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Microsoft word - cfar08-09.doc

Family Service Planning Team & Title XXI Intervention
CHILDREN’S MENTAL HEALTH OUTCOME/CFARS FORM
*Client Name:
[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:
59-3174674
3.*Provider Purpose of Evaluation:
1- Admission to agency
4- Administrative Discharge (Complete areas with
(Select a choice, then complete the sections 2- 3 month Interval
3- Discharge from Agency
5-Immediate Discharge
1- Admission to agency
4- Administrative Discharge (Complete areas
3.(a) *HSA Purpose of Evaluation:
2- 3 month Interval
3- Discharge from Agency
5-Immediate Discharge
4.*Evaluation Date:
5. *Provider ID:
5(a).*HSA Provider ID:
59-374674
Section 2 :
6. *Provider Site ID:
7. Client ID:
6(a) .*HSA Site ID:
8. *Mental Health
Diagnosis:
(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
Diagnosis
(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)
10. **CFARS
Rater ID: Note:
Full Rater ID is
Definition for first two digits:
03 – BA/BS
06 – PhD/PsyD/EdD – Licensed
required
01 – Non-Degree Trained Technician
04 – MA/MS
02 – AA Degree Trained Technician
05 – MA/MS Licensed Practitioner
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:
1- Admission to Agency
4- Administrative Discharge
2- 6 month Interval
5- None of the Above
3- Discharge from Agency
2. *Substance Abuse History:
1-Yes (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
Slight to
Moderate
Moderate
Severe to
Than Slight
Moderate
to Severe
a. Depression:
e. Cognitive Performance:
i. Interpersonal
m. Select:
Relationships:
Work/School:
b. Anxiety:
f. Medical/Physical:
j. Home Setting
n. Danger to Self:
Behavior
c. Hyper Activity:
g. Traumatic Stress:
o. Danger to
Functioning:
d. Thought Process:
h. Substance Abuse:
l. Socio-Legal:
p. Security
Management
HSA Form #4: Children MH Outcome/CFARS Page 1 of 4 Effective: 7/01/2008 Revised 4/11/2007, 5/29/2008, 7/30/2008 Family Service Planning Team & Title XXI Intervention
Section 2 Cont.
11. * Primary Source of Income:
1 - Salary
3 - Retirement/Pension/SSI
7 – Unknown
2 – WAGES/TANF
4 - Disability
12. *Psychiatric Disability Income:
13. *Service to Exceed or has Exceeded 12 Months
Adjudicated Children
Non-Adjudicated Children
01 – Delinquent – In physical custody
08 - Other DCF program status
02 - Delinquent – not in physical custody
09 - Under custody & supervision of
14.*Dependency/
03 - Dependent, in physical custody
Criminal Status:
04 - Dependent, not in physical custody
Incompetent to Proceed
05 - Dependent & Delinquent, in physical custody
27 - Incompetent to Proceed–Ages 0-17
06 - Dependent & Delinquent, not in physical custody
28- Incompetent to Proceed – Ages 18-20
07 – CINS, not in physical custody
15. *Admission Type:
1 - Voluntary Competent
3 - Involuntary Competent
2 – Voluntary Incompetent
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:
18. *Total School Days Available (last 30 days):
19. *School Days Attended (last 30 days):
20. *Current CGAS Rating:
21. *Committed to DJJ (last 90 days):
22. *Risk Factor: (No MH diagnosis, but risk factors for Emotion Disturbance)
07 - Foster Care/Home
01 - Independent – alone
08 - Group Home
02- Independent – shares costs with relatives
13 - Correctional Facility
09 - Homeless
03 - Independent – shares costs with non-relatives
14 - DJJ Facility
23. *Residential Status:
10 - Hospital
04 - Dependent – not sharing costs with relatives
99 - Not Available or Unknown
11 - Nursing Home
05 - Dependent – not sharing costs with non-relatives
12 - Supported Housing
06 - Assisted Living Facility (ALF)
1-Single
4-Divorced
24. *Marital Status:
7-Registered Domestic Partner
2-Married
5-Separated
8-Legally Separated
3-Widowed
6-Unreported
10 – Active military, overseas
50 – Leave of Absence
83 – Disabled
25. * Employment Status:
20 – Active military, USA
60 – Retired
84 – Criminal Inmate
30 – Full Time
70 – Terminated (unemployed)
85 – Other Inmate
31-Employed in Family Run Business
81 – Homemaker
86-Not Authorized to work
40 – Part Time
82 – Student
26. *County of Residence:
32 - Master’s Degree (MA, MS, MSW,
20 - No Schooling
26 - 11th Grade
21 - Nursery Schooling to 4th Grade
27 - 12th Grade, No Diploma
27.*Highest Education:
33 - Prof. Degree (MD, DDS, JD, etc.)
