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Attachment B: System of Care Assessment
System of Care Assessment Interview Protocols
NOTE TO OMB REVIEWER:
The alphanumeric organization of these interview guides and data collection forms differs from
the outline otherwise used in this submission (here capital letters are used to identify the guides
and forms). This labeling is specific to the System of Care Assessment for which the
instruments were developed. The letters “J” and “K” have been omitted intentionally from the
interview guide identification list.
Within the interview guides, questions that map to the framework tables are identified in
parentheses (e.g., B.5.a., where ‘B’ is the column on the framework, ‘5’ is the row on the
framework, and ‘a’ is the indicator in that cell). The guides include scoring criteria previously
recorded on a scoring sheet for ease of scoring by site visitors. This increases the number of
pages of the guide but has no effect on respondent burden. Where two sets of score points are
provided, the interviewer records the respondent’s appraisal of the process, and then the
interviewer rates the process based on the respondent’s description. Wording throughout
questionnaires reflects elapsed period since award funds were received.
The spacing between questions has been reduced in the interview guides provided for this
package to save paper. In actual use, the spacing is increased to allow for detailed note-taking.
OMB No. 0930-0307
Expiration Date: xx/xx/xx
System/Program__________________________
Interviewer___________________
Site ID#_________________________________
Date________________________
Respondent Data Entry#____________________
Assessment #_________________
A. Core Agency Representative
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
This guide should be administered to representatives of agencies and organizations involved in
shaping the service delivery system for children with severe emotional disturbance and their
families.
[Note to interviewer: Review Consent form with respondent and obtain signature before
proceeding with the interview]
Introduction
1.
What agency/organization do you represent?
1=Mental health public agency
2=Public health agency
3=Child welfare public agency
4=Public education
5=Juvenile justice public agency
2.
6=Private org. representing mental health
7=Private org. representing health
8=Private org. representing child welfare
9=Private org. representing education
10=Private org. representing juvenile justice
___________________________
What is your title/position? Do you have supervisory responsibilities? Do you provide
services directly?
1=Exec Director/Chief
2=Deputy or Assistant Exec Director/Chief
3=Middle manager
3.
11=Other, specify
4=Supervisor
5=Front-line staff
6=Other, specify ___________________________
Since CMHS grant funds were received, have you served on the (governing body)?
1=No If no, skip to Question 12
2=Yes If yes, continue
Governance
4.
Please describe the overall structure of the (governing body). [Probe for number of
members, agencies and organizations represented; location, time, and frequency
of meetings; existence of bylaws, subcommittees, etc.]
CMHS National Evaluation, Baseline Assessment
Agency Representative (A), February 2011
Phase VI
1
5.
Since grant funds were received, how involved or influential would you say the
(governing body) has been in the governance of (name of grant program) ?
a.
What have been some of the key functions and responsibilities related to
governance of (name of grant program) ? These can include activities of
subcommittee(s).
Probe for examples of activities related to:
- strategic planning
- budgetary decisions
- developing the service array
- establishing formal arrangements among community-based agencies
and/or other federally-funded entitlement or discretionary grant programs
(ask for a listing of such MOUs or MOAs)
- developing a cultural and linguistic competence plan
- other - please describe
b.
How are decisions or recommendations made? Do members have voting
rights? If yes, which members? [Probe for voting versus consensus or some
combination of both.]
c.
To what extent are the decisions or recommendations of the (governing body)
acted upon or implemented by (name of grant program) ? [Probe for whether the
body makes final decisions, makes formal recommendations, or is
primarily advisory.]
How often would you say the recommendations or decisions of the (governing
body) are implemented? [Probe for percentage of time.]
6.
To what extent have you, as a representative of your agency, been actively involved in
the (governing body)? (A.5.a.)
a.
Of the governing body functions we discussed earlier, which are you involved
in? [Probe for examples of participation in the (governing body)’s
functions that this respondent previously reported in 5.a.]
5=Involved in all activities of the governing body
4=Involved in most activities of the governing body
3=Involved in some activities of the governing body
2=Involved in few activities of the governing body
1=Involved in no activities of the governing body
b.
What percentage of (governing body) meetings have you attended? (A.5.a.)
5=Attended at least 90% of meetings
4=Attended 75% to 89% of meetings
CMHS National Evaluation, Baseline Assessment
Agency Representative (A), February 2011
Phase VI
2
3=Attended 50% to 74% of meetings
2=Attended 25% to 49% of meetings
1=Attended less than 25% of meetings
7.
How important is it to your agency that you be involved in the (governing body) and
attend meetings? [Probe for agency commitment and interest.]
8.
Is there anything in place that specifically requires your agency’s involvement in the
governance of the grant, for example, formal agreements, MOU or MOA? (A.5.b.)
[Data entry: code mechanisms used]
If yes, how well have these provisions/mechanisms worked to maximize your agency’s
involvement? Have they been effective?
[If no, score=1]
Have these provisions been sufficient? Is there anything else that could be done to
make it easier for your agency to be involved?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
9.
Since grant funds were received, which public agencies, including your own, have been
actively involved in the (governing body)? (A.5.a.)
1 = Mental Health
2 = Education
3 = Child Welfare
4 = Juvenile Justice
5 = Public Health
6 = other (describe)
[circle all that apply]
Are there any agencies that you think should have been actively involved but were not,
or any that should have been more involved than they were?
5=Five agencies actively involved
4=Four agencies actively involved
3=Three agencies actively involved
2=Two agencies actively involved
1=One (1) agency actively involved
10.
Since grant funds were received, to what extent have family members been actively
involved in the (governing body)? (A.1.a.)
a.
Of the governing body functions we discussed earlier, which ones are family
members involved in. [Probe for examples of participation in the
(governing body)’s functions that this respondent previously reported in
5.a.]
5=Involved in all activities of the governing body
4=Involved in most activities of the governing body
3=Involved in some activities of the governing body
2=Involved in few activities of the governing body
1=Involved in no activities of the governing body
CMHS National Evaluation, Baseline Assessment
Agency Representative (A), February 2011
Phase VI
3
b.
How have family members been regarded and treated by other participants of
the (governing body)? (A.1.a.)
Has that been the same for all participants, or have some participants
demonstrated respect, acceptance, and value for family input more than others?
5=All participants were very respectful, accepted, and highly valued family input
4=Most participants were very respectful, accepted, and valued family input and the rest were moderately respectful
3=Some participants were very respectful, accepted, and valued family input and the rest were moderately respectful
2=Few participants were very respectful, accepted, and valued family input and most others were at least somewhat respectful
1=No or almost no participants were respectful, accepted, or valued family input
c.
What percentage of (governing body) meetings have family members
attended? (A.1.a.)
5=Attended 90% to 100% of meetings
4=Attended 75% to 89% of meetings
3=Attended 50% to 74% of meetings
2=Attended 25% to 49% of meetings
1=Attended less than 25% of meetings
(NOTE TO INTERVIEWER: If early childhood site, skip to Question 12)
11.
Since grant funds were received, to what extent have youth been actively involved in
the (governing body)? (A.2.a.)
a.
Of the governing body functions we discussed earlier, which ones are youth
involved in. [Probe for examples of participation in the (governing body)’s
functions that this respondent previously reported.]
5=Involved in all activities of the governing body
4=Involved in most activities of the governing body
3=Involved in some activities of the governing body
2=Involved in few activities of the governing body
1=Involved in no activities of the governing body
b.
How have youth been regarded and treated by other participants of the
(governing body)? (A.2.a.)
Has that been the same for all participants, or have some participants
demonstrated respect, acceptance, and value for youth input more than others?
5=All participants were very respectful, accepted, and highly valued youth input
4=Most participants were very respectful, accepted, and valued youth input and the rest were moderately respectful
3=Some participants were very respectful, accepted, and valued youth input and the rest were moderately respectful
2=Few participants were very respectful, accepted, and valued youth input and most others were at least somewhat respectful
1=No or almost no participants were respectful, accepted, or valued youth input
c.
What percentage of (governing body) meetings have youth attended? (A.2.a.)
5=Attended 90% to 100% of meetings
4=Attended 75% to 89% of meetings
3=Attended 50% to 74% of meetings
2=Attended 25% to 49% of meetings
1=Attended less than 25% of meetings
CMHS National Evaluation, Baseline Assessment
Agency Representative (A), February 2011
Phase VI
4
Management and Operations
12.
Since grant funds were received, how has (name of grant program) informed supervisors and
line staff in your agency about program operations such as changes in eligibility
criteria, referral processes, service/program components? (B.6.a.)
[Data entry: code mechanisms]
On a scale of 1 to 5 (with 5 being best), how effective have these efforts been in
ensuring that all parties have been aware of program procedures and operations?
5=Very effective
4=Moderately effective
3=Somewhat effective
2=Minimally effective
1=Not effective
13.
What mechanisms have been put in place by the grant program to integrate staff
across the core child-serving agencies, including any of the following? [Probe for
descriptions of each mechanism and the agencies involved.] (B.5.b.)
a.
Joint training (i.e., staff from multiple agencies are trained together)?
1=no, 2=yes
b.
Shared staff (i.e., more than one agency funds one staff position)?
1=no, 2=yes
c.
Outstationing or outposting staff (i.e., staff from one agency are housed in
another agency’s office or service locations)?
1=no, 2=yes
d.
Other efforts? Please describe.
1=no, 2=yes
[Data entry: code mechanisms]
e.
How effective have these efforts been and in what ways?
Are these efforts sufficient to minimize barriers to staff working together across
agencies?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
14.
Does your agency and (name of grant program) have any shared administrative processes
such as jointly developing staff training materials; holding joint staff meetings;
hiring/recruiting staff together; using the same administrative forms, unified case
records, or integrated MIS; etc.? (B.5.a.)
CMHS National Evaluation, Baseline Assessment
Agency Representative (A), February 2011
Phase VI
5
If yes, what are all of the different shared processes put in place?
[Data entry: code ways]
[Continue to probe for examples until the respondent reports no more.]
5=Four examples of shared administrative processes across child-serving agencies
4=Three examples of shared administrative processes across child-serving agencies
3=Two examples of shared administrative processes across child-serving agencies
2=One example of shared administrative processes across child-serving agencies
1=No examples of shared administrative processes across child-serving agencies
15.a.
Are there decategorized funds that are pooled or blended across agencies (other
than for shared staff positions)? If yes, please describe. (B.5.c.)
If so, which agencies contribute to the blended funding?
1 = Mental Health
2 = Education
3 = Child Welfare
4 = Juvenile Justice
5 = Public Health
6 = other (describe)
[circle all that apply]
5=Five agencies actively involved
4=Four agencies actively involved
3=Three agencies actively involved
2=Two agencies actively involved
1=No blended funding
b.
For what purpose(s) are funds blended? (B.5.c.)
Have the blended or pooled funds been effective for these purposes?
Is the total amount of blended funds sufficient? Are individual agency contributions
sufficient?
Could more be done to blend funds?
[If 15.a.=1, then 15.b.=666]
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
666= No blended funding
16.
Are there any mechanisms in place or have any efforts been made by the grant program
to facilitate the coordination of services across agencies, organizations, and
providers (for example, interagency team meetings, joint staff treatment team meetings,
interagency case management meetings, etc)? (B.6.b.)
[Data entry: code mechanisms]
Have these efforts been effective? If yes, in what ways?
Have these efforts been sufficient—is there anything else that could have been done to
enhance coordination of services across agencies, organizations, and providers?
CMHS National Evaluation, Baseline Assessment
Agency Representative (A), February 2011
Phase VI
6
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
17.
How has (name of grant program) worked to minimize the need for children, youth, or
families to travel out of their home communities for services? [If response is “not
a problem,” probe for what allows them to serve all children, youth, or families in
their home communities.] (C.8.b.)
[Data entry: code mechanisms]
How effective have these efforts been and in what ways?
Have these efforts been sufficient to ensure that all children, youth, and families are
served in their communities? If not, what else could have been done?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
18.
How has (name of grant program) worked to reduce the number of children and youth who
are served in settings more restrictive than necessary? [If response is “not a
problem,” probe for what allows them to serve children in the least restrictive
settings.] (B.9.b.)
[Data entry: code mechanisms]
How effective have these efforts been?
Have these efforts been sufficient to eliminate the use of inappropriately restrictive
settings/service options?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
19.
Since grant funds were received, what has been done to ensure that services in (name of
grant program) ’s service array have sufficient capacity (for example, expanding network
of contract providers, increasing contracts to increase capacity)? [Probe for capacity
across all services in the array.] (C.7.a.)
[Data entry: code mechanisms]
Have these efforts been effective? If yes, provide some examples.
Have these efforts been sufficient? Are there any services that some children, youth,
and/or families cannot get because capacity is limited?
CMHS National Evaluation, Baseline Assessment
Agency Representative (A), February 2011
Phase VI
7
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
20.
Since grant funds were received, what has (name of grant program) done to make services
more accessible? [Probe for flexible hours including after hours and weekends;
services offered in settings such as home, schools, community. Probe for
applicability across all services in the array.] (C.7.b.)
[Data entry: code mechanisms]
Have these efforts been effective? If yes, in what ways?
Have these efforts been sufficient? What else could be done to make services more
accessible?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
Achievement of Goals
21.
Since grant funds were received, what have been
achievements?
22.
Has your agency’s involvement in the (name of grant program) affected the way your
agency does business, (for example, how it serves children, youth, and families, its
management and operations)? (B.5.d.)
(name of grant program) ’s
most important
Please provide examples of specific things you/your staff are doing differently. [Probe
for behavior changes beyond just knowledge acquisition and change in attitude or
philosophy.]
5=Agency has changed program operations and methods of service delivery in two or more ways to incorporate system-of-care principles
4=Agency has changed program operations and methods of service delivery in one way to incorporate system-of-care principles
3=Agency has accepted and adapted the philosophy inherent in the system-of-care model and program theory
2=Agency has received information or training related to the wraparound approach or system-of-care principles
1=Agency has not received any information or training related to the wraparound approach or system-of-care principles
23.
What influence has (name of grant program) had on the larger system across all childserving sectors during the last year?
24.
What have been the major obstacles to expanding the system of care principles and
philosophies beyond the scope of (name of grant program) ?
Sustainability
25.
Please tell me about your community’s effort to sustain the system of care as CMHS
grant funds decrease over time. [Probe to determine how they are responding to
increased matching fund requirements.]
CMHS National Evaluation, Baseline Assessment
Agency Representative (A), February 2011
Phase VI
8
Have any aspects of the system/program been changed, reduced, or eliminated due to
the decreases in CMHS funding? If so, what has occurred?
26.
What aspects of (name of grant program) do you anticipate will be sustained over time?
[Probe for family-driven, individualized and youth-guided care, cultural and
linguistic competence, interagency involvement, accessible services, coordinated,
community-based and least restrictive care, etc.]
What barriers exist that may hinder sustainability?
Those are all of the questions I have for you. Is there anything that I did not cover that you think
is important for us to know about (name of grant program)?
Thank you for taking the time to answer my questions. Do you have any questions for me?
CMHS National Evaluation, Baseline Assessment
Agency Representative (A), February 2011
Phase VI
9
OMB No. 0930-0307
Expiration Date: xx/xx/xx
System/Program__________________________
Interviewer___________________
Site ID#_________________________________
Date________________________
Respondent Data Entry#____________________________
Assessment #_________________
B. Project Director
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
[Note to interviewer: Review Consent form with respondent and obtain signature before
proceeding with the interview]
Overview [Request an annual report and logic model to keep, if available]
1.
Has the overall goal and mission of (name of grant program) changed since the grant was
written and received? If yes, please describe briefly.
2.
What are the primary service components (e.g., outpatient, school-based, case
management, etc)?
3.
What are the eligibility criteria for participation in (name of grant program) ? Have these
changed since CMHS grant funds were received? Please describe.
4.
How many children, youth, and families have been served since grant funds were
received?
(NOTE TO INTERVIEWER: Questions 5-7 skipped)
Outreach
8.
Since grant funds were received, have there been any outreach efforts to inform your
intended service population about (name of grant program) and its services? (E.7.a.)
[Data entry: code outreach efforts]
How effective have your outreach efforts been? For example, have you seen an
increase in calls to (name of grant program) or an increase in awareness or interest in the
community? Explain.
Have these efforts been sufficient, that is, has
everyone?
(name of grant program)
been able to reach
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
CMHS National Evaluation, Baseline Assessment
Project Director (B), February 2011
Phase VI
1
1=No or almost no effort has been made toward accomplishing larger goal
9.
Since grant funds were received, have there been any outreach efforts to specific
cultural groups or populations? (E.4.a.)
How effective would you say these efforts have been? For example, have you seen an
increase in interest or awareness?
Have these efforts been sufficient to reach all of the specific populations you have
targeted your efforts towards?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
10.
Since grant funds were received, have there been any outreach efforts to inform
other agencies, community-based providers, private providers, family
organizations, primary health care providers, etc. about the (name of grant program) and
its services? (E.6.a.)
How effective have these efforts been, and in what way?
Have these efforts been sufficient to ensure that all providers and organizations have
been aware of (name of grant program) ?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
Service Planning
11.
(NOTE TO INTERVIEWER: Question 11 skipped)
12.
Are there any mechanisms in place or have efforts been made to facilitate the
coordination of services across agencies, organizations, and providers (for
example, interagency team meetings, joint staff treatment team meetings, interagency
case management meetings, etc)? (B.6.b.)
[Data entry: code mechanisms]
Have these efforts been effective? If yes, in what ways?
Have these efforts been sufficient—is there anything else that could have been done to
enhance coordination of services across agencies, organizations, and providers?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
CMHS National Evaluation, Baseline Assessment
Project Director (B), February 2011
Phase VI
2
Service Array
13.
Since grant funds were received, what has been done to ensure that services in (name of
grant program) ’s service array have sufficient capacity such that all children, youth, and
families who need the services can get them (for example, expanding network of
contract providers, increasing contracts to increase capacity)? [Probe for capacity
across all services in the array.] (C.7.a.)
[Data entry: code mechanisms]
Have these efforts been effective? If yes, explain.
Have these efforts been sufficient? Are there any services that some children, youth,
and/or families cannot get because capacity is limited? [Probe for which specific
services.]
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
14.
What has (name of grant program) done to make services more accessible in terms of
scheduling of services or locations where services were provided? [Probe for flexible
hours including after hours and weekends; services offered in settings such as
home, schools, community. Probe for applicability across all services in the
array.] (C.7.b.)
[Data entry: code mechanisms]
Have these efforts been effective? If yes, in what ways?
Have these efforts been sufficient? What else could be done to make services more
accessible?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
15.
Since grant funds were received, have there been any efforts to make services more
affordable and to minimize financial barriers to care? [Probe for sliding scale fees,
scholarship funds, flexible funding, etc.] (B.7.a.)
[Data entry: code mechanisms]
Are children, youth, and families who are uninsured or privately insured able to
receive services through (name of grant program) ?
Have these efforts been effective? If yes, in what ways?
Overall, have efforts been sufficient or has cost continued to be a barrier for some
families to access needed services in the array?
CMHS National Evaluation, Baseline Assessment
Project Director (B), February 2011
Phase VI
3
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
16.
What efforts have been made to minimize the need for children, youth, and families
to travel out of their home communities for services? [If response is “not a
problem,” probe for what allows them to serve all children/families in their home
communities.] (C.8.b.)
[Data entry: code mechanisms]
How effective have these efforts been, and in what ways?
Have these efforts been sufficient to ensure that all children, youth, and families are
served in their home communities? If not, what else could be done?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
17.
What efforts have been made to reduce the number of children and youth who are
served in overly restrictive service settings? [If response is “not a problem,” probe
for what allows them to serve children and youth in the least restrictive settings.]
(B.9.b.)
[Data entry: code mechanisms]
How effective have these efforts been, and in what ways?
Have these efforts been sufficient to eliminate the use of overly restrictive
settings/service options?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
18.
Since grant funds were received, what policies, structures or mechanisms has (name of
grant program) implemented to promote the provision of individualized care? (For
example, use of flexible funds to meet unique needs, development of specific services,
training on the provision of individualized care) (B.3.a.)
[Data entry: code mechanisms]
Have these efforts been effective? If yes, in what ways?
Have these efforts been sufficient? What other things that could be done to maximize
the provision of individualized care?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
CMHS National Evaluation, Baseline Assessment
Project Director (B), February 2011
Phase VI
4
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
19.
Since grant funds were received, how has the cultural background of the children,
youth, and families you serve been considered in developing the service array?
(C.4.a.)
Have cultural organizations, community groups, etc. been involved in efforts such
as providing services, developing the service array, advising providers, etc.?
Have you added or modified any services to address the cultural needs of specific
groups?
How effective have these efforts been, and in what ways?
Have efforts been sufficient to address the cultural needs of all groups? Are some
groups’ needs still unmet? [Probe for specific groups.]
