence of risk factors High potential for suicide Unknown Street or shelter Private residence or household Supported or semi-supervised residence Specialized facility - on-site supervision Other institution Jail or correctional facility No educational, social or planned activity Part-time educational activity Full-time educational activity Meaningful social activity Volunteer or planned formal activities Other activities Unknown

RESIDENTIAL ARRANGEMENT (Field 37)

CONSUMER STATUS INFORMATION Required when BRC Target Population in Field 10 is coded H or L. BRC TARGET POPULATION UPDATE (Field 31)
Persons in need of: H Ongoing, high intensity, comprehensive services L Ongoing, low intensity services S Short-term situational services

DAILY ACTIVITY (Field 38)
SOS DESK (608) 266-9198 8:00 - 11:30 A.M. and 12:30 - 4:00 P.M. Or leave voice mail message. E-mail Address: [email protected] FAX: (608) 267-2437 HSRS Handbook and Terminal Operator's Guide: http://www.dhs.wisconsin.gov/HSRS/index.htm WI Department of Health Services Division of Enterprise Services F-20855I (Rev. 1/2009)

PSYCHOSOCIAL AND ENVIRONMENTAL STRESSORS (DSM IV, Axis IV) (Field 32)
1 2 3 4 5 6 0 None Mild Moderate Severe Extreme Catastrophic Inadequate information

EMPLOYMENT (Field 39)
Competitive Temporary Supported Sheltered Prevocational activity - job training, transitional, vocational rehabilitation 6 Not working - seeking employment 7 Unemployed / retired - uninterested in working 8 Other status - homemaker, student, caregiver, SSI disabled 9 Not in the labor force 99 Unknown

GLOBAL ASSESSMENT OF FUNCTIONING (DSM IV, Axis V) (Field 33)
Enter a specific 2 digit code. 91+ Superior functioning in a wide range of activities 81-90 Minimal symptoms, good functioning in all areas 71-80 Symptoms are transient and expectable reactions 61-70 Some mild symptoms 51-60 Moderate symptoms 41-50 Serious symptoms 31-40 Some impairment in reality testing and communication 21-30 Behavior is considerably influenced by delusions or hallucinations 11-20 Some danger of hurting self or others 01-10 Persistent danger of severely hurting self or others 00 Inadequate information

EMPLOYMENT LEVEL (Field 40)
1 2 3 1 2 3 4 5 6 Full time - 35+ hours per week Part-time - 20-34 hours per week Other - less than 20 hours per week Voluntary (no commitment status) Voluntary with settlement agreement Involuntary civil - Chapter 51 Involuntary civil - Chapter 55 Involuntary criminal Guardianship only

LEGAL/COMMITMENT STATUS UPDATE (Field 41)