22 - 5th to 6th Grade
28 - High School Graduate-Diploma
34 - Doc. Degree (PhD, EDD, etc.)
23 - 7th to 8th Grade
29 - 1 or > year College, No Degree
35 - Special School
24 - 9th Grade
30 - Associate’s Degree (AA, AS,
36 -Vocational School
25 - 10th Grade
HSA Form #4: Children MH Outcome/CFARS Page 2 of 4 Effective: 7/01/2008 Revised 4/11/2007, 5/29/2008, 7/30/2008 Family Service Planning Team & Title XXI Intervention
Section 3
28. ** IDENTIFY DISABILITY FACTORS:
a.*Developmental Disability:
b.*Physical Disability:
c.*Non-ambulatory (bedridden, wheelchair): f. *Person’s English Language understanding and speaking are severely limited g. *ADL Function: (Difficulty performing independently in day-to-day living) 29. *Zip Code:
88888 – Homeless 99999 – Unknown
30. *Mental Health Problem:
1 - Shows evidence of recent severe stressful event and problems with coping
2 - Displays symptomatology placing person at risk of more restrictive intervention if
3 – Both (1 & 2)
4 – None
31. *TANF Status:
1 - Temporary Cash Assistance
2 - Diversion Family Program
3 - Not a TANF Client
32. *Family Size:
Number living in home (1-9) 9 = 9 or more
33. *Annual Personal Income (00-99):
(98) - Income over $98,000 (99) – Unknown 34.*Primary
01 - Individual (Self-Referral)
08 - Other social
14 - Other court order/legal entity
22 - Physician/Dr
02 - SA Care Provider
service/health/Community Ref. 16 - CINS/FINS
23 - Law enforcement
Referral Source:
03 - MH Care Provider
24 - Fam Safe: Foster
04 - Juvenile Justice
10 - Probation/Parolee
18 - Outreach Program
05 - County Public Health Unit
11 - DUI/DWI
19 – DCF/ADM
25 - Fam Safe: Prof.
06 - School (Education)
12 - Pretrial
20 - Community Hospital
07 - Employer /EAP
13 - Prison/Jail
21 - State Hospital
35. *Baker Act: (Meets criteria for admission to Baker Act facility)
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 #:
39.*Contractor NPI #
40.*Provider NPI #:
Veteran of US Armed Services?
40(a). HSA Provider NPI #:
HSA Representative:
HSA Representative Signature:
HSA Form #4: Children MH Outcome/CFARS Page 3 of 4 Effective: 7/01/2008 Revised 4/11/2007, 5/29/2008, 7/30/2008 Family Service Planning Team & Title XXI Intervention
Children’s MH Outcomes/CFARS Form Schedule
~ Upon admission or initiation - MH Outcomes and CFARS
~ 3 months – MH Outcomes Section Only
~ 6 months – MH Outcomes and CFARS
~ 9 Months – MH Outcomes Section Only
~ 12 Months – MH Outcomes and CFARS
~ Discharge – MH Outcomes and CFARS
NOTE: Use above scheduled intervals until the client is discharged.
HSA Form #4: Children MH Outcome/CFARS Page 4 of 4 Effective: 7/01/2008 Revised 4/11/2007, 5/29/2008, 7/30/2008

Source: http://www.hsainc.org/forms/FSPT_forms/CFAR08-09.pdf