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
Staffing
20.
Since grant funds were received, have you had any difficulty hiring or retaining staff?
If yes, for which positions and why?
21.
Have any efforts been made to hire a pool of staff who reflect the cultural
background (for example, race, ethnicity, language, gender) of the children, youth, and
families you serve? (B.4.c.)
How effective have these efforts been? Explain.
Have efforts been sufficient to hire the number or type of staff needed to meet the
cultural needs of populations served?
[Note: If staff are already in place, i.e., no hiring was necessary, probe for diversity of staff vis a vis population served.]
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
22.
What efforts have been made to address the language needs of the children, youth,
and families you serve? (B.4.d.) Are formal policies in place that address language
needs?
What options are available for providing services in languages other than English?
[Probe for use of bilingual staff, professional interpreter services, informal
interpretation by family members.]
CMHS National Evaluation, Baseline Assessment
Project Director (B), February 2011
Phase VI
5
Are these efforts effective? If yes, explain.
Have efforts been sufficient to accommodate all language preferences of the
children, youth, and families you serve? Are more efforts needed?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
666=Not applicable; situation has not arisen
23.a.
What efforts have been made to have paraprofessionals, (for example, family
members, people from the community, or other lay persons) provide services directly to
children, youth, and families? (B.1.b.)
What services have they provided?
In your opinion, are there any other services not currently available that you think
paraprofessionals could provide to support families?
5=Four or more services provided by paraprofessionals
4=Three services provided by paraprofessionals
3=Two services provided by paraprofessionals
2=One service provide by paraprofessionals
1=No services provided by paraprofessionals
b.
What percentage of the children, youth, and families who need these services can get
them?
5=90%–100% of children, youth, and families who need the service get it
4=75%–89% of children and families who need the service get it
3=50%–74% of children and families who need the service get it
2=25%–49% of children and families who need the service get it
1=Less than 25% of children and families who need the service get it
666=No services provided by paraprofessionals
24.
What mechanisms have been used to integrate staff across the five core childserving agencies including any of the following? [Probe for descriptions of each
mechanism and agencies involved.] (B.5.b.)
a.
Joint training (i.e., staff from multiple agencies are trained together)?
1=no, 2=yes
b.
Shared staff (i.e., more than one agency funds one staff position)?
1=no, 2=yes
c.
Outstationing or outposting staff (i.e., staff from one agency is housed in
another agency’s office or service locations)?
1=no, 2=yes
d.
Other efforts? Please describe.
CMHS National Evaluation, Baseline Assessment
Project Director (B), February 2011
Phase VI
6
1=no, 2=yes
[Data entry: code mechanisms]
e.
How effective have these efforts been? Explain.
Have efforts been sufficient, that is, have they reduced the barriers for staff
across agencies to work together?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
(NOTE TO INTERVIEWER: Questions 25-29 skipped)
Management and Operations
30.
Are there any mechanisms in place or have efforts been made to involve family
members in program operations such as designing and implementing programs;
ensuring cultural and linguistic competent services, supports, and providers; providing
training; serving as staff; helping with staff recruitment; attending management meetings;
etc? (B.1.c.)
If yes, please tell me all of the different ways they have been involved.
[Note: Do not count involvement in governing body, evaluation, or conducting outreach activities.]
[Data entry: code ways]
Have family members and family organizations been involved in any other ways?
[Continue to probe for examples until the respondent reports no more.]
5=Four examples of family member involvement in grant operations
4=Three examples of family member involvement in grant operations
3=Two examples of family member involvement in grant operations
2=One example of family member involvement in grant operations
1=No examples of family member involvement in grant operations
(NOTE TO INTERVIEWER: If early childhood site, skip to Question 32)
31.
Since grant funds were received have youth been involved in program operations?
(B.2.a.)
If yes, please tell me all of the different ways they have been involved .[Probe for .
designing and implementing programs; ensuring cultural and linguistic competent
services, supports, and providers; providing training; serving as staff; helping
with staff recruitment; attending management meetings; etc.]
[Note: Do not count involvement in governing body, evaluation, or conducting outreach activities.]
[Data entry: code ways]
CMHS National Evaluation, Baseline Assessment
Project Director (B), February 2011
Phase VI
7
Have youth been involved in any other ways?
[Continue to probe for examples until the respondent reports no more.]
5=Four examples of youth involvement in grant operations
4=Three examples of youth involvement in grant operations
3=Two examples of youth involvement in grant operations
2=One example of youth involvement in grant operations
1=No examples of youth involvement in grant operations
32.a.
Since grant funds were received, have there been any shared administrative
processes across child-serving agencies such as jointly developing staff training
materials; holding joint staff meetings; hiring/recruiting staff together; using the same
administrative forms, unified case records, or integrated MIS; etc.? (B.5.a.)
If yes, what are all of the different shared processes put in place?
[Data entry: code ways]
[Continue to probe for examples until the respondent reports no more.]
5=Four examples of shared administrative processes across child-serving agencies
4=Three examples of shared administrative processes across child-serving agencies
3=Two examples of shared administrative processes across child-serving agencies
2=One example of shared administrative processes across child-serving agencies
1=No examples of shared administrative processes across child-serving agencies
b.
Which agencies participated in these shared processes? (B.5.a.)
1 = Mental Health
2 = Education
3 = Child Welfare
4 = Juvenile Justice
5 = Public Health
6 = other (describe)
[circle all that apply]
5=Five agencies
4=Four agencies
3=Three agencies
2=Two agencies
1=No shared processes
33.a.
Are there decategorized funds that are pooled or blended across agencies (other
than for shared staff positions)? If yes, please describe. (B.5.c.)
If yes, which agencies contribute to the blended funding?
1 = Mental Health
2 = Education
3 = Child Welfare
4 = Juvenile Justice
5 = Public Health
6 = other (describe)
[circle all that apply]
5=Five agencies contribute
4=Four agencies contribute
3=Three agencies contribute
2=Two agencies contribute
1=No blended funding
CMHS National Evaluation, Baseline Assessment
Project Director (B), February 2011
Phase VI
8
b.
For what purpose(s) are funds blended? (B.5.c.)
Have the blended or pooled funds been effective for these purposes?
Is the total amount of blended funds sufficient? Are individual agency contributions
sufficient?
Could more be done to blend funds?
[If 31.a.=1, then 31.b.=666]
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
666=No blended funding
34.
Since grant funds were received, how have you shared information about program
operations (for example, changes in eligibility criteria, referral processes,
service/program components) with supervisors and direct line staff in the different
agencies, and organizations with whom you work? (B.6.a.)
[Data entry: code mechanisms]
Have these mechanisms been effective? If yes, in what ways?
Have these efforts been sufficient to ensure that all parties have been aware of
procedures and operations?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
Managed Care
35.
What is the current status of managed care planning or implementation for mental
health services in your state? [Probe for Medicaid waiver, carve-out, demonstration
or statewide implementation, etc.]
36.
How has the state’s use of managed care techniques/approaches facilitated or
impeded your reaching the goals of your grant? (Or what effects do you
anticipate?)
37.
How has the implementation of managed care (whether state initiated, locally initiated, or
both) affected the implementation of the system of care through your grant? (Or
what effects do you anticipate?)
Lessons Learned
38.
Since grant funds were received, what have been the most effective strategies or
activities undertaken to develop and implement this system of care?
CMHS National Evaluation, Baseline Assessment
Project Director (B), February 2011
Phase VI
9
39.
Since grant funds were received, what have been the least effective strategies or
activities undertaken to implement this system of care?
Achievement of Goals
most important
40.
Since grant funds were received, what have been
achievements?
41.
What influence has (name of grant program) had on the larger system across all childserving sectors? In what ways?
42.
What have been the major obstacles to expanding the system of care principles and
philosophies beyond the scope of (name of grant program) ?
(name of grant program) ’s
Sustainability
43.
Please tell me about the status of your grant community’s efforts to sustain itself as
grant funds decrease over time. [Probe to determine how they are responding to
increased matching funds requirements.]
Have any aspects of the system/program been changed, reduced, or eliminated due
to decreases in CMHS funding? If so, what has occurred?
44.
What aspects of the system/program do you anticipate will be sustained over time?
[Probe for family-driven, individualized and youth-guided care, cultural and
linguistic competence, interagency involvement, accessible services, coordinated,
community-based and least restrictive care, etc.]
What barriers exist that may hinder sustainability?
Those are all of the questions I have for you. Is there anything that I did not cover that you think
is important for us to know about (name of grant program)?
Thank you for taking the time to answer my questions. Do you have any questions for me?
CMHS National Evaluation, Baseline Assessment
Project Director (B), February 2011
Phase VI
10
OMB No. 0930-0307
Expiration Date: xx/xx/xx
System/Program__________________________
Interviewer___________________
Site ID#_________________________________
Date________________________
Respondent Data Entry#______________________
Assessment #_________________
C. Family Representative/Representative of Family/Advocacy Organizations
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
[Note to interviewer: Review Consent form with respondent and obtain signature before
proceeding with the interview]
Background
1.
Do you represent a family organization?
1=No If no, skip to Question 4 on Page 2
2=Yes If yes, continue
2.
a.
What is the name of the organization you represent?
b.
What is your role in that organization?
Please provide a brief history of the family organization you represent.
How long has it been active?
What are its funding sources?
What are its primary functions? [Probe for any indirect or direct services provided.]
[Data entry: code services]
What group of people does it represent or serve?
3.
How would you characterize your organization’s relationship with the children’s mental
health service system? [Probe for the formal and informal relationships, nature of
the working relationship, funding, etc.]
To what extent do you think that the goals of the service system fit with the mission or
goals of your organization?
4.
Are you a member of the (governing body)?
CMHS National Evaluation, Baseline Assessment
Family Representative Guide (C), February 2011
Phase VI
1
1=No If no, go to Question 12
2=Yes If yes, continue
Governance
5.
Please describe the overall structure of the (governing body). [Probe for number of
members, agencies and organizations represented; location, time, and frequency
of meetings; existence of bylaws, subcommittees, etc.]
6.
Since CMHS grant funds were received, how involved or influential would you say the
(governing body) has been in the governance of (name of grant program) ?
a.
What have been some of the key functions and responsibilities related to
governance of (name of grant program) ? These can include activities of
subcommittees.
Probe for examples of activities related to:
- strategic planning
- budgetary decisions
- developing the service array
- establishing formal arrangements among community-based agencies
and/or other federally-funded entitlement or discretionary grant programs
(ask for a listing of such MOUs or MOAs)
- developing a cultural and linguistic competence plan
- other - please describe
b.
How are decisions or recommendations made? Do members have voting
rights? If yes, which members? [Probe for voting versus consensus or some
combination of both.]
c.
To what extent are the decisions or recommendations of the (governing body)
acted upon or implemented by (name of grant program) ? [Probe for whether the
body makes final decisions, makes formal recommendations, or is
primarily advisory.]
How often would you say the recommendations or decisions of (governing body)
are implemented? [Probe for percentage of time.]
7.
Since grant funds were received, have family members been actively involved in the
(governing body)? (A.1.a.)
a.
Of the governing body functions we discussed earlier, which ones are family
members involved in? [Probe for examples of participation in the
(governing body)’s functions that this respondent previously reported.]
CMHS National Evaluation, Baseline Assessment
Family Representative Guide (C), February 2011
Phase VI
2
5=Involved in all activities of the governing body
4=Involved in most activities of the governing body
3=Involved in some activities of the governing body
2=Involved in few activities of the governing body
1=Involved in no activities of the governing body
b.
How have family members been regarded and treated by other participants of
the (governing body)? (A.1.a.)
Has that been the same for all participants, or have some participants
demonstrated respect, acceptance, and value for family input more than others?
5=All participants were very respectful, accepted, and highly valued family input
4=Most participants were very respectful and valued family input and the rest were moderately respectful
3=Some participants were very respectful and valued family input and the rest were moderately respectful
2=Few participants were very respectful and valued family input and most others were at least somewhat respectful
1=No or almost no participants were respectful or valued family input
c.
What percentage of (governing body) meetings have family members
attended? (A.1.a.)
5=Attended 90% to 100% of meetings
4=Attended 75% to 89% of meetings
3=Attended 50% to 74% of meetings
2=Attended 25% to 49% of meetings
1=Attended less than 25% of meetings
8.
Are family representatives given information necessary to fulfill their role on the
governing body? If yes, is the information accurate, understandable, and complete?
(A.1.b.)
5=Adequately informed all of the time
4=Adequately informed most of the time
3=Adequately informed some of the time
2=Adequately informed a few times
1=Adequately informed none of the time
(NOTE TO INTERVIEWER: If early childhood site, skip to Question 10)
9.
Since grant funds were received, have youth been actively involved in the (governing
body)? (A.2.a.)
a.
Of the governing body functions we discussed earlier, which ones are youth
involved in? [Probe for examples of participation in the (governing body)’s
functions that this respondent previously reported.]
5=Involved in all activities of the governing body
4=Involved in most activities of the governing body
3=Involved in some activities of the governing body
2=Involved in few activities of the governing body
1=Involved in no activities of the governing body
b.
How have youth been regarded and treated by other participants of the
(governing body)? (A.2.a.)
Has that been the same for all participants, or have some participants
demonstrated respect, acceptance, and value for youth input more than others?
CMHS National Evaluation, Baseline Assessment
Family Representative Guide (C), February 2011
Phase VI
3
5=All participants were very respectful, accepted, and highly valued youth input
4=Most participants were very respectful and valued youth input and the rest were moderately respectful
3=Some participants were very respectful and valued youth input and the rest were moderately respectful
2=Few participants were very respectful and valued youth input and most others were at least somewhat respectful
1=No or almost no participants were respectful or valued youth input
c.
What percentage of (governing body) meetings have youth attended? (A.2.a.)
5=Attended 90% to 100% of meetings
4=Attended 75% to 89% of meetings
3=Attended 50% to 74% of meetings
2=Attended 25% to 49% of meetings
1=Attended less than 25% of meetings
10.
When and where have (governing body) meetings typically been held? How were these
times and locations determined? (A.1.c.)
Have the meeting times and location been convenient for you and other family
members? Why or why not?
Has the location or time of meetings ever prevented you or other family
representatives from attending?
On a scale of 1 to 5, with 5 being the most convenient, how would you rate the
convenience of the meetings for family representatives?
Respondent’s rating
5=Extremely convenient
4=Very convenient
3=Moderately convenient
2=Somewhat convenient
1=Not at all convenient
11.
Interviewer’s rating
5=Extremely convenient
4=Very convenient
3=Moderately convenient
2=Somewhat convenient
1=Not at all convenient
Are there any mechanisms in place that facilitate family member participation on the
(governing body)? Please provide examples. [Probe for reimbursed costs, stipends,
childcare, compensated time from work, training, written/oral language
interpretation or translation, etc.] (A.1.d.)
If yes, have these made a difference for you or other family members?
If no, would it be helpful to you or other family members if there were?
Is there anything else that could be done to make it easier for you or other family
representatives to participate?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
Management and Operations
12.
Are there any mechanisms in place or have efforts been made to involve family
members in program operations such as designing and implementing programs;
ensuring cultural and linguistic competent services, supports, and providers; providing
CMHS National Evaluation, Baseline Assessment
Family Representative Guide (C), February 2011
Phase VI
4
staff training; serving as staff, helping with staff recruitment; attending management
meetings, etc? (B.1.c.)
If yes, please describe all of the different ways family members have been involved.
[Note: Do not count involvement in governing body, evaluation, or conducting outreach activities.]
[Continue to probe for examples until the respondent reports no more.]
[Data entry: code ways]
5=Four examples of family involvement in program operations
4=Three examples of family involvement in program operations
3=Two examples of family involvement in program operations
2=One example of family involvement in program operations
1=No examples of family involvement in program operations
(NOTE TO INTERVIEWER: If early childhood site, skip to Question 14)
13.
Are there any mechanisms in place or have efforts been made to involve youth in
program operations such as designing and implementing programs, providing staff
training, serving as staff, helping with staff recruitment, attending management meetings,
etc? (B.2.a.)
If yes, please describe all of the different ways youth have been involved.
[Note: Do not count involvement in governing body, evaluation, or conducting outreach activities.]
[Continue to probe for examples until the respondent reports no more.]
[Data entry: code ways]
5=Four examples of youth involvement in program operations
4=Three examples of youth involvement in program operations
3=Two examples of youth involvement in program operations
2=One example of youth involvement in program operations
1=No examples of youth involvement in program operations
14.a.
What efforts have been made to have paraprofessionals, (for example, family
members, people from the community, or other lay persons) provide services directly to
children, youth, and families? (B.1.b.)
What, if any, services have paraprofessionals provided? [Probe for service options
such as respite, mentor, parent or sibling support, etc.]
In your opinion, are there any other services not currently available that you think
paraprofessionals could provide to support families?
5=Four or more services provided by paraprofessionals
4=Three services provided by paraprofessionals
3=Two services provided by paraprofessionals
2=One service provided by paraprofessionals
1=No services provided by paraprofessionals
If any services were provided by paraprofessionals, ask:
CMHS National Evaluation, Baseline Assessment
Family Representative Guide (C), February 2011
Phase VI
5
b.
What percentage of the children, youth, and families who need these services can get
them? (B.1.b.)
5=90%–100% of children, youth, and families who need the service get it
4=75%–89% of children, youth, and families who need the service get it
3=50%–74% of children, youth, and families who need the service get it
2=25%–49% of children, youth, and families who need the service get it
1=Less than 25% of children, youth, and families who need the service get it
666=No services provided by paraprofessionals
(NOTE TO INTERVIEWER: Questions 15-16 skipped)
Service Array
17.
Since grant funds were received, what has been done to ensure that services in (name of
grant program) ’s service array have sufficient capacity such that all the children, youth,
and families who need the services can get them (for example, expanding network of
contract providers, increasing contracts to increase capacity)? [Probe for capacity
across all services in the array.] (C.7.a.)
[Data entry: code mechanisms]
Have these efforts been effective? If yes, how?
Have these efforts been sufficient? Are there any services that some children, youth,
and/or families cannot get because capacity is limited?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
18.
Since grant funds were received, what has been done to make services more
accessible in terms of scheduling of services or locations where services are
provided? [Probe for flexible hours including after hours and weekends; services
offered in settings such as home, schools, community. Probe for applicability
across all services in the array.] (C.7.b.)
[Data entry: code mechanisms]
Have these efforts been effective? If yes, how?
Have these efforts been sufficient? What else could be done to make services more
accessible?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
19.
Has the project put any mechanisms in place to minimize financial barriers to care for
children, youth, and families served by (name of grant program) ? [Probe for sliding scale
fees, scholarship funds, flexible funding, etc.] (B.7.a)
CMHS National Evaluation, Baseline Assessment
Family Representative Guide (C), February 2011
Phase VI
6
[Data entry: code mechanisms]
Are children, youth, and families who are uninsured or privately insured able to
receive services through (name of grant program) ?
Have these efforts been effective? If yes, how?
Overall, have efforts been sufficient or has cost continued to be a barrier for some
families to access the services they need?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
20.
How has the cultural and linguistic background of the intended service population
been considered in developing the service array? (C.4.a.)
Since grant funds were received, have cultural organizations, community groups,
etc. been involved in efforts such as providing services, developing the service array,
advising providers, etc.?
Has (name of grant program) added or modified any services to address the cultural or
linguistic needs of specific groups?
How have these efforts been effective?
Have efforts been adequate or sufficient to fully address the cultural and linguistic
needs of all service groups? Are some groups’ needs still unmet?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
Least Restrictive & Community Based
21.
What efforts have been made to minimize the need for children, youth, and families
to travel out of their home communities for services? [If response is “not a
problem,” probe for what allows them to serve all children, youth, and families in
their home communities.] (C.8.b.)
[Data entry: code mechanisms]
Have these efforts been effective? If yes, in what ways?
Have these efforts been sufficient to ensure that all children, youth, and families are
served in their home communities? If no, what else could have been done?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
CMHS National Evaluation, Baseline Assessment
Family Representative Guide (C), February 2011
Phase VI
7
1=No or almost no effort has been made toward accomplishing larger goal
22.
What efforts have been made to reduce the number of children and youth who are
served in settings more restrictive than necessary? [If response is “not a problem,”
probe for what allows them to serve children and youth in the least restrictive
settings.] (B.9.b.)
[Data entry: code mechanisms]
Have these efforts been effective? If yes, in what ways?
Have these efforts been sufficient to eliminate the use of inappropriately restrictive
settings/service options?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
23.
Since grant funds were received, what policies, structures or mechanisms has (name of
grant program) implemented to promote the provision of individualized care (for example,
use of flexible funds to meet unique needs, development of specific services, training on
the provision of individualized care)? (B.3.a.)
[Data entry: code mechanisms]
Have these efforts been effective? If yes, in what ways?
Have these efforts been sufficient? Are there other things that could be done to
maximize the provision of individualized care?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
(NOTE TO INTERVIEWER: Questions 24-28 skipped)
Lessons Learned
29.
Since grant funds were received, what have been the most effective strategies or
activities undertaken to develop and implement the system/program?
30.
Since grant funds were received, what have been the least effective strategies or
activities undertaken to implement the system/program?
Achievement of Goals
31.
Since grant funds were received, what have been the grant program’s most important
achievements?
32.
What influence has (name of grant program) had on the larger system across all childserving agencies?
CMHS National Evaluation, Baseline Assessment
Family Representative Guide (C), February 2011
Phase VI
8
33.
What have been the major obstacles to expanding the system of care principles and
philosophies beyond the scope of (name of grant program) ?
Sustainability
34.
Please tell me about the status of your community’s effort to sustain its system of care
as CMHS grant funds decrease over time. [Probe to determine how they are
responding to increased matching fund requirements.]
Have any aspects of the system/program been changed, reduced, or eliminated due
to the decreases in CMHS funding? If so, what has occurred?
35.
What aspects of the system/program do you anticipate will be sustained over time?
[Probe for family-driven, individualized and youth-guided care, cultural and
linguistic competence, interagency involvement, accessible services, coordinated,
community-based and least restrictive care, etc.]
What barriers exist that may hinder sustainability?
Those are all of the questions I have for you. Is there anything that I did not cover that you think
is important for us to know about (name of grant program)?
Thank you for taking the time to answer my questions. Do you have any questions for me?
CMHS National Evaluation, Baseline Assessment
Family Representative Guide (C), February 2011
Phase VI
9
OMB No. 0930-0307
Expiration Date: xx/xx/xx
System/Program__________________________
Interviewer___________________
Site ID#_________________________________
Date________________________
Respondent Data Entry#_______________________
Assessment #_________________
D. Program Evaluator
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
[Note to interviewer: Review Consent form with respondent and obtain signature before
proceeding with the interview]
1.
What is the name of the agency that employs you?
What is your position/title?
2.
Are you involved in any structured program evaluation efforts?
If yes, what is your role?
3.
Briefly describe the (name of grant program) ’s efforts to evaluate its program. What types of
evaluation activities have you engaged in during the past year? Are these activities part
of the national or local evaluation efforts? [Probe for peer review efforts, use of
evaluation data, examination of consumer satisfaction, special studies, etc.]
4.
How are these efforts structured and organized? [Probe for specialized office,
standing versus rotating committee(s), types of committees.]
5.
How are family representatives involved in the program evaluation process for (name
[Probe for membership on committees, initiating special studies,
participating in data collection, reporting findings to stakeholders, etc.] (D.1.c.)
of grant program) ?
Have there been any other program evaluation activities that family members have
participated in?
[Data entry: code roles]
[Continue to probe for examples until the respondent reports no more.]
5=Families involved in four different roles
4=Families involved in three different roles
3=Families involved in two different roles
2=Families involved in one role
1=Families involved in no roles
CMHS National Evaluation, Baseline Assessment
Quality Monitoring Guide (D), February 2011
Phase VI
1
(NOTE TO INTERVIEWER: If early childhood site, skip to Question 7)
6.
How are youth involved in the program evaluation process for (name of grant program) ?
[Probe for membership on committees, initiating special studies, participating in
data collection, reporting findings to stakeholders, etc.] (D.2.a.)
Have there been any other program evaluation activities that youth have participated
in?
[Data entry: code roles]
[Continue to probe for examples until the respondent reports no more.]
5=Youth involved in four different roles
4=Youth involved in three different roles
3=Youth involved in two different roles
2=Youth involved in one role
1=Youth involved in no roles
7.a.
Have there been any efforts to involve other child-serving agencies in the program
evaluation process? [Probe for membership on committees, initiating special
studies, participating in data collection, reporting findings to stakeholders, etc.]
(D.5.a.)
If yes, which agencies have been involved?
1 = Mental Health
2 = Education
3 = Child Welfare
4 = Juvenile Justice
5 = Public Health
6 = other (describe)
[circle all that apply]
5=Five or more agencies involved
4=Four agencies involved
3=Three agencies involved
2=Two agencies involved
1=One agency involved
b.
If yes to 7.a., in what roles have the agencies been involved? (D.5.a.)
[Data entry: code roles]
5=Agencies involved in four different roles
4=Agencies involved in three different roles
3=Agencies involved in two different roles
2=Agencies involved in one role
1=Agencies involved in no roles
8.
What efforts have been made to ensure that the program evaluation process is
culturally and linguistically competent? [Probe for efforts to have diversity and
members of the intended population on committees, to make the process
comfortable for all, facilitate contributions, etc.] (D.4.b.)
Have any of these efforts been effective in getting you closer to the goal of having a
culturally and linguistically competent quality monitoring process?
Do you think these efforts have been sufficient? What else could be done?
CMHS National Evaluation, Baseline Assessment
Quality Monitoring Guide (D), February 2011
Phase VI
2
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
Now I’m going to ask you about (name of grant program) ’s overall program evaluation efforts.
In particular, I’ll be asking whether data are being collected in certain areas and how
those data are being used to improve services across the overall system.
9.
Since CMHS grant funds were received, what efforts have been made to evaluate
family outcomes, that is, whether families served by the grant program are being
strengthened by the services they receive (for example, reduced stress, improved
communication and conflict resolution, better management of child behavior)? (D.1.a.)
Has that information been examined or analyzed?
If yes, have changes in services or in the system been made to respond to any
identified problems? Please give me an example.
Has there been a follow-up examination to find out whether the changes led to
service or system improvements?
If yes, were improvements found? Please describe.
[Note: If only baseline data have been collected but not yet analyzed, score=3]
5=Data collected and examined in this area AND changes have been made to respond to problems found AND follow-up examination found
improvement in problem OR examination of information collected found no need for improvement
4=Data collected and examined in this area AND changes have been made to respond to the problems found BUT follow-up examination of
improvement in problem has not been conducted or is incomplete OR follow-up examination showed no improvements resulted from the change
3=Data collected in this area AND data examined BUT respondent reported NO changes have been made to respond to problems found
2=Data collected in this area but the information has not yet been examined
1=No data collected in this area; no effort to monitor quality in this area
888=Respondent unaware of quality monitoring or evaluation activities
10.
Since grant funds were received, has there been any effort to evaluate families’
experiences with (name of grant program) , for example, how satisfied families have been with
the service system and/or direct service provision? (D.1.b.)
Has that information been examined or analyzed?
If yes, have changes in services or in the system been made to respond to any
identified problems? Please give me an example.
Has there been a follow-up examination to find out whether the changes led to
service or system improvements?
If yes, were improvements found? Please describe.
5=Data collected and examined in this area AND changes have been made to respond to problems found AND follow-up examination found
improvement in problem OR examination of information collected found no need for improvement
4=Data collected and examined in this area AND changes have been made to respond to the problems found BUT follow-up examination of
improvement in problem has not been conducted or is incomplete OR follow-up examination showed no improvements resulted from the change
3=Data collected in this area AND data examined BUT respondent reported NO changes have been made to respond to problems found
2=Data collected in this area but the information has not yet been examined
CMHS National Evaluation, Baseline Assessment
Quality Monitoring Guide (D), February 2011
Phase VI
3
1=No data collected in this area; no effort to monitor quality in this area
888=Respondent unaware of quality monitoring or evaluation activities
11.
What efforts have been made, since grant funds were received, to evaluate and improve
how well services have been individualized for children and youth served by the
grant program? (D.3.b.)
Has that information been examined or analyzed?
If yes, have changes in services or in the system been made to respond to any
identified problems? Please give me an example.
Has there been a follow-up examination to find out whether the changes led to
service or system improvements?
If yes, were improvements found? Please describe.
5=Data collected and examined in this area AND changes have been made to respond to problems found AND follow-up examination found
improvement in problem OR examination of information collected found no need for improvement
4=Data collected and examined in this area AND changes have been made to respond to the problems found BUT follow-up examination of
improvement in problem has not been conducted or is incomplete OR follow-up examination showed no improvements resulted from the change
3=Data collected in this area AND data examined BUT respondent reported NO changes have been made to respond to problems found
2=Data collected in this area but the information has not yet been examined
1=No data collected in this area; no effort to monitor quality in this area
888=Respondent unaware of quality monitoring or evaluation activities
12.
Since grant funds were received, have there been any efforts to evaluate child and
youth outcomes (for example, reduction of symptoms, improvement of social
functioning, etc.)? (D.3.a.)
Has that information been examined or analyzed?
If yes, have changes in services or in the system been made to respond to any
identified problems? Please give me an example.
Has there been a follow-up examination to find out whether the changes led to service
or system improvements?
If yes, were improvements found? Please describe.
[Note: If only baseline data have been collected but not yet analyzed, score=3]
5=Data collected and examined in this area AND changes have been made to respond to problems found AND follow-up examination found
improvement in problem OR examination of information collected found no need for improvement
4=Data collected and examined in this area AND changes have been made to respond to the problems found BUT follow-up examination of
improvement in problem has not been conducted or is incomplete OR follow-up examination showed no improvements resulted from the change
3=Data collected in this area AND data examined BUT respondent reported NO changes have been made to respond to problems found
2=Data collected in this area but the information has not yet been examined
1=No data collected in this area; no effort to monitor quality in this area
888=Respondent unaware of quality monitoring or evaluation activities
(NOTE TO INTERVIEWER: If early childhood site, skip to Question 14)
13.
Since grant funds were received, have there been any efforts to evaluate youth
experiences with (name of grant program) , for example, how satisfied youth have been with
services? (D.2.b.)
CMHS National Evaluation, Baseline Assessment
Quality Monitoring Guide (D), February 2011
Phase VI
4
Has that information been examined or analyzed?
If yes, have changes in services or in the system been made to respond to any
identified problems? Please give me an example.
Has there been a follow-up examination to find out whether the changes led to
service or system improvements?
If yes, were improvements found? Please describe.
5=Data collected and examined in this area AND changes have been made to respond to problems found AND follow-up
examination found improvement in problem OR examination of information collected found no need for improvement
4=Data collected and examined in this area AND change has been made to respond to the problems found BUT follow-up
examination of improvement in problem has not been conducted or is incomplete OR follow-up examination showed no
improvements resulted from the change
3=Data collected in this area AND data examined BUT respondent reported NO changes that have been made to respond to
problems found
2=Data collected in this area but the information has not yet been examined
1=No data collected in this area; no effort to monitor quality in this area
888=Respondent unaware of quality monitoring or evaluation activities
14.
Has there been any effort to evaluate the cultural and linguistic competence of the
care provided through (name of grant program) in particular? Please describe. (D.4.a.)
Has that information been examined or analyzed?
If yes, have changes in services or in the system been made to respond to any
identified problems? Please give me an example.
Has there been a follow-up examination to find out whether the changes led to service
or system improvements?
If yes, were improvements found? Please describe.
5=Data collected and examined in this area AND changes have been made to respond to problems found AND follow-up examination found
improvement in problem OR examination of information collected found no need for improvement
4=Data collected and examined in this area AND changes have been made to respond to the problems found BUT follow-up examination of
improvement in problem has not been conducted or is incomplete OR follow-up examination showed no improvements resulted from the change
3=Data collected in this area AND data examined BUT respondent reported NO changes have been made to respond to problems found
2=Data collected in this area but the information has not yet been examined
1=No data collected in this area; no effort to monitor quality in this area
888=Respondent unaware of quality monitoring or evaluation activities
15.
Has there been any effort to evaluate interagency involvement in the system and
service delivery? (D.5.b.)
Has that information been examined or analyzed?
If yes, have changes in services or in the system been made to respond to any
identified problems? Please give me an example.
Has there been a follow-up examination to find out whether the changes led to
service or system improvements?
If yes, were improvements found? Please describe.
CMHS National Evaluation, Baseline Assessment
Quality Monitoring Guide (D), February 2011
Phase VI
5
5=Data collected and examined in this area AND changes have been made to respond to problems found AND follow-up examination found
improvement in problem OR examination of information collected found no need for improvement
4=Data collected and examined in this area AND changes have been made to respond to the problems found BUT follow-up examination of
improvement in problem has not been conducted or is incomplete OR follow-up examination showed no improvements resulted from the change
3=Data collected in this area AND data examined BUT respondent reported NO changes have been made to respond to problems found
2=Data collected in this area but the information has not yet been examined
1=No data collected in this area; no effort to monitor quality in this area
888=Respondent unaware of quality monitoring or evaluation activities
16.
Since grant funds were received, which public agencies have referred children,
youth, and families to (name of grant program) ? (E.5.a.)
1 = Mental Health
2 = Education
3 = Child Welfare
4 = Juvenile Justice
5 = Public Health
6 = other (describe)
[circle all that apply]
What was the distribution of referrals received from these agencies?
5=Five or more agencies refer children, youth, or families to the grant
4=Four agencies refer children/families to the grant
3=Three agencies refer children/families to the grant
2=Two agencies refer children/families to the grant
1=One agency refers children/families to the grant
17.
Has there been any effort to evaluate how well services are coordinated (for example,
continuity of care, service transitions, information sharing among providers involved in
the care of an individual family, etc.)? Can you give me an example? (D.6.a.)
Has that information been examined or analyzed?
If yes, have changes in services or in the system been made to respond to any
identified problems? Please give me an example.
Has there been a follow-up examination to find out whether the changes led to service
or system improvements?
If yes, were improvements found? Please describe.
5=Data collected and examined in this area AND changes have been made to respond to problems found AND follow-up examination found
improvement in problem OR examination of information collected found no need for improvement
4=Data collected and examined in this area AND changes have been made to respond to the problems found BUT follow-up examination of
improvement in problem has not been conducted or is incomplete OR follow-up examination showed no improvements resulted from the change
3=Data collected in this area AND data examined BUT respondent reported NO changes have been made to respond to problems found
2=Data collected in this area but the information has not yet been examined
1=No data collected in this area; no effort to monitor quality in this area
888=Respondent unaware of quality monitoring or evaluation activities
18.
What efforts have been made to evaluate the accessibility of services and of the
system as a whole? Can you give me an example? (D.7.a.)
Has that information been examined or analyzed?
If yes, have changes in services or in the system been made to respond to any identified
problems? Please give me an example.
CMHS National Evaluation, Baseline Assessment
Quality Monitoring Guide (D), February 2011
Phase VI
6
Has there been a follow-up examination to find out whether the changes led to
service or system improvements?
If yes, were improvements found? Please describe.
5=Data collected and examined in this area AND changes have been made to respond to problems found AND follow-up examination found
improvement in problem OR examination of information collected found no need for improvement
4=Data collected and examined in this area AND changes have been made to respond to the problems found BUT follow-up examination of
improvement in problem has not been conducted or is incomplete OR follow-up examination showed no improvements resulted from the change
3=Data collected in this area AND data examined BUT respondent reported NO changes have been made to respond to problems found
2=Data collected in this area but the information has not yet been examined
1=No data collected in this area; no effort to monitor quality in this area
888=Respondent unaware of quality monitoring or evaluation activities
19.
Have there been any attempts to evaluate how often, how many, or how long children
and youth are served outside of their home communities? Can you give me an
example? (D.8.a.)
Has that information been examined or analyzed?
If yes, have changes in services or in the system been made to respond to any
identified problems? Please give me an example.
Has there been a follow-up examination to find out whether the changes led to service
or system improvements?
If yes, were improvements found? Please describe.
5=Data collected and examined in this area AND changes have been made to respond to problems found AND follow-up examination found
improvement in problem OR examination of information collected found no need for improvement
4=Data collected and examined in this area AND changes have been made to respond to the problems found BUT follow-up examination of
improvement in problem has not been conducted or is incomplete OR follow-up examination showed no improvements resulted from the change
3=Data collected in this area AND data examined BUT respondent reported NO changes have been made to respond to problems found
2=Data collected in this area but the information has not yet been examined
1=No data collected in this area; no effort to monitor quality in this area
888=Respondent unaware of quality monitoring or evaluation activities
20.
Since grant funds were received, have there been any efforts to evaluate whether
children and youth are being served in settings that are more restrictive than is
necessary? Can you give me some examples? (D.9.a.)
Has that information been examined or analyzed?
If yes, have changes in services or in the system been made to respond to any
identified problems? Please give me an example.
Has there been a follow-up examination to find out whether the changes led to service
or system improvements?
If yes, were improvements found? Please describe.
5=Data collected and examined in this area AND changes have been made to respond to problems found AND follow-up examination found
improvement in problem OR examination of information collected found no need for improvement
4=Data collected and examined in this area AND changes have been made to respond to the problems found BUT follow-up examination of
improvement in problem has not been conducted or is incomplete OR follow-up examination showed no improvements resulted from the change
CMHS National Evaluation, Baseline Assessment
Quality Monitoring Guide (D), February 2011
Phase VI
7
3=Data collected in this area AND data examined BUT respondent reported NO changes have been made to respond to problems found
2=Data collected in this area but the information has not yet been examined
1=No data collected in this area; no effort to monitor quality in this area
888=Respondent unaware of quality monitoring or evaluation activities
Those are all of the questions I have for you. Is there anything that I did not cover that you think
is important for us to know about (name of grant program)?
Thank you for taking the time to answer my questions. Do you have any questions for me?
CMHS National Evaluation, Baseline Assessment
Quality Monitoring Guide (D), February 2011
Phase VI
8
OMB No. 0930-0307
Expiration Date: xx/xx/xx
System/Program__________________________
Interviewer___________________
Site ID#_________________________________
Date________________________
Respondent Data Entry#____________________
Assessment #_________________
E. Intake Worker
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting
burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry
Road, Room 7-1044, Rockville, Maryland, 20857.
.
This guide should be administered to a staff person who has responsibility for conducting intake
into the grant funded program (which may or may not be a separate process from conducting
intake into the sponsoring organization or agency).
[Note to interviewer: Review Consent form with respondent and obtain signature before
proceeding with the interview]
1.
What are the eligibility criteria for children and youth to participate in
program) ?
2.a.
Since grant funds were received, which agencies have referred children and
youth to (name of grant program) ? (E.5.a.)
1 = Mental Health
2 = Education
3 = Child Welfare
(name of grant
4 = Juvenile Justice
5 = Public Health
6 = other (describe)
[circle all that apply]
What is the distribution of referrals received from these agencies?
5=Five or more agencies refer children/families to the grant
4=Four agencies refer children/families to the grant
3=Three agencies refer children/families to the grant
2=Two agencies refer children/families to the grant
1=One agency refers children/families to the grant
3.
Are other agencies in the child-serving systems (for example, mental health,
education, child welfare, health, juvenile justice) able to conduct intake into
(name of grant program) ? If yes, which agencies? (E.5.b.)
1 = Mental Health
2 = Education
3 = Child Welfare
4 = Juvenile Justice
5 = Public Health
6 = other (describe)
[circle all that apply]
5=Five agencies are able to conduct intake into the grant program
4=Four agencies are able to conduct intake into the grant program
CMHS National Evaluation, Baseline Assessment
Intake Worker (E), February 2011
Phase VI
1
3=Three agencies are able to conduct intake into the grant program
2=Two agencies are able to conduct intake into the grant program
1=One agency is able to conduct intake into the grant program
4.
Describe the step-by-step process that takes place after children, youth, and
families are referred to (name of grant program) . [Probe for how families are
referred, what occurs between referral and the first service contact after
intake and the initial screening assessment has been completed.] (E.7.b.)
On a scale of 1 to 5 (with 5 being the easiest) how difficult is it for children, youth,
and families to enter (name of grant program) ?
Respondent’s rating
5=Entry process was not at all complicated/difficult. Very few steps were involved.
4=Entry process was slightly complicated/difficult.
3=Entry process was somewhat complicated/difficult. Several steps were involved.
2=Entry process was moderately. Many steps involved.
1=Entry process was extremely complicated/difficult. Very many steps involved.
5.
How much time (in calendar days) typically passes between referral to and the
first service contact by the grant program after the intake and initial
screening assessment are completed (not including emergencies or crises)?
(E.7.c.)
What is the range of times from referral to services? What accounts for the
differences?
5=Service typically received in 7 days or fewer
4=Service typically received between 8 to 14 days
3=Service typically received between 15 and 21 days
2=Service typically received between 22 and 28 days
1=Service typically received in more than 28 days
(NOTE TO INTERVIEWER: Question 6 skipped)
7.
In what languages has the entry process been conducted? (E.4.c.)
What options are available for conducting intake in languages other than
English (e.g., process conducted entirely in other languages, interpretation by
staff, interpretation by someone brought by family)?
What usually happens when a child, youth, or family prefers a language other
than English?
5=Bilingual project staff conducted intake process in at least two languages other than English AND professional interpretation
services used to accommodate other languages
4=Bilingual project staff conducted intake process in at least one language other than English AND professional interpretation
services used to accommodate other languages
3=Bilingual project staff typically did not conduct intake (i.e., has happened on occasion but not regularly) BUT professional
interpretation services (not affiliated with project) were available for most languages needed
2=Informal interpretation services were used in most cases (e.g., family brings AN ADULT relative, friend, etc. who speaks English)
1=No efforts were made to meet family language needs (e.g.. families were not asked about their language of choice; intake was
conducted in the preferred language of the staff; the child provided interpretation)
666=Not applicable; situation has not arisen
Those are all of the questions I have for you. Is there anything that I did not cover that
you think is important for us to know about (name of grant program)?
CMHS National Evaluation, Baseline Assessment
Intake Worker (E), February 2011
Phase VI
2
Thank you for taking the time to answer my questions. Do you have any questions for
me?
CMHS National Evaluation, Baseline Assessment
Intake Worker (E), February 2011
Phase VI
3
OMB No. 0930-0307
Expiration Date: xx/xx/xx
System/Program __________________________
Interviewer___________________
Site ID#_________________________________
Date________________________
Respondent Data Entry#____________________
Assessment #_________________
F. Care Coordinator
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
.
[Note to interviewer: Review Consent form with respondent and obtain signature before
proceeding with the interview]
These questions relate specifically to services provided to children, youth, and families
served by (name of grant program) since receiving your CMHS grant funds.
Service Planning
1.
What is your title? How long have you been employed by this agency?
2.
Since grant funds were received, how have cases been assigned to you for care
coordination (case management)? [Probe for whether children, youth, or families
are assigned care coordinators based upon cultural or linguistic preferences,
gender, etc.]
What has been your typical or average caseload size? Was this manageable? Why or
why not?
(NOTE TO INTERVIEWER: Question 3 skipped)
4.
Since grant funds were received, what hours have you typically worked? (G.7.b.)
Have you been available to children, youth, and families evenings or weekends?
How frequently or in what percentage of cases have you worked with children, youth,
and families after hours or on weekends?
Have you been able to accommodate special scheduling requests?
5=Available at a wide range of times (including after-hours AND weekends), and there was also broad flexibility in scheduling
4=Available at a wide range of times (including after-hours OR weekends), and moderate flexibility in scheduling
3=Range of hours available but SET times for after-hours OR weekends; little flexibility to accommodate special requests
2=Business hours only; special requests accommodated in special (non-emergency) circumstances only
1=Business hours only; special requests not accommodated
5.
Can children, youth, and families reach you in emergencies? If so, how?
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
1
If no, can children, youth, and families reach someone from
how?
6.
(name of grant program) ?
If so,
Since grant funds were received, where have you typically worked? (G.7.c.)
Have you been available to work with children, youth, and families in flexible
settings (e.g., homes, schools, community settings, etc.)?
How much of your time (directly providing services) has been spent in these locations or
settings? [Probe for breakdown of time spent in each location.]
Have you been able to accommodate special requests? Please provide examples.
5=Services offered in a wide range of locations (for example, homes, schools, in the community); in addition, there was also very broad
flexibility in locations to meet family needs
4=Range of locations offered and moderately broad flexibility in locations to meet family needs
3=Range of locations offered but little flexibility to accommodate special requests
2=Agency offices only; special requests accommodated in special (non-emergency situations) circumstances only
1=Agency offices only; special requests not accommodated
In this section, I’ll be asking you about the service planning process.
7.
Since grant funds were received, have service plans been developed for ALL
children, youth, and families served by (name of grant program) ? If no, in which cases were
service plans developed? (F.3.a.)
What percentage of children, youth, and families have had plans in place?
5=All children and youth (100%) have had individualized service plans
4=Almost all (90–99%) children and youth have had individualized service plans
3=Many (75–89%) children and youth have had individualized service plans
2=Some (50–74%) children and youth have had individualized service plans
1=Few (less than 50%) children and youth have had individualized service plans
8.
Since grant funds were received, what time of day have service planning meetings
typically taken place? (F.7.a.)
Have meetings been held at flexible times, such as evenings or weekends?
How frequently have meetings been held after hours or on weekends?
Have you been able to accommodate special scheduling requests? If so, how
frequently?
5=Meetings held in a wide range of times (including after-hours AND weekends), and there was also broad flexibility in scheduling
4=Meetings held in a wide range of times (including after-hours OR weekends), and moderate flexibility in scheduling
3=Range of hours available but SET times for after-hours OR weekends; little flexibility to accommodate special requests
2=Business hours only; special requests accommodated in special (non-emergency) circumstances only
1=Business hours only; special requests not accommodated
666=No service planning meetings held
9.
In what locations have service planning meetings typically taken place? (F.7.b.)
Have meetings ever been held in non-office or agency settings such as family homes,
in the community, etc.?
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
2
How frequently have meetings been held outside of the agency or office?
Have you been able to accommodate special requests for meeting locations? If so,
how frequently?
5=Meetings held in a wide range of locations (for example, homes, schools, in the community); in addition, there was also very broad flexibility
in locations to meet family needs
4=Range of locations offered and moderately broad flexibility in locations to meet family needs
3=Range of locations offered but little flexibility to accommodate special requests
2=Agency offices only; special requests accommodated in special (non-emergency situations) circumstances only
1=Agency offices only; special requests not accommodated
666=No service planning meetings held
Child, Youth, and Family Involvement
10.a.
Since grant funds were received, have parents, other caregivers or family members
typically been present at their service planning meetings? (F.1.a.)
Approximately, in what percentage of meetings have parents, other caregivers or
family members been present?
5=Family member present in all or almost all (98–100%) meetings
4=Family member present in most (90–97%) meetings
3=Family member present in many (75–89%) meetings
2=Family member present in some (50–75%) meetings
1=Family member present in few (less than 50%) meetings
666=No planning meetings were held
b.
Since grant funds were received, has the service planning process involved family
members as decision-makers and partners? (F.1.a.)
Please provide specific examples of how parents, other caregivers or family
members have participated and led in:
- identifying and prioritizing their problems or concerns
- developing goals and objectives
- requesting participants in the service planning process
- rejecting participants in the service planning process
- identifying and choosing service options
- rejecting service options
In general, has the process involved and empowered family members as much as it
could have? If no, in what ways could it have been better?
[Note: If the situation has not come up but it would be possible, assign ½ point.]
5=Families have been involved as partners in service planning in at least 6 ways AND respondent reported that family leadership has been
sufficient
4=Families have been involved as partners in service planning in 5 ways OR involved in 6 ways but respondent reported it could have been better
3=Families have been involved as partners in service planning in 4 ways
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
3
2=Families have been involved as partners in service planning in 3 ways
1=Families have been involved as partners in service planning in fewer than 3 ways
11.a.
Have you commonly involved children and youth in service planning? Under what
circumstances do you think it is appropriate for children and youth to participate in their
own service planning?
[If children/youth are commonly involved:]
b.
Please provide specific examples of how children and youth have been involved in:
(F.2.a.)
- identifying and prioritizing their problems or concerns
- developing goals and objectives
- requesting participants in the service planning process
- rejecting participants in the service planning process
- identifying and choosing service options
- rejecting service options
In general, has the process involved children and youth as much as it could have? If
no, in what ways could it have been better?
[Note: If the situation has not come up but it would be possible, assign ½ point.]
5=Children/youth have been involved in service planning in at least 6 ways AND respondent reported that involvement has been sufficient
4=Children/youth have been involved in service planning in 5 ways OR involved in 6 ways but respondent reported it could have been better
3=Children/youth have been involved in service planning in 4 ways
2=Children/youth have been involved in service planning in 3 ways
1=Children/youth have involved in service planning in fewer than 3 ways
666=Early childhood site
12.a.
Please describe your process for assessing the needs of the family as a whole,
including parents, other caregivers, siblings, etc. during service planning. (F.1.b.)
For approximately what percentage of families have you assessed needs?
5=Needs assessed for all (100%) families
4=Needs assessed for almost all (90–99%) families
3=Needs assessed for many (75–89%) families
2=Needs assessed for some (50–74%) families
1=Needs assessed for few (less than 50%) families
b.
Can you give me several examples of the kinds of services and supports that you
have identified and arranged to meet the needs of families? (F.1.b.)
[Keep probing for more examples until it is clear that the respondent can think of
no more examples or until four examples have been reported.]
Have these efforts been sufficient to assess needs and put services in place to
meet the needs, or could more have been done?
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
4
5=Four or more examples of needs incorporated into service plan AND respondent reported it could not have been better
4=Three examples of needs incorporated into service plan OR 4 or more examples but respondent reported it could have been better
3=Two examples of needs incorporated into service plan
2=One example of needs incorporated into service plan
1=No examples of needs incorporated into service plan
13.a.
Since grant funds were received, has the service planning process typically included an
assessment of the strengths of the CHILD or YOUTH? (F.3.b.)
What kinds of questions are asked? [Probe for identification of child and youth
strengths in life domains, identification of child and youth strengths using a form,
etc.]
For approximately what percentage of children and youth have you assessed
strengths?
5=Strengths assessed for all (100%) children and youth
4=Strengths assessed for almost all (90–99%) children and youth
3=Strengths assessed for many (75–89%) children and youth
2=Strengths assessed for some (50–74%) children and youth
1=Strengths assessed for few (less than 50%) children and youth
b.
Please give me several examples of how you have incorporated children and youth
strengths into the identification and planning of services. (F.3.b.) [Note: Examples
should identify a strength, a service planned based on that strength, AND how the
service benefited the child or youth]
[Keep probing for more examples until it is clear that the respondent can think of
no more examples or until four examples have been reported.]
Have these efforts been sufficient to assess, identify and incorporate children and
youth’s strengths into the service plan, or could more have been done?
5=Four or more examples of child or youth strengths incorporated into service plan AND respondent reported it could not have been better
4=Three examples of child or youth strengths incorporated into service plan OR 4 or more examples but respondent reported it could have been
better
3=Two examples of child or youth strengths incorporated into service plan
2=One example of child or youth strengths incorporated into service plan
1=No examples of child or youth strengths incorporated into service plan
14.a.
Has the service planning process typically included an assessment of the strengths of
the FAMILY? (F.1.c.)
What kinds of questions are asked? (e.g., identify family strengths in life domains,
identify family strengths using a checklist, etc.)
For approximately what percentage of families have you assessed strengths?
5=Strengths assessed for all (100%) families
4=Strengths assessed for almost all (90–99%) families
3=Strengths assessed for many (75–89%) families
2=Strengths assessed for some (50–74%) families
1=Strengths assessed for few (less than 50%) families
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
5
b.
Please give me several examples of how you have used family strengths to identify
and plan services. (F.1.c.)
[Keep probing for more examples until it is clear that the respondent can think of
no more examples or until four examples have been reported.]
Have these efforts been sufficient to assess, identify and incorporate family
strengths into the service plan, or could more have been done?
5=Four or more examples of family strengths incorporated into service plan AND respondent reported it could not have been better
4=Three examples of family strengths incorporated into service plan OR 4 or more examples but respondent reported it could have been better
3=Two examples of family strengths incorporated into service plan
2=One example of family strengths incorporated into service plan
1=No examples of family strengths incorporated into service plan
Cultural and Linguistic Competence
(NOTE TO INTERVIEWER: Question 15 skipped)
16.
In what languages has service planning been conducted? (F.4.b.)
What options are available for conducting service planning in languages other than
English (e.g., process conducted entirely in other languages, interpretation by staff,
interpretation by someone brought by family)?
What usually happens when a child, youth, or family prefers a language other than
English?
5=Bilingual project staff conducted service planning in at least two languages other than English AND professional interpretation services used to
accommodate other languages
4=Bilingual project staff conducted service planning in at least one language other than English AND professional interpretation services used to
accommodate other languages
3=Bilingual project staff typically did not conduct service planning (i.e., has happened on occasion but not regularly) BUT professional
interpretation services (not affiliated with project) were available for most languages needed
2=Informal interpretation services were used in most cases (e.g., family brings AN ADULT relative, friend, etc. who speaks English)
1=No efforts were made to meet family language needs (e.g.. families were not asked about their language of choice; service planning was
conducted in the preferred language of the staff; the child provided interpretation)
666=Not applicable; situation has not arisen
17.a.
Since grant funds were received, has the service planning process included an
assessment of the culture of the child, youth, and family, for example, things that are
important to them such as religion, race/ethnicity, family traditions, beliefs about health
and illness, etc.? If so, please describe this process. (F.4.a.)
What kinds of questions do you ask, what kinds of things do you look for?
For approximately what percentage of children, youth, and families have you
assessed culture?
5=Culture assessed for all (100%) children, youth, and families
4=Culture assessed for almost (90–99%) children, youth, and families
3=Culture assessed for many (75–89%) children, youth, and families
2=Culture assessed for some (50–74%) children, youth, and families
1=Culture assessed for few (less than 50%) children, youth, and families
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
6
b.
Please give me several examples of how you have used the culture of a child, youth,
and family to identify or plan services. (F.4.a.)
[Keep probing for more examples until it is clear that the respondent can think of
no more examples or until four examples have been reported.]
Have these efforts been sufficient, or could more work be done to utilize families’
culture in the planning of services?
5=Four or more examples of family culture incorporated into service plan AND respondent reported it could not have been better
4=Three examples of family culture incorporated into service plan OR 4 or more examples but respondent reported it could have been better
3=Two examples of family culture incorporated into service plan
2=One example of family culture incorporated into service plan
1=No examples of family culture incorporated into service plan
Coordination/Collaboration
18.
Since grant funds were received, have any of the public child-serving agencies (for
example, mental health, health, juvenile justice, education, child welfare) routinely
participated in service planning? (F.5.a.) If yes, which ones?
1 = Mental Health
2 = Education
3 = Child Welfare
4 = Juvenile Justice
5 = Public Health
6 = other (describe)
[circle all that apply]
Have any agencies been difficult to engage in the planning process (for example,
agencies that did not routinely participate, rarely responded to requests to attend
planning meetings)?
1 = Mental Health
2 = Education
3 = Child Welfare
4 = Juvenile Justice
5 = Public Health
6 = other (describe)
[circle all that apply]
Overall, how frequently would you say that all of the agencies involved with a child,
youth, or family have participated in the service planning process?
5=Routine participation of most or all involved child-serving agencies such that they routinely and actively participated
4=Frequent but not routine participation of most or all involved child-serving agencies
3=Frequent participation was not routine for all agencies; some involved agencies routinely participated but others participated only sporadically
2=Few agencies routinely participated such that it was rare that all involved agencies participated in service planning
1=None of the involved agencies participated in service planning
(NOTE TO INTERVIEWER: Question 19 skipped)
20.
Since grant funds were received, have others who provide support or services to a
child, youth, or family, such as organizations in the community, direct service
providers, or private providers, participated in service planning? (F.6.a)
If yes, who tends to participate (generally)?
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
7
Overall, how frequently would you say that ALL of the other organizations and
providers involved with a child, youth, or family have participated in service
planning?
5=Routine participation of most or all involved organizations and providers such that they routinely and actively participated
4=Frequent but not routine participation of most or all involved organizations and providers
3=Frequent participation was not routine for all organizations and providers; some routinely participated but others participated only sporadically
2=Few organizations and providers routinely participated such that it was rare that all involved organizations and providers participated in service
planning
1=None of the involved organizations and providers participated in service planning
21.a.
What efforts, if any, have been made to coordinate service planning processes
across agencies, organizations, or providers? (F.6.b)
Is there a unified service planning meeting or process (for example, all agencies come
together to develop cross-agency service plans together)?
Have staff attended service planning meetings across agencies? How frequently?
Have you ever attended a service planning meeting at another agency (for example, IEP
at the schools, case planning meetings at child welfare)? If yes, please describe.
b.
Have efforts to coordinate service planning processes been effective? Please
describe. (F.6.b.)
Have efforts been sufficient? What else could be done to improve coordination across
agencies, organizations, and providers?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
(NOTE TO INTERVIEWER: Questions 22-23 skipped)
Service Provision
I would like to now spend time talking about services other than care coordination (case
management) children, youth, and families have received.
24.
Since grant funds were received, have there been occasions when CHILDREN OR
YOUTH have not received all of the services that were planned? (G.3.a.)
If yes, under what circumstances (for example, certain services or providers)? Why?
In what percentage of cases has this occurred?
What steps were taken to address this situation?
5=All (100%) children and youth received all services planned for them
4=Almost all (90–99%) children and youth received all services planned
3=Many (75–89% ) children and youth received all services planned
2=Some (50–74%) children and youth received all services planned
1=Few (less than 50%) children and youth received all services planned
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
8
25.
Have there been occasions when FAMILIES did not receive all of the services that
were planned? (G.1.b.)
If yes, under what circumstances (e.g., certain services or providers)?
In what percentage of cases has this occurred?
What steps were taken to address this situation?
5=All (100%) families received all services planned for them
4=Almost all (90–99%) families received all services planned
3=Many (75–89% ) families received all services planned
2=Some (50–74%) families received all services planned
1=Few (less than 50%) families received all services planned
Service Array
Using the Services Card for Interviewing, ask:
26.
Of the services you see listed on this card, which are present in (name of grant program) ?
[Refer to the Service Array Card for Interviewing. Clarify that this means that the
service is available to children, youth, and families served by the grant program
regardless of whether the service is in the community or has low capacity.]
(C.3.a.)
[Show the respondent the Service Array Card for Interviewing and read each
service option listed. Have the respondent indicate whether each service has been
present in the array since receiving grant funds. On the Service Array Card for
Scoring, place a check for each service that has been present.]
Are there any other formal or support services for children, youth, and families not
listed on this card that are part of (name of grant program) ’s service array? Please list.
[Determine whether the service can be coded elsewhere on the list. If not, write
additional services on the Service Array Card for Scoring.]
Use completed Service Array Card for Scoring to score this item
5=All required services are in the array AND additional services are also available
4=All required services are in the array BUT no additional service are present
3=Most required services are in the array (1–3 missing) (Presence of additional services is not relevant)
2=Some required services are in the array (4 missing) (Presence of additional services is not relevant)
1=Few required services are in the array (more than 4 missing) (Presence of additional services is not relevant)
27.
Of the services you’ve identified as having been present in (name of grant program) ‘s service
array, which have sufficient capacity to meet the needs of all the children, youth,
and/or families who need them? [Circle whether or not each service has sufficient
capacity to meet the need.] (G.7.a.)
[Clarify that insufficient capacity relates to services that some children, youth,
and/or families cannot get at all, or that the respondent does not refer to because
of limited capacity.]
Use completed Service Array Card for Scoring to score this item
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
9
5=All services in the array have fully sufficient capacity such that all children, youth, and families who need them can get them
4=Most services in the array (75–95%) have fully sufficient capacity such that all children, youth, and families who need them can get them
3=Many services in the array (50–74%) have fully sufficient capacity such that all children, youth, and families who need them can get them
2=Some services in the array (25–49%) have fully sufficient capacity such that all children, youth, and families who need them can get them
1=Few services in the array (less than 25%) have fully sufficient capacity such that all children, youth, and families who need them can get them
28.
Of the services in your array, how long (in days) have children, youth, and families
you’ve served had to wait for non-emergency or non-crisis services? [Refer again
to the Service Array Card for Interviewing.] (G.7.f.)
[On the Service Array Card for Scoring record the wait for each service (in days).]
5=All required services (except emergency/crisis) accessed within 14 days or less
4=Most required services (at least 75%) accessed within 14 days or less; all others accessed within 21 days
3=Many required services (at least 50%) accessed within 14 days or less; all others accessed within 21 days
2=Some required services (at least 25%) accessed within 14 days or less; all others accessed within 21 days
1=Few required services (less than 25%) accessed within 14 days or less
(NOTE TO INTERVIEWER: Question 29 skipped)
30.a.
Of the services in your array, which are provided in the community? [Refer again to
the Service Array Card for Interviewing and circle whether or not each service is
available in the community. Ask the respondent to define “community” (e.g.,
neighborhood, city, county, etc.] (G.8.a.)
Use completed Service Array Card for Scoring to score this item
5=All services in the array are provided in the community
4=Most services in the array (75–95%) are provided in the community
3=Many services in the array (50–74%) are provided in the community
2=Some services in the array (25–49%) are provided in the community
1=Few services in the array (less than 25%) are provided in the community
b.
How many of the children, youth, and families you’ve worked with since grant funds
were received have had to travel outside of their home communities to receive
services? (G.8.a.)
How far have these children, youth, and families had to travel?
5=No children, youth, or families have had to leave the community for services
4=Few (1–2) children, youth, or families have had to leave the community for services
3=Some (3–4) children, youth, or families have had to leave the community for services
2=Many (5–6) children, youth, or families have had to leave the community for services
1=Very many (7 or more) children, youth, or families have had to leave the community for services
Accessibility
31.a.
Since grant funds were received, have children, youth, and families served by
grant program) had to pay for any of the services they received? (G.7.e.)
(name of
If yes, for which services? [List services and how families paid for them (e.g.,
sliding scale fee, co-payment, full payment, etc.]
What proportion of children, youth, or families who needed these services were able
to receive them despite the cost for the services? [For each paid service listed,
indicate the proportion of families needing the service who could access it.]
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
10
5=Virtually all services were accessible to virtually all children, youth, and families such that it rarely occurred that needed services could not be
accessed due to financial constraints
4=Most services were accessible to at least most children, youth, and families such that it rarely occurred that needed services could not be
accessed due to financial constraints
3=Many services were accessible to at least many children, youth, and families but there were still key services that could not be accessed or
there continue to be a few children, youth, or families who experienced difficulty accessing services due to financial constraints
2=Some services were financially accessible to at least some children, youth, and families
1=Few services were financially accessible to children, youth, and families
b.
Are there any services that could have benefited the children, youth, and families you
serve but have not been not provided because they were too expensive for the
family? (G.7.e.)
5=No services were too expensive
4=One service was too expensive
3=Two services were too expensive
2=Three services were too expensive
1=Four or more services were too expensive
32.
Since grant funds were received, has (name of grant program) provided or arranged for
transportation assistance to families? (G.7.d.)
If yes, what types of transportation assistance are provided and by whom?
Have there been any restrictions or limitations on transportation assistance, such as
time of day, part of town, emergencies only, distances, etc.?
What percentage of children, youth, or families who needed it have been able to
receive transportation assistance?
Overall, has the level of assistance provided by
(name of grant program)
been adequate?
5=Transportation assistance has been widely available such that all or almost all families could easily access it
4=Transportation assistance has been widely available but a few problems reported; transportation assistance has met the needs of most but not
all families
3=Some transportation assistance has been available and sufficient to meet the needs of many families
2=Limited assistance has been available (e.g., assistance was limited to certain services, certain times of day, certain parts of town, certain
distances, emergencies only, or certain income levels)
1=Very little or no transportation assistance has been available such that transportation needs for many families have not been met
Least Restrictive
33.a.
Thinking across all of the different children, youth, and families you’ve worked with since
grant funds were received, has it ever been necessary for a child or youth to be
served in a restrictive setting (for example, alternative school, hospital, group home,
etc.)? If yes, please describe. (G.9.a.)
How frequently has this occurred?
b.
In these situations, were any efforts made to transition or move the child or youth
into less restrictive services or settings once appropriate? If so, please describe.
(G.9.a.)
Have these efforts been effective?
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
11
Have these efforts been sufficient (such that children and youth were transitioned
to less restrictive services/settings as soon as possible)? If no, why not?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
(NOTE TO INTERVIEWER: Question 34 skipped)
Coordination/Collaboration
35.
Since grant funds were received, how have you worked with other agencies,
organizations and providers to coordinate the various services that children youth,
and families receive? (G.6.a.)
What kinds of information have you typically shared? What kinds of information have
you typically received?
Have there been any obstacles or barriers that inhibit the coordination of services
(for example, confidentiality regulations, agency policies, etc.)?
Have efforts in this area been effective? In what ways?
Do you think that efforts in this area have been sufficient? Why or why not?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
(NOTE TO INTERVIEWER: Questions 36-39 skipped)
Those are all of the questions I have for you. Is there anything that I did not cover that you think
is important for us to know about (name of grant program)?
Thank you for taking the time to answer my questions. Do you have any questions for me?
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
12
System/Program___________________________
Interviewer____________________________________
Respondent Data Entry #_______________________________
Date_________________________________________
Service Array Card for Scoring
Data
Entry
Service Options
Present in
the array
✔
[Q. 26]
Sufficient
capacity?
[Q. 27]
Wait
(in days)
[Q. 28]
Provided in
the
community?
[Q. 30]
No
Yes
No
Yes
1
40.
Diagnostic and evaluation services
1
2
1
2
2
41.
Neurological and/or neuro-psychological
assessment
1
2
1
2
3
42.
Outpatient individual counseling
1
2
1
2
4
43.
Outpatient group counseling
1
2
1
2
5
44.
Outpatient family counseling
1
2
1
2
6
45.
Medication management
1
2
1
2
7
46.
Care management/coordination
1
2
1
2
8
47.
Respite care
1
2
1
2
9
48.
Professional consultation
1
2
1
2
10
49.
24-hour, 7-day-a-week emergency services,
including mobile crisis outreach and crisis
intervention
1
2
1
2
11
50.
Intensive day treatment services
1
2
1
2
12
51.
Therapeutic foster care
1
2
1
2
13
52.
Therapeutic group home
1
2
1
2
14
53.
Intensive home-based services (e.g., family
preservation services)
1
2
1
2
15
54.
Transition-to-adult services
1
2
1
2
16
55.
Family advocacy and peer support
1
2
1
2
17
56.
Youth advocacy and peer support
1
2
1
2
18
57.
Residential treatment
1
2
1
2
19
58.
Inpatient hospitalization
1
2
1
2
20
59.
Alcohol and Drug Prevention
1
2
1
2
21
60.
Alcohol and Drug Treatment
1
2
1
2
1
2
1
2
Other formal or support services (specify)
22
61.
Note: When scoring, if responses are missing (e.g., don’t know) for more than 3 services in a given column, do not score the item that relates
to that column. Required services are listed as 1 through 16 above.
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
13
Service Array Card for Interviewing
Service Options
1
Diagnostic and evaluation services
2
Neurological and/or neuro-psychological assessment
3
Outpatient individual counseling
4
Outpatient group counseling
5
Outpatient family counseling
6
Medication management
7
Care management/coordination
8
Respite care
9
Professional consultation
10
24-hour, 7-day-a-week emergency services, including mobile crisis outreach
and crisis intervention
11
Intensive day treatment services
12
Therapeutic foster care
13
Therapeutic group home
14
Intensive home-based services (e.g., family preservation services)
15
Transition-to-adult services
16
Family advocacy and peer support
17
Youth advocacy and peer support
18
Residential Treatment
19
Inpatient hospitalization
20
Alcohol and Drug Prevention
21
Alcohol and Drug Treatment
Other formal or support services (specify)
CMHS National Evaluation, Baseline Assessment
Care Coordinator (F), February 2011
Phase VI
14
OMB No. 0930-0307
Expiration Date: xx/xx/xx
System/Program__________________________
Interviewer___________________
Site ID#_________________________________
Date________________________
Respondent Data Entry#____________________
Assessment #_________________
G. Direct Service Delivery Staff
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
[Note to interviewer: Review Consent form with respondent and obtain signature before
proceeding with the interview]
Introduction
1.
Briefly describe your agency/organization and its relationship with (name of grant program)
(e.g., partner, subcontractor, volunteer organization, etc.).
What kinds of services does your agency/organization provide—what does your
organization do?
2.
How long have you been working with this agency/organization?
3.a.
What kinds of services or support has your agency provided to children, youth, and
families served by (name of grant program) since their CMHS grant funds were received?
b.
What is your function?
4.
How many of the children, youth, and families you have worked with since grant funds
were received were also involved with (name of grant program) ?
Service Provision
I would like to now spend some time talking about access to the services that you
provide to children, youth, and families.
5.
Since grant funds were received, how have children or youth and their families been
assigned or referred to you for services?
Have any attempts been made to match children, youth, and families with providers
based on race, language needs, gender, clinical specialty, etc.?
6.
Since grant funds were received, what hours have you typically worked? (G.7.b.)
Do you typically work with children, youth, and families in the evenings or weekends?
If so, when and how frequently?
CMHS National Evaluation, Baseline Assessment
Direct Service Provider (G), February 2011
Phase VI
1
What happens when a child, youth, or family can’t meet during the hours you work?
Have you been able to make special arrangements to work with them when they are
available? Please provide examples.
How frequently have you done this?
5=Available at a wide range of times (including after-hours AND weekends), and there was also broad flexibility in scheduling
4=Available at a wide range of times (including after-hours OR weekends), and moderate flexibility in scheduling
3=Range of hours available but SET times for after-hours OR weekends; little flexibility to accommodate special requests
2=Business hours only; special requests accommodated in special (non-emergency) circumstances only
1=Business hours only; special requests not accommodated
7.
Can children, youth, and families reach you in emergency situations? If yes, how?
If not, can they reach someone from
8.
(name of grant program)
who can help? If yes, how?
Since grant funds were received, in what locations have you typically worked? (G.7.c.)
Have you ever worked with children, youth, and families in their homes, at the
school, or other places outside of your office or building? If yes, where?
How much of your time (directly providing services) have you spent working with
children, youth, and families in these locations or settings? [Probe for breakdown of
time spent in each location.]
If a child, youth, or family can’t meet you in your office or at the places you normally
work—have you been able to make special arrangements? How frequently have you
done this?
5=Services offered in a wide range of locations (for example, homes, schools, in the community); in addition, there was also very broad
flexibility in locations to meet family needs
4=Range of locations offered and moderately broad flexibility in locations to meet family needs
3=Range of locations offered but little flexibility to accommodate special requests
2=Agency offices only; special requests accommodated in special (non-emergency situations) circumstances only
1=Agency offices only; special requests not accommodated
9.a.
Do you routinely incorporate children and youth strengths into your provision of
services? (G.3.b.)
Do you do this with all children and youth or just certain children?
If not all (100%), for approximately what percentage do you incorporate children and
youth strengths?
5=Strengths incorporated for all (100%) children and youth
4=Strengths incorporated for almost all (90-99%) children and youth
3=Strengths incorporated for many (75-89%) children and youth
2=Strengths incorporated for some (50-74%) children and youth
1=Strengths incorporated for few (less than 50%) children and youth
9.b.
Please provide several examples of how you have incorporated children and youth
strengths when you are working with them. (G.3.b.) [Note: Examples should identify a
CMHS National Evaluation, Baseline Assessment
Direct Service Provider (G), February 2011
Phase VI
2
strength, a service activity or treatment procedure that was provided based on
that strength, and how this benefited the child or youth]
[Continue probing for more examples until it is clear that the respondent can think
of no more examples or until four examples have been reported.]
Overall, do you think that you have been able to use children and youth strengths
as well as you could have? What could be done to better use children and youth
strengths?
5=Four or more examples of child/youth strengths incorporated into service provision AND respondent reported it could not have been better
4=Three examples of child/youth strengths incorporated into service provision OR 4 or more examples but respondent reported it could have been
better
3=Two examples of child/youth strengths incorporated into service provision
2=One example of child/youth strengths incorporated into service provision
1=No examples of child/youth strengths incorporated into service provision
10.a.
Do you routinely incorporate family strengths into your provision of services? (G.1.c.)
For approximately what percentage of families do you do this?
5=Strengths incorporated for all (100%) families
4=Strengths incorporated for almost all (90–99%) families
3=Strengths incorporated for many (75–89%) families
2=Strengths incorporated for some (50–74%) families
1=Strengths incorporated for few (less than 50%) families
b.
Please provide several examples of how you have incorporated family strengths into
service provision for the families with whom you have worked. (G.1.c.)
[Continue probing for more examples until it is clear that the respondent can think
of no more examples or until four examples have been reported.]
Overall, do you think that you have been able to use family strengths as well as you
could have? What could be done to better use family strengths?
5=Four or more examples of family strengths incorporated into service provision AND respondent reported it could not have been better
4=Three examples of family strengths incorporated into service provision OR 4 or more examples but respondent reported it could have been
better
3=Two examples of family strengths incorporated into service provision
2=One example of family strengths incorporated into service provision
1=No examples of family strengths incorporated into service provision
11.a.
Do you routinely assess child, youth, and family cultural background? (G.4.a.)
If yes, for approximately what percentage of children, youth, and families?
5=Culture assessed for all (100%) children, youth, and families
4=Culture assessed for almost all (90–99%) children, youth, and families
3=Culture assessed for many (75–89%) children, youth, and families
2=Culture assessed for some (50–74%) children, youth, and families
1=Culture assessed for few (less than 50%) children, youth, and families
b.
Please give me several examples of how you have incorporated child, youth, and
family culture into your provision of services or treatments or have adjusted your
CMHS National Evaluation, Baseline Assessment
Direct Service Provider (G), February 2011
Phase VI
3
treatment strategies to more closely align them with the cultural and linguistic needs of
the children, youth and families you work with including issues such as race, ethnicity,
gender, lifestyle, age, and ability. (G.4.a.)
[Continue probing for more examples until it is clear that the respondent can think
of no more examples or until four examples have been reported.]
Have these efforts been sufficient to incorporate culture. What more could be done to
better incorporate culture into services provided?
5=4 or more examples of child, youth, and family culture incorporated into service provision AND respondent reported that it could not have
been better
4=3 examples of child, youth, and family culture incorporated into service provision OR 4 or more examples but respondent reported it could
have been better
3=2 examples of child, youth, and family culture incorporated into service provision
2=1 example of child, youth, and family culture incorporated into service provision
1=No examples of child, youth, and family culture incorporated into service provision
12.
What do you do to involve families in their child’s, youth’s, or family’s services or
treatment? (G.1.a.)
Have you routinely kept caregivers informed about what is going on in
services/treatment with their child, youth, or family and their child’s, youth’s, or family’s
progress? Please describe.
Have you routinely encouraged caregivers to express their opinion or offer advice
about what you should be doing with their child or youth, what kinds of things you should
be working on, etc.? Please provide examples.
Can you give me any examples of when you have altered the way you have worked
with a child, youth, or family due to concerns or feedback you received from families?
(IF APPLICABLE) Have families ever been involved or participated in services to
their child youth, or family, for example attending a session with you and the child or
youth, going with you and the child or youth or other family members on outings, etc.? If
yes, please describe.
Overall, have you involved families as much as you could have in their child, youth, or
family’s services/treatment or are there things that you think could be done to help them
become more involved?
5=Families have been involved in service provision in at least 4 ways AND respondent reported that involvement has been sufficient
4=Families have been involved in service provision in 3 ways OR families have been involved in 4 or more ways but respondent reports that
more involvement needed
3=Families have been involved in service provision in 2 ways
2=Families have been involved in service provision in 1 way
1=Families have not been involved in service provision
13.
Since grant funds were received, how have agencies, organizations and providers
worked to coordinate the various services that children, youth, and families receive?
(G.6.a.)
What kinds of information have you typically shared? What kinds of information have
you typically received?
CMHS National Evaluation, Baseline Assessment
Direct Service Provider (G), February 2011
Phase VI
4
Which agencies, organizations, or providers typically work well together to
coordinate services? Which do not?
Do primary health providers and substance abuse treatment providers participate and
collaborate together with other providers?
Is there anything that inhibits or compromises the coordination of services (e.g.,
confidentiality regulations, agency policies, etc.)?
Do you think efforts in this area have been effective? In what ways?
Do you think that efforts in this area have been sufficient so that all providers,
organizations, and agencies know their roles, and what is going on with the child, youth,
and family? Why or why not?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
(NOTE TO INTERVIEWER: Question 14 skipped)
Those are all of the questions I have for you. Is there anything that I did not cover that you think
is important for us to know about (name of grant program)?
Thank you for taking the time to answer my questions. Do you have any questions for me?
CMHS National Evaluation, Baseline Assessment
Direct Service Provider (G), February 2011
Phase VI
5
OMB No. 0930-0307
Expiration Date: xx/xx/xx
System/Program__________________________
Interviewer___________________
Site ID#_________________________________
Date________________________
Respondent Data Entry#____________________
Assessment #_________________
H. Care Review Participant
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
This guide should be administered to a representative from a core agency or other organization
who has been involved in the care review process during the assessment period.
[Note to interviewer: Review Consent form with respondent and obtain signature before
proceeding with the interview]
Introduction
1.
We are interested in learning about the processes and activities related to the formal
review of the care of individual children and youth who receive services from
(name of grant program) to address complex issues and challenging problems to prevent
the use of more restrictive services or settings.
Information has been supplied to us by (name of grant program) that the (name of care review group
from Table 6) provides that function and that you are member of (name of care review group from
Table 6). [Confirm membership and use the name of the group throughout the rest
of the interview.]
2.
What are the primary functions of the (name of care review group) ? [Probe for placement
decisions or diversion efforts, monitoring of care of children and youth whose
care was previously reviewed by this committee, problem solving for complex
cases.]
[Data entry: code functions]
3.
Since grant funds were received, what percentage of the children, youth, and
families served by (name of grant program) have had their care reviewed by (name of care review
group) ?
4.
How often does
and families?
5.
Please describe how children, youth, and families are typically identified for
review by (name of care review group) .
(name of care review group)
CMHS National Evaluation, Baseline Assessment
Care Review Participant (H), February 2011
Phase VI
conduct reviews of the care of children, youth,
1
Have referrals for review ever been initiated by families?
Have referrals for review ever been initiated by children or youth?
6.
Has the care review team had access to any financial resources (such as flexible
funds or other sources of discretionary monies)? If yes, how much and for what
purposes?
(NOTE TO INTERVIEWER: Questions 7-8 skipped)
Family Driven
9.
Since grant funds were received, has the (name of care review group) involved families in the
review process? (H.1.a.)
1=No If no, go to Question 14
2=Yes If yes, continue
Have family members typically attended the (name of care review group) meetings? Were
there ever any times when families weren’t present? If yes, what were the
circumstances?
Has the (name of care review group) typically encouraged families to bring someone
besides their providers, who could help support them such as a relative, friend or
advocate? If yes, provide some examples.
Have families typically been asked whether there were any individuals they would
prefer not be present?
Has the (name of care review group) typically asked families for their opinions and input in
identifying and prioritizing problems being faced?
Has the (name of care review group) typically encouraged families to participate in finding
remedies or solutions? Please provide examples.
Has the (name of care review group) given families full choice in the services they would
receive, including rejecting service options they didn’t want?
Are there other ways that you think families could have been involved by the review
group but were not?
5=Families have been involved in review process in at least 6 ways AND respondent reported that involvement has been sufficient
4=Families have been involved in review process in 5 ways OR involved in 6 ways but respondent reported it could have been better
3=Families have been involved in review process in 4 ways
2=Families have been involved in review process in 3 ways
1=Families have been involved in review process in fewer than 3 ways
10.
What efforts have been made to inform or help guide families through the care
review process? For example, have families received information regarding the
process, is there an orientation, etc.? (H.1.b.)
CMHS National Evaluation, Baseline Assessment
Care Review Participant (H), February 2011
Phase VI
2
Who provided families with this information? When did families typically receive this
information?
What has been done to make the process family friendly (e.g., non-threatening and
supportive)?
Have these efforts been effective?
Have these efforts been sufficient to ensure that ALL families were fully informed and
aware about the care review and that the process was family friendly?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
(NOTE TO INTERVIEWER: If early childhood site, skip to Question 14)
Youth Guided
11.
Has the (name of care review group) involved children and youth in the care review
process? (H.2.a.)
1=No If no, go to Question 14
2=Yes If yes, continue
Have children/youth typically attended the (name of care review group) meetings? Were there
ever any times when children/youth weren’t present? If yes, what were the
circumstances?
Has the (name of care review group) typically encouraged children/youth to bring someone
besides their caregivers or providers, who could help support them such as a relative,
friend or advocate? If yes, provide some examples.
Have children/youth typically been asked whether there were any individuals they
would prefer not be present?
Has the (name of care review group) typically asked children/youth for their opinions and
input in identifying and prioritizing problems being faced?
Has the (name of care review group) typically encouraged children/youth to participate in
finding remedies or solutions? Please provide examples.
Has the (name of care review group) given children/youth full choice in the services they
would receive, including rejecting service options they didn’t want?
Are there other ways that you think children/youth could have been involved by the
review group but were not? Please describe.
5=Children/youth have been involved in review process in at least 6 ways AND respondent reported that involvement has been sufficient
4=Children/youth have been involved in review process in 5 ways OR involved in 6 ways but respondent reported it could have been better
3=Children/youth have been involved in review process in 4 ways
CMHS National Evaluation, Baseline Assessment
Care Review Participant (H), February 2011
Phase VI
3
2=Children/youth have been involved in review process in 3 ways
1=Children/youth have been involved in review process in fewer than 3 ways
12.
Since grant funds were received, what efforts have been made to inform or help
guide children and youth through the care review process? For example, have
children and youth received information regarding the process, is there an orientation,
etc.? (H.2.b.)
Who provided children and youth with this information? When did children and youth
typically receive this information?
What has been done to make the process child or youth friendly (e.g., non-threatening
and supportive)?
Have these efforts been effective?
Have these efforts been sufficient to ensure that ALL children and youth were fully
informed and aware about the care review and that the process was family friendly?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
(NOTE TO INTERVIEWER: Question 13 skipped)
Interagency
14.
Since grant funds were received, have any public child-serving agencies participated
in the (name of care review group) process (e.g., mental health, health, juvenile justice,
education, child welfare)? (H.5.a.)
If so, which agencies — ALL agencies or only those agencies involved with the
child/family?
Have any agencies been difficult to engage in the (name of care review group) process (for
example, agencies that did not routinely participate, rarely responded to requests to
attend case review meetings)?
Overall, how frequently would you say that all of the agencies involved with a
child/family participated in the (name of care review group) process?
5=Routine participation of most or all involved child-serving agencies such that they actively participated
4=Frequent but not routine participation of most or all involved child-serving agencies
3=Frequent participation was not routine; some involved agencies routinely participated but not all
2=Few agencies routinely participated such that it was rare that all involved agencies participated
1None of the involved agencies participated
Coordination/Collaboration
15.
Have any other organizations or individual providers involved with a child, youth,
or family made referrals to or initiated reviews? (H.6.b.)
CMHS National Evaluation, Baseline Assessment
Care Review Participant (H), February 2011
Phase VI
4
If yes, how frequently has this occurred?
5=Routine referral or initiation of reviews by most or all involved organizations and providers such that they were routinely engaged in review
referral/initiation process
4=Frequent but not routine referral or initiation of reviews by most or all involved organizations and providers
3=Frequent referral/initiation of reviews was not routine for all organizations and providers; some routinely referred/initiated reviews but others
made referrals or initiated reviews only sporadically
2=Few organizations and providers routinely made referrals or initiated reviews such that it was rare that all involved organizations and providers
participated in the review initiation/referral process
1=None of the involved organizations and providers referred or initiated a review
16.
Have any efforts been made to exchange information (e.g., proceedings, findings, and
decisions) from the care review process with all involved agencies, organizations, or
providers? (H.6.a.)
What kinds of information have been shared? With whom?
How frequently has information been shared?
Have these efforts been effective?
Have these efforts been sufficient to ensure that EVERYONE involved with a
child/family is informed about the outcomes of the care review process?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
(NOTE TO INTERVIEWER: Questions 17-19 skipped)
Community Based
20.
Since grant funds were received, have you reviewed the care of children and youth
who were at risk of being served outside of their home communities?
If yes, have you reviewed ALL such cases? [Probe to determine whether all cases
reviewed or just out-of-community placements in restrictive settings.]
21.
Of the cases reviewed last year, what percentage of children or youth had to travel out
of their home communities for services?
Why (or for which services) did children, youth, and families have to travel out of their
home communities?
How far did these children, youth, and families typically have to travel?
22.
Since grant funds were received, what efforts have been taken to limit the need for
children and youth to receive services outside of their home communities? (e.g.,
explore options in the community, develop needed services in the community, etc.)?
(H.8.a.)
Do you think that these efforts have been effective? If yes, in what ways?
CMHS National Evaluation, Baseline Assessment
Care Review Participant (H), February 2011
Phase VI
5
Have these efforts been sufficient to eliminate the need for children, youth, and
families to travel outside of their home communities for services?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
Least Restrictive
23.
Since grant funds were received, has it ever been necessary to place children or youth
in more restrictive settings than necessary to receive services?
In these situations, were any efforts made to ensure that less restrictive service
options were exhausted before placing these children and youth in more restrictive
settings? If so, please describe. (H.9.a.)
Have these efforts been effective in reducing the use of service settings that are more
restrictive than necessary?
Do you think that efforts in this area have been sufficient to eliminate the need for
children and youth from ever having to receive services in settings more restrictive than
necessary?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
Those are all of the questions I have for you. Is there anything that I did not cover, that you think
is important for us to know about the (name of grant program)’s care review activities?
Thank you for taking the time to answer my questions. Do you have any questions for me?
CMHS National Evaluation, Baseline Assessment
Care Review Participant (H), February 2011
Phase VI
6
OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
System/Program__________________________
Interviewer___________________
Site ID#_________________________________
Date________________________
Respondent Data Entry#____________________
Assessment #_________________
L. Direct Service Staff from Other Public Child-Serving Agencies
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
This interview is to be administered to staff from partner public agencies who provide direct services
to children, youth, and families served by the grant program including teachers, probation officers,
child welfare case workers, and public health nurses.
[Note to interviewer: Review Consent form with respondent and obtain signature before
proceeding with the interview]
Introduction
1.
Please briefly describe your agency and its relationship with the
(name of grant program) .
[Data entry: Code agency]
What kinds of services does your agency/organization provide — what does your
organization do?
2.
How long have you been working with this agency/organization?
What is your function?
[Data entry: Code function]
3.
Since CMHS grant funds were received, what types of services or support has your
agency provided to children, youth, and families served by (name of grant program) ? What
services do you specifically provide?
4.
Since grant funds were received, what percentage of the children, youth, and
families you served have also been involved with (name of grant program) ?
5.
Since grant funds were received, how has (name of grant program) informed you about
program operations such as changes in eligibility criteria, referral processes,
service/program components? (B.6.a.)
[Data entry: code mechanisms]
On a scale of 1–5 (with 5 being best) how effective have these efforts been in ensuring
that all parties have been aware of program procedures and operations?
CMHS National Evaluation, Baseline Assessment
Other Agency Staff (L), February 2011
Phase VI
1
5=very effective
4=moderately effective
3=somewhat effective
2=minimally effective
1=not effective
Entry into Grant Services
6.
How complicated is it for families to enter into
(name of grant program)
services? (E.7.b.)
Can you describe the steps involved in the entry process after families are referred to
(name of grant program) ? [Probe for what occurs between referral and the first service
contact.]
On a scale of 1 to 5 (with 5 being the easiest or least difficult) how easy is it for children,
youth, and families to enter (name of grant program) ?
Respondent’s rating
5=Entry process was not at all complicated/difficult. Very few steps were involved.
4=Entry process was slightly complicated/difficult.
3=Entry process was somewhat complicated/difficult. Several steps were involved.
2=Entry process was moderately complicated/difficult. Many steps involved.
1=Entry process was extremely complicated/difficult. Very many steps involved.
7.
How much time typically passes between referral to the grant program and the first
service contact after the intake and screening assessment are completed (not
including emergencies or crises)? (E.7.c.)
In your experience, what was the shortest time between referral and first service
contact?
What was the longest time?
5=Service typically received in less than one week
4=Service typically received in more than one but less than two weeks
3=Service typically received in more than two but less than three weeks
2=Service typically received in more than three but less than four weeks
1=Service typically received in more than four weeks
Service Planning
8.
Since grant funds were received, have you had any involvement in service planning
for children and youth served by the (name of grant program) (e.g., attending child and family
team service planning meetings, providing input, etc.)?
1=No If no, skip to Question 15
2=Yes If yes, continue
9.
Have staff from any of the other public agencies routinely participated in service
planning (for example, staff from mental health, health, juvenile justice, education, child
welfare)? (F.5.a.) If yes, which ones?
1 = Mental Health
4 = Juvenile Justice
2 = Education
5 = Public Health
3 = Child Welfare
6 = other (describe)
[circle all that apply]
CMHS National Evaluation, Baseline Assessment
Other Agency Staff (L), February 2011
Phase VI
2
Have ALL partner agencies participated, or only those involved with the child,
youth, or family?
Have any agencies been difficult to engage in the planning process? (e.g., agencies
that did not routinely participate, rarely responded to requests to attend planning
meetings, etc.) If yes, which ones?
1 = Mental Health
4 = Juvenile Justice
2 = Education
5 = Public Health
3 = Child Welfare
6 = other (describe)
[circle all that apply]
Overall, how frequently would you say that all of the agencies involved with a child,
youth, or family participated in the child and family team service planning process?
5=Routine participation of most or all involved child-serving agencies such that they routinely and actively participated
4=Frequent but not routine participation of most or all involved child-serving agencies
3=Frequent participation was not routine for all agencies; some involved agencies routinely participated but others participated only sporadically
2=Few agencies routinely participated such that it was rare that all involved agencies participated in service planning
1=None of the involved agencies participated in service planning
10.
Have others who provided support or services to a child, youth, or family, such as
organizations in the community, direct service providers, or private providers,
participated in service planning? (F.6.a.)
If yes, who tends to participate (generally)?
Overall, how frequently would you say that ALL of the other organizations and
providers involved with a child, youth, or family participated in service planning?
5=Routine participation of most or all involved organizations and providers such that they routinely and actively participated
4=Frequent but not routine participation of most or all involved organizations and providers
3=Frequent participation was not routine for all organizations and providers; some routinely participated but others participated only sporadically
2=Few organizations and providers routinely participated such that it was rare that all involved organizations and providers participated in service
planning
1=None of the involved organizations and providers participated in service planning
11.a.
Since grant funds were received, have efforts been made to coordinate service
planning processes across agencies, organizations, or providers? (F.6.b.)
Is there a unified service planning meeting or process? (e.g., all agencies come
together to develop unified or complementary service plans together)
b.
Have staff attended service planning meetings across agencies? How frequently?
Have efforts to coordinate service planning processes been effective? If yes, in
what ways? (F.6.b.)
Have efforts been sufficient? What else could be done to improve coordination of the
service planning process across agencies, organizations, and providers?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
CMHS National Evaluation, Baseline Assessment
Other Agency Staff (L), February 2011
Phase VI
3
12.
Since grant funds were received, have service plans been developed for ALL
children, youth, and families served by (name of grant program) ? If no, in which cases have
service plans been developed? (F.3.a.)
What percentage of children, youth, and families have had plans in place?
5=All children and youth (100%) have had individualized service plans
4=Almost all (90–99%) children and youth have had individualized service plans
3=Many (75–89%) children and youth have had individualized service plans
2=Some (50–74%) children and youth have had service plans
1=Few (less than 50%) children and youth have had service plans
13.a.
Since grant funds were received, have parents, other caregivers or family members
typically been present at their service planning meetings? (F.1.a.)
Approximately what percentage of the meetings have parents, other caregivers or
family members been present?
5=Family member present in all (100%) meetings
4=Family member present in almost all (90–99%) meetings
3=Family member present in many (75–89%) meetings
2=Family member present in some (50–75%) meetings
1=Family member present in few (less than 50%) meetings
666=No planning meetings have been held
13.b.
Since grant funds were received, has the service planning process involved family
members as decision-makers and partners? (F.1.a.)
Please provide specific examples of how parents, other caregivers or family
members have participated and led in:
- identifying and prioritizing their problems or concerns
- developing goals and objectives
- requesting participants in the service planning process
- rejecting participants in the service planning process
- identifying and choosing service options
- rejecting service options
In general, has the process involved and empowered families as much as it could
have? Could it have been better?
[Note: If the situation has not come up but it would be possible, assign ½ point.]
5=Families have been involved as partners in service planning in at least 6 ways AND respondent reported that family leadership has been
sufficient
4=Families have been involved as partners in service planning in 5 ways OR involved in 6 ways but respondent reported that it could have been
better
3=Families have been involved as partners in service planning in 4 ways
2=Families have been involved as partners in service planning in 3 ways
1=Families have been involved as partners in service planning in fewer than 3 ways
CMHS National Evaluation, Baseline Assessment
Other Agency Staff (L), February 2011
Phase VI
4
14.a.
Have children and youth commonly been involved in service planning? Under what
circumstances do you think it is appropriate for children and youth to participate in their
own service planning?
[If children/youth have been commonly involved:]
14.b.
Please provide specific examples of how children and youth have been involved in:
(F.2.b.)
- identifying and prioritizing their problems or concerns
- developing goals and objectives
- requesting participants in the service planning process
- rejecting participants in the service planning process
- identifying and choosing service options
- rejecting service options
In general, did the process involve children and youth as much as it could have? Could it
have been better?
[Note: If the situation has not come up but it would be possible, assign ½ point.]
5=Children/youth have been involved in service planning in at least 6 ways AND respondent reported that involvement has been sufficient
4=Children/youth have been involved in service planning in 5 ways OR involved in 6 ways but respondent reported it could have been better
3=Children/youth have been involved in service planning in 4 ways
2=Children/youth have been involved in service planning in 3 ways
1=Children/youth have involved in service planning in fewer than 3 ways
666=Early childhood site
Service Provision
Using the Services Card for Interviewing, ask:
15.
Of the services you see listed on this card, which are present in (name of grant program) ‘s
service array? [Refer to the Service Array Card for Interviewing. Clarify that this
means that the service is available to children, youth, and families served by the
grant program regardless of whether the service is in the community or has low
capacity.] (C.3.a.)
[Show the respondent the Service Array Card for Interviewing and read each
service option listed. Have the respondent indicate whether each service was
present in the array since receiving grant funds. On the Service Array Card for
Scoring, place a check in each service that was present.]
Are there any other formal or support services for children, youth, and families not
listed on this card that are part of your community’s service array? Please list.
[Determine whether the service can be coded elsewhere on the list. If not, write
additional services on the Service Array Card for Scoring.]
Use completed Service Array Card for Scoring to score this item
CMHS National Evaluation, Baseline Assessment
Other Agency Staff (L), February 2011
Phase VI
5
5=All required services are in the array AND additional services are also available
4=All required services are in the array BUT no additional service are present
3=Most required services are in the array (1–3 missing) (Presence of additional services is not relevant)
2=Some required services are in the array (4 missing) (Presence of additional services is not relevant)
1=Few required services are in the array (more than 4 missing) (Presence of additional services is not relevant)
16.
Of the services you’ve identified as having been present in (name of grant program) ’s service
array, which have sufficient capacity to meet the needs of all the children, youth,
and/or families who need them? [Circle whether or not each service has sufficient
capacity to meet the need.] (G.7.a.)
[Clarify that insufficient capacity relates to services that some children, youth,
and/or families cannot get at all even though they need them, or that the
respondent does not refer to because of the limited capacity.]
Use completed Service Array Card for Scoring to score this item
5=All services in the array have fully sufficient capacity. All children, youth, and families can get all the services they need
4=Most services in the array (75–95%) have fully sufficient capacity such that all children, youth, and families who need them can get them
3=Many services in the array (50–74%) have fully sufficient capacity such that all children, youth, and families who need them can get them
2=Some services in the array (25–49%) have fully sufficient capacity such that all children, youth, and families who need them can get them
1=Few services in the array (less than 25%) have fully sufficient capacity
17.a.
Of the services in your array, which are provided in the community? [Refer again to
the Service Array Card for Interviewing and circle whether or not each service is
available in the community. Ask respondent to define “community” (e.g.,
neighborhood, city, county, etc.] (G.8.a.)
Use completed Service Array Card for Scoring to score this item
5=All services in the array are provided in the community
4=Most services in the array (75–95%) are provided in the community
3=Many services in the array (50–74%) are provided in the community
2=Some services in the array (25–49%) are provided in the community
1=Few services in the array (less than 25%) are provided in the community
b.
How many children, youth, or families you’ve worked with since grant funds were
received have had to travel outside of their home communities to receive services?
(G.8.a.)
How far have these children, youth, and families had to travel?
5=No children, youth, or families had to leave the community for services
4=Few (1–2) children, youth, or families had to leave the community for services
3=Some (3–4) children, youth, or families had to leave the community for services
2=Many (5–6) children, youth, or families had to leave the community for services
1=Very many (7 or more) children, youth, or families had to leave the community for services
18.a.
Thinking across all of the different children, youth, and families you’ve worked with since
grant funds were received, has it ever been necessary for a child or youth to be
served in a restrictive setting (for example, alternative school, hospital, group home,
etc.)? If yes, please describe. (G.9.a.)
How frequently has this occurred?
b.
In these situations, were any efforts made to transition or move the child or youth
into less restrictive services or settings once appropriate? If so, please describe.
(G.9.a.)
Have these efforts been effective?
CMHS National Evaluation, Baseline Assessment
Other Agency Staff (L), February 2011
Phase VI
6
Have these efforts been sufficient (such that children and youth were transitioned
to less restrictive services/settings as soon as possible)? If no, why not?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
(NOTE TO INTERVIEWER: Questions 19-23 skipped)
Those are all of the questions I have for you. Is there anything that I did not cover that you think
is important for us to know about (name of grant program)?
Thank you for taking the time to answer my questions. Do you have any questions for me?
CMHS National Evaluation, Baseline Assessment
Other Agency Staff (L), February 2011
Phase VI
7
System/Program___________________________
Interviewer____________________________________
Respondent Data Entry #_______________________________
Date_________________________________________
Service Array Card for Scoring
Data
Entry
Service Options
Present in
the array
✔
[Q. 16]
Sufficient
capacity?
[Q. 17]
Provided in the
community?
[Q. 18a]
No
Yes
No
Yes
1
24.
Diagnostic and evaluation services
1
2
1
2
2
25.
Neurological and/or neuro-psychological
assessment
1
2
1
2
3
26.
Outpatient individual counseling
1
2
1
2
4
27.
Outpatient group counseling
1
2
1
2
5
28.
Outpatient family counseling
1
2
1
2
6
29.
Medication management
1
2
1
2
7
30.
Case management/care coordination services
1
2
1
2
8
31.
Respite care
1
2
1
2
9
32.
Professional consultation
1
2
1
2
10
33.
24-hour, 7-day-a-week emergency services,
including mobile crisis outreach and crisis
intervention
1
2
1
2
11
34.
Intensive day treatment services
1
2
1
2
12
35.
Therapeutic foster care
1
2
1
2
13
36.
Therapeutic group home
1
2
1
2
14
37.
Intensive home-based services (e.g., family
preservation services)
1
2
1
2
15
38.
Transition-to-adult services
1
2
1
2
16
39.
Family advocacy and peer support
1
2
1
2
17
40.
Youth advocacy and peer support
1
2
1
2
18
41.
Residential treatment
1
2
1
2
19
42.
Inpatient hospitalization
1
2
1
2
20
43.
Alcohol and Drug Prevention
1
2
1
2
21
44.
Alcohol and Drug Treatment
1
2
1
2
1
2
1
2
Other formal or support services (specify)
22
45.
Note: When scoring, if responses are missing (e.g., don’t know) for more than 3 services in a given column, do not score the item that relates
to that column. Required services are listed as 1 through 16 above.
CMHS National Evaluation, Baseline Assessment
Other Agency Staff (L), February 2011
Phase VI
8
Service Array Card for Interviewing
Service Options
1
Diagnostic and evaluation services
2
Neurological and/or neuro-psychological assessment
3
Outpatient individual counseling
4
Outpatient group counseling
5
Outpatient family counseling
6
Medication management
7
Care management/coordination
8
Respite care
9
Professional consultation
10
24-hour, 7-day-a-week emergency services, including mobile crisis outreach
and crisis intervention
11
Intensive day treatment services
12
Therapeutic foster care
13
Therapeutic group home
14
Intensive home-based services (e.g., family preservation services)
15
Transition-to-adult services
16
Family advocacy and peer support
17
Youth advocacy and peer support
18
Residential Treatment
19
Inpatient hospitalization
20
Alcohol and Drug Prevention
21
Alcohol and Drug Treatment
Other formal or support services (specify)
CMHS National Evaluation, Baseline Assessment
Other Agency Staff (L), February 2011
Phase VI
9
OMB No. 0930-0307
Expiration Date: xx/xx/xx
System/Program__________________________
Reviewer_____________________
CHILD ID#_______________________________
Date_________________________
Site ID#__________________________________
Assessment #_________________
Respondent Data Entry#____________________
M. Care Record/Chart Review
This record review is completed by national evaluation staff and has no public burden associated with it.
1.
What was the date of intake into the grant-funded program?
2.
Through which agency/organization did the child, youth, and family enter the grantfunded program?
1=Mental Health
2=Education
3=Child Welfare
4=Juvenile Justice
5=Public Health
3.
6=Other Health
7=Family Organization
8=Self Referral
9=Other (please describe)___________ ___
888=Unknown
What was the child’s or youth’s most recent diagnosis(es) as given in the chart?
[If Axes not reported, record diagnoses here:
___
]
Axis 1:
Axis 2:
Axis 3:
Axis 4:
Axis 5:
Who assigned the diagnosis(es)?
1=Psychiatrist
2=Psychologist
3=Social Worker
4=Other (please describe)
888=Unknown
4.
Were any of the child or youth’s strengths described in the assessment?
1=No, 2=Yes
Please list:
[Code child’s strengths]
5.
Were any of the family’s strengths described in the assessment?
1=No, 2=Yes
Please list:
[Code family’s strengths]
CMHS National Evaluation, Baseline Assessment
Case Record Review (M), February 2011
Phase VI
1
6.
Were any cultural or linguistic issues discussed in the assessment?
1=No, 2=Yes
Please list:
[Code cultural issues]
7.
Was there an initial service plan filed in the chart?
1=No, 2=Yes
If yes, move on to question 8. If no, go to question 9.
8.
Circle below all who participated in service planning.
(Evidence of participation includes signatures of attendees on the plan, or attendees were listed
or mentioned as being present for the meeting.)
1=Child’s or youth’s caregiver or guardian
2=Child or youth
3=Other family member
4=Case manager/care coordinator
5=Therapist
6=Other mental health staff (e.g., behavioral aide, respite worker)
7=Education staff (e.g., teacher, counselor)
8=Child welfare staff (e.g., caseworker)
9=Juvenile justice (e.g., probation officer)
10=Health staff (e.g., pediatrician, nurse)
11=Family advocate
12=Other (please describe)
13=Other (please describe)
888=Unknown
9.
Was there a subsequent service plan filed in the chart?
1=No, 2=Yes
If yes, move on to question 10. If no, go to question 11.
10.
Circle below all who participated in any subsequent service plan or update. (Evidence of
participation includes signatures of attendees on the plan, or attendees were listed or mentioned
as being present for the meeting.)
1=Child’s or youth’s caregiver or guardian
2=Child or youth
3=Other family member
4=Case manager/care coordinator
5=Therapist
6=Other mental health staff (e.g., behavioral aide, respite worker)
7=Education staff (e.g., teacher, counselor)
8=Child welfare staff (e.g., caseworker)
9=Juvenile justice (e.g., probation officer)
10=Health staff (e.g., pediatrician, nurse)
11=Family advocate
12=Other (please describe)
13=Other (please describe)
888=Unknown
CMHS National Evaluation, Baseline Assessment
Case Record Review (M), February 2011
Phase VI
2
11.
Were child or youth’s strengths integrated into one or more of the initial, subsequent, or
updated service plans? Strengths include such things as child or youth’s competencies,
skills, interests, aspirations.
1=No, 2=Yes, 666=No service plans in chart
Describe:
[Code child’s strengths]
12.
Were any of the family’s strengths integrated into one or more of the initial, subsequent,
or updated service plans? Strengths include such things as the family’s competencies,
skills, interests, aspirations.
1=No, 2=Yes, 666=No service plans in chart
Describe:
[Code family’s strengths]
13.
Were any aspects of the family’s cultural background integrated into any of the service
plans or updates?
1=No, 2=Yes, 666=No service plans in chart
Describe:
[Code cultural issues]
14.
Were any service/treatment plans from other agencies, organizations, or providers found
in the file?
1=No, 2=Yes
If yes, please answer question 15. If no, move on to question 16.
15.
What agencies/organizations had plans in the chart? Circle all that apply.
1=Mental Health
2=Education
3=Child Welfare
4=Juvenile Justice
666=N/A no other plans in chart
16.
5=Public Health
6=Other Health
7=Family Organization
8=Other (please describe)
Was there a safety or emergency plan in the file?
1=No, 2=Yes
CMHS National Evaluation, Baseline Assessment
Case Record Review (M), February 2011
Phase VI
3
SERVICES
Service Type
Service ever
PLANNED?
Service ever
RECEIVED?
Definition
No
Yes
No
Yes
17. Case
Management
Service may include establishing and facilitating
interagency treatment teams, preparing, monitoring and
revising
individual
service
plans,
conducting
assessments, identifying and coordinating multiple
treatment and support services, advocating on behalf of
the child and family, and providing supportive counseling
and outreach services.
1
2
1
2
18. Assessment/
evaluation
Involves an assessment of a child or youth’s
psychological, social and behavioral strengths and
challenges in order to determine the extent and nature of
a child or youth condition. This service is typically
performed by a psychologist or psychiatrist. Types of
assessment may include neurological, psychosocial,
educational and vocational.
1
2
1
2
19. Crisis
stabilization
Interventions designed to stabilize a child or youth
experiencing acute emotional or behavioral difficulties.
Services may include the development of crisis plans, 24hour telephone support, short-term counseling, mobile
outreach services to children and families, intensive inhome support during crisis, and short-term emergency
residential services.
1
2
1
2
20. Family
preservation services
An intensive combination of therapeutic and support
services provided to the child, youth, and/or family within
the home typically for the purpose of averting out-of-home
placement. May include therapy and enhancement of
conflict resolution and communication skills.
1
2
1
2
21. Individual
therapy for child or
youth
Therapeutic intervention with a child or youth that relies
on interaction between therapist/clinician and child or
youth to promote psychological and behavior change.
Includes a variety of approaches (e.g., behavior,
psychodynamic, cognitive, family systems) provided
outside of the home.
1
2
1
2
22. Group therapy
for child or youth
Therapeutic intervention with a child or youth that relies
on interaction among a group of children or youth,
facilitated by a clinician/therapist to promote psychological
and behavior change.
1
2
1
2
23. Parent/family
therapy
Therapeutic family oriented services provided to
caregivers and siblings with or without the child or youth
present (e.g., individual/group therapy, family therapy,
multi-family therapy).
1
2
1
2
24. Day treatment or
therapeutic day camp
Intensive, non-residential service that provides an
integrated array of counseling, education, and/or
vocational training which involves a child or youth for at
least 5 hours a day, for at least 3 days a week. Day
treatment may be provided in a variety of settings
including: schools, mental health centers, hospitals or in
other community locations.
1
2
1
2
25. Therapeutic
camp (residential)
Involves children/youth and staff living together in a
wilderness or other camp environment often located
outside of the community in which the child resides.
Treatment focuses on group process and social skills
development.
1
2
1
2
CMHS National Evaluation, Baseline Assessment
Case Record Review (M), February 2011
Phase VI
4
SERVICES
Service ever
PLANNED?
Service ever
RECEIVED?
Service Type
Definition
No
Yes
No
Yes
26. Medication
treatment/ monitoring
for child or youth
Prescription of psychoactive medications by a physician
or other qualified health care specialist to a child/youth
designed to alleviate symptoms and promote
psychological growth. Treatment includes periodic
assessment and monitoring of the child’s reaction(s) to
the drug.
1
2
1
2
27. Inpatient
hospitalization
Residential placement of child/youth in inpatient hospital
setting for observation, evaluation and/or treatment. This
treatment is characterized by a strong medical orientation
and 24-hour nursing supervision and is often used for
short-term treatment and crisis stabilization or to conduct
comprehensive evaluations where specialized medical
tests are warranted.
1
2
1
2
28. Residential
treatment center
Treatment provided in secure residential facilities that
typically serve 10 or more children or youth, provide 24hour staff supervision, and can provide a full array of
treatment interventions and approaches including
individual therapy, group and family therapy, behavior
modification, skills development, education and
recreational services.
1
2
1
2
29. Foster care
Non-treatment oriented alternative living situation for
children and youth who cannot live with their families.
Foster care provides a home environment with a daily
living routine and supervision.
1
2
1
2
30. Therapeutic
foster care
Out-of-home placement of a child/youth with foster
caregiver(s) who are especially trained to care for children
and youth with emotional and/or behavioral problems.
Therapeutic foster care employs a variety of treatment
approaches and includes supportive counseling, crisis
back-up, behavior management and social development.
1
2
1
2
31. Therapeutic
group home
Out-of-home placement of a child/youth in a home-like
setting with 3–10 children or youth with emotional and/or
behavior problems. Therapeutic care employs a variety of
treatment
approaches
and
includes
supportive
counseling, crisis back-up, behavior management and
social and independent living skill development.
1
2
1
2
32. Independent
living
Services designed to prepare older adolescents to live
independently and reduce reliance on the service system.
Services may include social and community living skills
development, peer support and counseling. May also
include independent living expenses used for monthly
rent, apartment deposits, utility deposits, moving
expenses, etc.
1
2
1
2
33. Attendant care
Supervision of a child or youth with serious emotional or
behavioral challenges by trained adults in-home or out-ofhome who offer supervision and support and may assist
with other household chores, tutoring, or recreational
activities.
1
2
1
2
34. Family/sibling
support or
wraparound services
Non-therapeutic and support services provided to
caregivers or siblings (e.g., family activities) not including
recreational activities, transportation services or respite
care.
1
2
1
2
CMHS National Evaluation, Baseline Assessment
Case Record Review (M), February 2011
Phase VI
5
SERVICES
Service Type
Service ever
PLANNED?
Service ever
RECEIVED?
Definition
No
Yes
No
Yes
35. Recreational
activities
Use of community recreation resources (e.g., YMCA or
other physical fitness activities, youth sports programs,
karate classes, etc.), summer camps (with no treatment
component), club memberships and other recreational
projects.
1
2
1
2
36. Respite care
A planned break for families who are caring for a child or
youth with a serious emotional or behavioral disturbance
where trained parents or counselors assume the duties of
caregiving for a brief period to allow the parent/caregivers
a break. The service may be provided in the child’s home
or in other community locations.
1
2
1
2
37. Transportation
Includes providing transportation to appointments and
other scheduled services and activities, reimbursement
for public transportation, van rentals, etc.
1
2
1
2
38. Other formal
services
Specify:
1
2
1
2
39. Other informal
support services
Specify:
1
2
1
2
CMHS National Evaluation, Baseline Assessment
Case Record Review (M), February 2011
Phase VI
6
OMB No. 0930-0307
Expiration Date: xx/xx/xx
System/Program__________________________
Interviewer___________________
Site ID#_________________________________
Date________________________
Respondent Data Entry#____________________
Assessment #_________________
N. Other Staff
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
To be used with staff representing other child-serving sectors or agencies involved with children/families
also served by the grant. This guide should NOT be used with those (including subcontractors) who
are DIRECTLY involved in providing mental health related services to children/families (for
example, therapists, behavioral aides, respite staff, day treatment staff, crisis intervention staff,
psychologists, counselors, etc.). These staff should be interviewed with the G. guide. Direct service
providers from partner agencies such teachers, probation officers, child welfare case workers, and public
health nurses should be interviewed using the L. guide.
[Note to interviewer: Review Consent form with respondent and obtain signature before
proceeding with the interview]
Introduction
1.
Please briefly describe your agency/organization and its relationship with
grant program) .
(name of
What kinds of services does your agency/organization provide — what does your
organization do?
2.
How long have you been working with this agency/organization?
3.
Since CMHS grant funds were received, what kinds of services or support has your
agency provided to children, youth, and families served by (name of grant program) ? What
services do you provide?
4.
Since grant funds were received, what percentage of children, youth, and families
served by your organization have also been involved with (name of grant program) ?
5.
Since grant funds were received, how have children, youth, and families been referred
or sent to you/your organization for services?
Could any person, agency, or provider refer children, youth, and families to you for
services? If no, why not?
CMHS National Evaluation, Baseline Assessment
Other Agency Staff (N), February 2011
Phase VI
1
6.
Has your or your organization’s involvement with
(name of grant program)
changed
--your operations, how your organization does business?
--how your organization serves children, youth, and families?
7.
Since grant funds were received, have you received or participated in any training
sessions provided as part of (name of grant program) activities?
If yes, please describe the topics or content areas covered. [Probe on CASSP
principles such as family involvement, cultural and linguistic competency,
individualized care, strengths-based care, etc.]
8.
How has information been shared or communicated between you/your
organization and (name of grant program) (e.g., memos, shared staff meetings, via the
interagency structure, etc.)?
9.
What kinds of information have you/your organization typically RECEIVED from
(e.g., information on children, youth, and families served, information
regarding grant policies and procedures, etc.)?
(name of grant program)
10.
What kinds of information have you provided TO the (name of grant program) (e.g.,
information on children, youth, and families served, information regarding organization
policies and procedures, etc.)?
11.
Are there any mechanisms in place to facilitate collaboration between you/your
organization and (name of grant program) (e.g., interagency committees, special task forces,
etc.)?
12.
Are there any mechanisms in place to facilitate the coordination of services that
you/your organization provides, the services provided by (name of grant program) , and
other organizations in the community who serve children, youth, and families (e.g.,
joint or shared service planning meetings, etc.)?
Have you or any of the staff from your organization participated in service planning
meetings at (name of grant program) ? If yes, how frequently? What was your role in those
meetings?
13.
Have you/your organization put any mechanisms in place to encourage family
involvement as full partners in services?
14.
Have you/your organization put any mechanisms in place to enhance cultural and
linguistic competency?
Those are all of the questions I have for you. Is there anything that I did not cover that you think
is important for us to know about (name of grant program)?
Thank you for taking the time to answer my questions. Do you have any questions for me?
CMHS National Evaluation, Baseline Assessment
Other Agency Staff (N), February 2011
Phase VI
2
System/Program__________________________
Interviewer___________________
Date________________________
O. Debriefing Document
I.
Date of Debriefing
II.
Participants
III.
Infrastructure Level: Choose from any of the following areas: Governance,
Management and Operations, Service Array, or Program Evaluation — 2 strengths and
2 areas for enhancement.
Strength (1)
Strength (2)
Area for Enhancement (1)
Area for Enhancement (2)
IV.
Service Delivery: Choose from any of the following areas: Entry, Service Planning,
Service Provision, Care Review — 2 strengths and 2 areas for enhancement.
Strength (1)
Strength (2)
Area for Enhancement (1)
Area for Enhancement (2)
CMHS National Evaluation, Baseline Assessment
Debriefing Document (O), February 2011
Phase VI
1
V.
Notes on Debriefing meeting
- What did the grant community like?
- What didn’t they like?
- Did they find the meeting helpful?
- Is there anything else they wanted more information on or about?
CMHS National Evaluation, Baseline Assessment
Debriefing Document (O), February 2011
Phase VI
2
OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
System/Program__________________________
Interviewer___________________
Site ID#_________________________________
Date________________________
Respondent Data Entry#____________________
Assessment #_________________
Q. Youth Coordinator
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
Hello, my name is
. Thank you for taking time today to help us. I’ll be asking
you questions about how youth are involved in the (name of grant program). Before we start, I
want to make sure that you know that the information you give me today will be kept
private and will not be shared with the (name of grant program). In our report, everyone’s
answers will be combined and the people who gave us the information will not be
identified.
[Note to interviewer: Review Consent form with respondent. Ascertain age of respondent to
determine consent to participate (must be 18). Obtain respondent signature before proceeding
with the interview]
Background Information
1.
What is the structure of (name of grant program), and how does the youth component fit in it?
2.
Since grant funds were received, what supports has the (name of grant program) provided to
the youth component? [Probe for financial, materials, training, supervision,
monitoring, etc.]
3.
Do you participate in the (governing body)?
1=No If no, go to Question 7
2=Yes If yes, continue
Governance
4.
Since grant funds were received, to what extent do you think youth have been actively
involved in the (governing body)? [Probe for examples of participation in the
(governing body)’s functions such as committee membership, strategic planning,
budget discussions, service array development]. (A.2.a.)
a.
How have youth been regarded and treated by other participants of the
(governing body)? (A.2.a.)
Has that been the same for all participants, or have some participants demonstrated
respect, acceptance, and value for youth input more than others?
CMHS National Evaluation, Baseline Assessment
Youth Coordinator (Q), February 2011
Phase VI
1
5=All participants were very respectful, accepted, and highly valued youth input
4=Most participants were very respectful and valued youth input and the rest were moderately respectful
3=Some participants were very respectful and valued youth input and the rest were moderately respectful
2=Few participants were very respectful and valued youth input and most others were at least somewhat respectful
1=No or almost no participants were respectful or valued youth input
b.
What percentage of (governing body) meetings have youth attended? (A.2.a.)
5=Attended 90% to 100% of meetings
4=Attended 75% to 89% of meetings
3=Attended 50% to 74% of meetings
2=Attended 25% to 49% of meetings
1=Attended less than 25% of meetings
5.
Since grant funds were received, when and where have the (governing body) meetings
been held? Have the locations and times been convenient for youth? (A.2.c.)
On a scale of 1 to 5, with 5 being the most convenient, how would you rate the
convenience of the meetings for youth to attend?
Respondent’s rating
5=Extremely convenient
4=Very convenient
3=Moderately convenient
2=Somewhat convenient
1=Not at all convenient
6.
Interviewer’s rating
5=Extremely convenient
4=Very convenient
3=Moderately convenient
2=Somewhat convenient
1=Not at all convenient
Since grant funds were received, has the (governing body) provided anything to youth to
make it easier for them to participate in the (governing body)? Please provide examples.
[Probe for whether transportation, stipends/compensation, food, childcare, training,
written/oral language interpretation or translation were provided]. (A.2.d.)
If yes, have these things made a difference for youth?
If no, would it be helpful to youth if there were some type of support?
Is there anything else that could be done to make it easier for youth to participate?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
Management and Operations
7.
Since grant funds were received, have efforts been made to involve youth in program
operations such as providing staff training, serving as volunteer or paid program staff, peer
mentors, youth group leaders, attending management meetings, etc? (B.2.a.)
If yes, please describe all of the different ways youth have been involved.
[Note: Do not count involvement in governing body, evaluation, or conducting outreach activities.]
[Continue to probe for examples until the respondent reports no more.]
[Data entry: code ways]
CMHS National Evaluation, Baseline Assessment
Youth Coordinator (Q), February 2011
Phase VI
2
5=Four examples of youth involvement in program operations
4=Three examples of youth involvement in program operations
3=Two examples of youth involvement in program operations
2=One example of youth involvement in program operations
1=No examples of youth involvement in program operations
8.
Since grant funds were received, has the (name of grant program) used youth to provide training
to other youth or adults about youth concerns/issues or how to work with youth?
What type of training was it and to whom was it given?
9.
Has the (name of grant program) provided any training to youth about the service system?
[Probe for training on how the system operates, its purpose, youth involvement and
development opportunities, and youth rights?
Service Array
10.
Since grant funds were received, have there been support services available to youth?
Please describe. [Probe for advocacy, youth group, mentoring, informal peer-to-peer
support, etc.]
(NOTE TO INTERVIEWER: Questions 11-13 skipped)
Entry into Services
Now, let’s talk about when youth first enter (name of grant program). We are interested in their
involvement in the enrollment process, as well as your perspective on the process as a
youth coordinator.
14.
Since grant funds were received, have efforts been made by (name of grant program) to reach out
to youth in your community to inform them about the project and available services? If yes,
please describe. (E.7.a.)
[Data entry: code outreach activities]
Have these efforts been effective? If yes, how?
Have these efforts been sufficient to ensure that all youth who need
know that it is here?
(name of grant program)
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made but have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
15.
Since grants funds were received what has been the process of engaging and informing
youth about (name of grant program) and the services available to them through it?
As youth coordinator, have you been you involved in this process? If yes, how?
16.
What efforts have been made to ensure that the process and information are easy for youth
to understand? [Probe for language level, youth-friendly, etc.] (E.2.a.)
Have these efforts been effective? If yes, how?
CMHS National Evaluation, Baseline Assessment
Youth Coordinator (Q), February 2011
Phase VI
3
Have they been sufficient?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made but have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
Do you participate in the service planning meetings?
1=No If no, go to Question 18
2=Yes If yes, continue
Service Planning
17.
.
Since grant funds were received has (name of grant
planning and developing their own plans of care?
program)
involved children and youth in
Please provide specific examples of how you have observed children and youth to be
involved in: (F.2.a.)
- identifying and prioritizing their problems or concerns
- developing goals and objectives
- requesting participants in the service planning process
- rejecting participants in the service planning process
- identifying and choosing service options
- rejecting service options
In general, has the process involved children and youth as much as it could have? If
no, in what ways could it have been better?
[Note: If the situation has not come up but it would be possible, assign ½ point.]
5=Children/youth have been involved in service planning in at least 6 ways AND respondent reported that involvement has been sufficient
4=Children/youth have been involved in service planning in 5 ways OR involved in 6 ways but respondent reported it could have been better
3=Children/youth have been involved in service planning in 4 ways
2=Children/youth have been involved in service planning in 3 ways
1=Children/youth have involved in service planning in fewer than 3 ways
Summary
18.
On a scale from 1 to 5, with 5 being the best, how much would you say (name of grant program)
has helped young people?
5=Very much
4=A lot
3=Moderately
2=Somewhat
1=Not at all
19.
Do you have any suggestions or recommendations for how (name of grant program) could
improve the way that it serves youth and their families?
CMHS National Evaluation, Baseline Assessment
Youth Coordinator (Q), February 2011
Phase VI
4
Those are all of the questions I have for you. Is there anything that I did not cover that you think is
important for us to know about (name of grant program)?
Thank you for taking the time to answer my questions. Do you have any questions for me?
CMHS National Evaluation, Baseline Assessment
Youth Coordinator (Q), February 2011
Phase VI
5
OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
System/Program__________________________
Interviewer___________________
Site ID#_________________________________
Date________________________
Respondent Data Entry#____________________
Assessment #_________________
R. Cultural and Linguistic Competence Coordinator
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
This interview is to be administered to the staff person who has the authority and responsibility for
assisting leadership, management staff, families, youth, contractors and all other system partners in
ensuring culturally and linguistically competent practices in all aspects of the system of care.
[Note to interviewer: Review Consent form with respondent and obtain signature before
proceeding with the interview]
Are you a member of or attend meetings of the (governing body)?
1=No If no, go to Question 3
2=Yes If yes, continue
Governance
1.
Since grant funds were received, what efforts has the (governing body) made to promote
the cultural and linguistic competence of the (name of grant program)? (A.4.b.)
Probe for efforts to:
-develop, review, and implement a cultural and linguistic competence plan
-set agenda items that discuss cultural and linguistic competence efforts
and issues
-establish a cultural and linguistic sub-committee
-help develop and review policies that promote culturally and linguistically
competent practices
-develop and approve budget items that promote culturally and
linguistically competent practices and efforts
-encourage diversity within the governing body
CMHS National Evaluation, Baseline Assessment
Cultural Competence Coordinator (R), February 2011
Phase VI
1
How effective have these efforts been? Explain.
Have these efforts been sufficient? What more could be done?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
2.
Since grant funds were received, what efforts have been made to ensure cultural and
linguistic competence of the (governing body)? (A.4.c.)
Probe for efforts to:
- accommodate language preferences of all governing body members and
meeting attendees
- conduct meetings in clear and understandable language that meets the
needs of members and attendees
- develop and use meeting protocols and communications that are
respectful of various cultures regarding race, ethnicity, lifestyle, gender,
age, and ability differences
-develop a cultural competence plan
- other - please describe
How effective have these efforts been? Explain.
Have efforts been sufficient to meet the cultural and linguistic needs of the governing
body members and attendees?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
Management and Operations
3.
Since grant funds were received, what efforts have been made to ensure that cultural
and linguistic competence standards are integrated into the (name of grant program)’s
management and operations? (B.4.b.)
Probe for efforts to:
-develop and implement a cultural and linguistic plan
-include a line-item on the program budget to implement the cultural and
linguistic plan
CMHS National Evaluation, Baseline Assessment
Cultural Competence Coordinator (R), February 2011
Phase VI
2
- establish policies and procedures to identify the cultural and linguistic
needs of the intended and served population, staff, and service providers
- ensure a range of oral and written language assistance options is
available across the service system
- develop and implement a plan for providing written program materials in
languages other than English
- ensure mechanisms are in place to notify persons with limited English
proficiency of the right to free language assistance
-train and monitor direct service staff, their supervisors, and service
providers on the provision of cultural and linguistic competent care
- other - please describe
How effective have these efforts been? Explain.
Have efforts been sufficient to ensure cultural and linguistic competence of the
program’s management and operations?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
4.
Have any efforts been made to hire, retain and/or contract with a pool of staff and
service providers who reflect the cultural and linguistic background (for example,
race, ethnicity, language, gender) of the children, youth, and families you serve? (B.4.c.)
How effective have these efforts been? Explain.
Have efforts been sufficient to hire and/or contract with the number or type of staff
and service providers needed to meet the cultural and linguistic needs of populations
served?
[Note: If staff are already in place, i.e., no hiring was necessary, probe for diversity of staff vis population served.]
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
Service Array
5.
Since grant funds were received, how has the cultural and linguistic background of
the children, youth, and families you serve been considered in developing the
service array to assure that available service and treatment options align with the
culture of the children, youth, and families served including issues such as race,
ethnicity, gender, lifestyle, age, and ability? (C.4.a.)
CMHS National Evaluation, Baseline Assessment
Cultural Competence Coordinator (R), February 2011
Phase VI
3
Have cultural organizations, community groups, etc. been involved in efforts such
as providing services, developing the service array, advising providers, etc.?
Have you added or modified any services to address the cultural and linguistic
needs of specific groups?
How effective have these efforts been, and in what ways?
Have efforts been sufficient to address the cultural and linguistic needs of all
groups? Are some groups’ needs still unmet? [Probe for specific groups.]
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
(NOTE TO INTERVIEWER: Questions 6-13 skipped)
Those are all of the questions I have for you. Is there anything that I did not cover that you think
is important for us to know about (name of grant program)’s cultural and linguistic competence
activities?
Thank you for taking the time to answer my questions. Do you have any questions for me?
CMHS National Evaluation, Baseline Assessment
Cultural Competence Coordinator (R), February 2011
Phase VI
4
OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
System/Program__________________________
Interviewer___________________
Site ID#_________________________________
Date________________________
Respondent Data Entry#____________________
Assessment #_________________
S. Social Marketing-Communications Manager
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
This interview is to be administered to the staff person who is responsible for developing a
comprehensive social marketing/communications strategy for the system of care community,
including a social marketing strategic plan, public education activities and overall outreach activities.
[Note to interviewer: Review Consent form with respondent and obtain signature before
proceeding with the interview]
Overview
1.
What is the name of the agency that employs you?
What is your position/title?
2.
Are you involved in any structured social marketing efforts?
If yes, what is your role?
3.
Briefly describe the (name of grant program) ’s social marketing efforts. What types of social
marketing activities have you engaged in during the past year?
4.
How are these activities structured and organized?
5.
How have program evaluation information and data been used in social marketing
activities?
6.
Since grant funds were received, have any social marketing activities focused on
stigma reduction? If so, please describe.
7.
How are family representatives and members of the intended service population
involved in social marketing activities for (name of grant program)?
8.
How are youth involved in social marketing activities for (name of grant program) ?
9.
Have there been any efforts to involve other child-serving agencies in social
marketing activities?
CMHS National Evaluation, Baseline Assessment
Social Marketing Manager (S), February 2011
Phase VI
1
If yes, which agencies have been involved and in what roles?
1 = Mental Health
2 = Education
3 = Child Welfare
4 = Juvenile Justice
5 = Public Health
6 = other (describe)
[circle all that apply]
10.
What efforts have been made to ensure that social marketing activities are culturally
and linguistically competent?
Have these efforts been effective in getting you closer to the goal of having a culturally
and linguistically competent social marketing process?
Do you think these efforts have been sufficient? What else could be done?
Outreach
11.
Since grant funds were received, have there been any outreach efforts to inform your
intended service population about (name of grant program) and its services? (E.7.a.)
[Data entry: code outreach efforts]
How effective have the outreach efforts been? For example, have you seen an increase
in calls to (name of grant program) or an increase in awareness or interest in the community?
Explain.
Have these efforts been sufficient, that is, has
everyone?
(name of grant program)
been able to reach
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
12.
Since grant funds were received, have there been any outreach efforts to inform
other agencies, community-based providers, private providers, family
organizations, primary health care providers, etc. about the (name of grant program) and
its services? (E.6.a.)
How effective have these efforts been, and in what way?
Have these efforts been sufficient to ensure that all providers and organizations have
been aware of (name of grant program) ?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
13.
Since grant funds were received, have there been any outreach efforts to specific
cultural groups or populations? (E.4.a.)
CMHS National Evaluation, Baseline Assessment
Social Marketing Manager (S), February 2011
Phase VI
2
How effective would you say these efforts have been? For example, have you seen an
increase in interest or awareness?
Have these efforts been sufficient? What more could be done?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
14.
Since grant funds were received, how have you used social marketing activities to
share information about (name of grant program) with other agencies and organizations
that serve children, youth, and families? (B.6.a.)
[Data entry: code mechanisms]
Have these mechanisms been effective? If yes, in what ways?
Have these efforts been sufficient? What more could be done?
5=Efforts made have been very effective and sufficient to accomplish larger goals; no or only minor additional efforts needed
4=Efforts made have been moderately effective but not sufficient to accomplish larger goal; some additional efforts needed
3=Efforts made have been somewhat effective but not sufficient to accomplish larger goal; considerable additional efforts needed
2=Efforts have been made BUT have not been effective or have been minimally effective
1=No or almost no effort has been made toward accomplishing larger goal
(NOTE TO INTERVIEWER: Question 15 skipped)
16.
What options are available for conducting social marketing activities in languages
other than English?
Those are all of the questions I have for you. Is there anything that I did not cover that you think
is important for us to know about the social marketing efforts of (name of grant program)?
Thank you for taking the time to answer my questions. Do you have any questions for me?
CMHS National Evaluation, Baseline Assessment
Social Marketing Manager (S), February 2011
Phase VI
3
Attachment C: Cross-Sectional Descriptive Study
NOTE TO OMB REVIEWER:
No burden is attached to this instrument. It is included here for illustrative purposes only.
ENROLLMENT AND DEMOGRAPHIC
INFORMATION FORM (EDIF)
/
EDIFDATE (Today’s date)
Month
/
Day
Year
CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)
A. Sources of information used to complete this
form [Select all that apply]
1 = Caregiver (child’s caregiver in a family,
household environment)
2 = Staff as Caregiver (staffperson who has acted
as the child’s day-to-day caregiver for the
majority of the past 6 months)
3 = Youth
4 = Case record review
5 = Other
B. Agency that the child is currently involved
with [Select all that apply]
1 = Corrections
2 = Juvenile court
3 = Probation
4 = School
5 = Mental health agency/clinic/provider
6 = Physical health care agency/clinic/provider
7 = Public child welfare
8 = Substance abuse agency/clinic/provider
9 = Family court
10 = Early care: Early Head Start program
11 = Early care: Head Start program
12 = Early care: Early intervention (Part C)
13 = Early care: Preschool special education
program (Part B)
14 = Early care: Other early care and education
programs/providers (including
childcare/providers)
15 = Other—please specify
__________________________
[If 7 = Public child welfare not selected above, go
to Item C.]
Date last modified: December 2009
1 = Intake
B1. Child welfare involvement
1 = Receiving child abuse and neglect
investigation/assessment
2 = Court-ordered out-of-home placement—
Foster care
3 = Court-ordered out-of-home placement—
Kinship care
4 = Court-ordered out-of-home placement—
Residential treatment
5 = Voluntary out-of-home placement— Foster
care
6 = Voluntary out-of-home placement— Kinship
care
7 = Voluntary out-of-home placement—
Residential treatment
8 = Court-ordered in-home services
9 = Voluntary in-home services
C. Agency or individual who referred child to the
program [Select primary referral agency]
1 = Corrections
2 = Juvenile court
3 = Probation
4 = School
5 = Mental health agency/clinic/provider
6 = Physical health care agency/clinic/provider
7 = Public child welfare
8 = Tribal child welfare agency
9 = Substance abuse agency/clinic/provider
10 = Family court
11 = Caregiver
12 = Self (youth referred himself or herself)
13 = Early care: Early Head Start program
14 = Early care: Head Start program
15 = Early care: Early intervention (Part C)
16 = Early care: Preschool special education
program (Part B)
17 = Early care: Other early care and education
programs/providers (including
childcare/providers)
18 = Other—please specify
__________________________
666 = Not applicable
777 = Refused
888 = Don’t know
999 = Missing
Date last modified: December 2009
CHILD ID:
SECTION I.
1.
Enrollment and Demographic Information Form (EDIF)
Child Demographic Information
/
What is (child’s name) date of birth?
Month
2.
/
Day
Year
With which gender does (child’s name) identify?
1 = Male
2 = Female
3 = Transgender (male to female)
4 = Transgender (female to male)
5 = I don’t know/I’m not sure
6 = Other—please specify ____________________________________________
3.
Is (child’s name) of Hispanic, Latino, or Spanish origin?
1 = No
2 = Yes, Mexican, Mexican American, or Chicano
3 = Yes, Puerto Rican
4 = Yes, Cuban
5 = Yes, another Hispanic, Latino, or Spanish origin—please specify
____________________________________
4.
What is (child’s name)’s race? [Select one or more]
1 = White
2 = Black or African American
3 = American Indian or Alaska Native—please specify enrolled or principal tribe
____________________________________
4 = Asian Indian
5 = Chinese
6 = Filipino
7 = Japanese
8 = Korean
9 = Vietnamese
10 = Other Asian—please specify race (for example, Hmong, Laotian, Thai, Pakistani,
Cambodian, and so on) ____________________________________
11 = Native Hawaiian
12 = Guamanian or Chamorro
13 = Samoan
14 = Other Pacific Islander—please specify race (for example, Fijian, Tongan, and so
on) ____________________________________
5.
What is the ZIP Code of the address where (child’s name) currently lives?
_______________
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
1
CHILD ID:
6.
Enrollment and Demographic Information Form (EDIF)
What were the problems leading to (child’s name) being referred for services? [Select all that
apply]
1 = Suicide-related problems (including suicide ideation, suicide attempt, self-injury)
2 = Depression-related problems (including major depression, dysthymia, sleep disorders,
somatic complaints)
3 = Anxiety-related problems (including fears and phobias, generalized anxiety, social
avoidance, obsessive–compulsive behavior, posttraumatic stress disorder)
4 = Hyperactive and attention-related problems (including hyperactive, impulsive,
attentional difficulties)
5 = Conduct/delinquency-related problems (including physical aggression, extreme verbal
abuse, noncompliance, sexual acting out, property damage, theft, running away, sexual
assault, fire setting, cruelty to animals, truancy, police contact)
6 = Substance use, abuse, and dependence-related problems
7 = Adjustment-related problems (including changes in behaviors or emotions in reaction to
a significant life stress)
8 = Psychotic behaviors (including hallucinations, delusions, strange or odd behaviors)
9 = Pervasive developmental disabilities (including autistic behaviors, extreme social
avoidance, attachment disorder, stereotypes, perseverative behavior)
10 = Specific developmental disabilities (including enuresis, encopresis, expressive or
receptive speech and language delay)
11 = Learning disabilities
12 = School performance problems not related to learning disabilities
13 = Eating disorders (including anorexia, bulimia)
14 = Gender identity
15 = Feeding problems in young children (including failure to thrive)
16 = Disruptive behaviors in young children (including aggression, severe defiance, acting
out, impulsivity, recklessness, and excessive level of overactivity)
17 = Persistent noncompliance (when directed by caregivers/adults)
18 – Excessive crying/tantrums
19 = Separation problems
20 = Non-engagement with people
21 = Sleeping problems
22 = Excluded from preschool or childcare program, not related to learning disabilities
(including behavioral issues, repeated noncompliance)
23 = At risk for or has failed family home placement
24 = Maltreatment (child abuse and neglect)
25 = Other problems that are related to child’s health (cancer, illness, or disease-related
problems)
26 = High-risk environment: Maternal depression
27 = High-risk environment: Maternal mental health (other than depression)
28 = High-risk environment: Paternal mental health
29 = High-risk environment: Caregiver mental health (other than maternal or paternal)
30 = High-risk environment: Maternal substance abuse/use
31 = High-risk environment: Paternal substance abuse/use
32 = High-risk environment: Caregiver substance abuse/use (other than maternal or
paternal)
33 = High-risk environment: Family health problems (maternal, paternal, caregiver, or
other family member)
34 = High-risk environment: Other parent/caregiver/family problems
35 = High-risk environment: Problems related to housing (including homelessness)
36 = Other—please specify ____________________________________
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
2
CHILD ID:
7.
Enrollment and Demographic Information Form (EDIF)
During the past 6 months, was (child’s name) the recipient of . . . ? [Select all that apply]
1 = Medicaid
2 = CHIP
3 = SSI
4 = TANF
5 = Private insurance
6 = Other—please specify ____________________________________
Children and youth may have diagnostic codes for more than one classification system. Section II
addresses diagnostic classification for DSM–IV–R and/or ICD–9 only. Because all children and youth
served in systems of care must have diagnostic information, diagnostic codes for younger children (i.e.,
codes for the Revised DC:0–3) may be entered in Section IV.
8.
Does (child’s name) have a DSM–IV–R or ICD–9 diagnosis?
1 = No [GO TO QUESTION #13]
2 = Yes
SECTION II. Child Diagnostic Information: DSM–IV–R and ICD–9
In this section, please record the DSM–IV–R or ICD–9 diagnostic codes in the indicated fields. When
entering diagnostic codes, please use the following prefixes in front of the codes without spaces:
DSM–IV–R — DSM
ICD–9 — ICD
Examples: A DSM–IV–R diagnosis of Alcohol-Induced Anxiety Disorder should be entered as
DSM291.89. An ICD–9 diagnosis of Drug-Induced Delirium should be entered as ICD292.81.
The entire list of diagnostic codes is available in PDF format for your reference.
9.
Has diagnostic evaluation been done as part of the intake into the system of care program?
1 = No
2 = Yes
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
10.
Date of the most recent multiaxial diagnostic evaluation
________________________________
(mm/dd/yyyy)
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
3
CHILD ID:
11.
Enrollment and Demographic Information Form (EDIF)
Who provided the diagnosis?
1 = Child psychiatrist
2 = General psychiatrist
3 = Child psychologist
4 = General psychologist
5 = Licensed mental health staff (clinical social worker/professional counselor/
therapist)
6 = Primary care physician
7 = Nurse practitioner/psychiatric nurse practitioner/physician’s assistant
8 = Other licensed physical health staff
9 = Unlicensed staff (mental health assessment specialist)
10 = Other—please specify ____________________________________
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
[Primary diagnosis should be listed as the first diagnosis on each axis (1a, 2a).]
12.
AXIS I: Clinical Disorders
Diagnostic code
DSM–IV–R name
axis_1a
_________.____
_________________________________________
axis_1b
_________.____
_________________________________________
axis_1c
_________.____
_________________________________________
AXIS II: Personality Disorders and Mental Retardation
Diagnostic code
DSM–IV–R name
axis_2a
_________.____
_________________________________________
axis_2b
_________.____
_________________________________________
AXIS III: General Medical Condition (ICD–9–CM numeric code)
[Separate multiple codes with commas]
ICD–9–CM numeric code
axis 3 ______________________________________________________________________
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
4
CHILD ID:
Enrollment and Demographic Information Form (EDIF)
AXIS IV: Psychosocial and Environmental Problems [Select all that apply]
1 = Problems with primary support group
2 = Problems related to the social environment
3 = Educational problems
4 = Occupational problems
5 = Housing problems
6 = Economic problems
7 = Problems with access to health care services
8 = Problems related to interaction with the legal system/crime
9 = Other psychosocial and environmental problems
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
AXIS V: Global Assessment of Functioning Scale (GAF)
[Enter current GAF score]
_______________
SECTION III. Child Enrollment Information
13.
Date of child’s assessment for system of care eligibility
________________________________
(mm/dd/yyyy)
13a. System of care enrollment status of the child
1 = Child is receiving, or has received, a service that is provided through the system of
care (e.g., assessment, crisis intervention, etc.) but is NOT eligible for additional
system of care services [GO TO QUESTION #17]
2 = Child has received a system of care service and is eligible for additional services
but will NOT be receiving any additional services [GO TO QUESTION #17]
3 = Child is eligible for system of care services and is receiving, or about to receive,
system of care services [GO TO QUESTION #13b]
13b. Date of the child’s first service (after assessment for system of care eligibility) received
through the system of care
________________________________
(mm/dd/yyyy)
[Questions #13c–13e are skipped, as they are not applicable at intake.]
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
5
CHILD ID:
Enrollment and Demographic Information Form (EDIF)
13f. If the child is younger than age 6, how was system of care eligibility determined?
1 = Child has an emotional, socio-emotional, behavioral, or mental disorder
diagnosable under the DSM–IV or its ICD–9–CM equivalents, or subsequent
revisions, or under the Diagnostic Classification of Mental Health and
Developmental Disorders of Infancy and Early Childhood–Revised (DC:0–3R)
[GO TO QUESTION #14]
2 = Child (aged birth through 3 years) has a DC:0–3R Axis II Relationship Disorder
and a PIRGAS score of 40 or below indicating a Relationship Disorder in the
“Disturbed” category. [GO TO QUESTION #14]
3 = Child (aged birth through 5 years) was assessed using a standardized instrument
such as the BABES, Strengths and Difficulties Questionnaire, or Vineland
Screener, and was judged by a licensed professional to be at “imminent risk” for
developing a mental health or serious emotional disorder. [GO TO QUESTION
#13g]
4 = Not applicable, as the child is aged 6 or older. [GO TO QUESTION #14]
13g. Which standardized instrument(s) were used to assess system of care eligibility? [Select all
that apply]
1 = Behavioral Assessment of Baby’s Emotional and Social Style (BABES)
2 = Strengths and Difficulties Questionnaire
3 = Family Resource Scale
4 = Vineland Screener
5 = Other—please specify ____________________________________
14.
Who participated in the development of the service plan? (Evidence of participation includes
signatures of attendees on the plan, or attendees mentioned as being present for the meeting.)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
Child’s caregiver or guardian
Child
Other family member
Case manager/service coordinator/
wraparound specialist
Therapist
Other mental health staff
(e.g., behavioral aide, respite worker)
Education staff (e.g., teacher, counselor)
Child welfare staff (e.g., case worker)
Juvenile justice (e.g., probation officer)
Health staff (e.g., pediatrician, nurse)
Family advocate
Other
Other
1 = No 2 = Yes
1 = No 2 = Yes
1 = No 2 = Yes
1 = No 2 = Yes
1 = No 2 = Yes
1 = No 2 = Yes—specify _____________________
1 = No
1 = No
1 = No
1 = No
1 = No
1 = No
1 = No
2 = Yes—specify _____________________
2 = Yes—specify _____________________
2 = Yes—specify _____________________
2 = Yes—specify _____________________
2 = Yes—specify _____________________
2 = Yes—specify _____________________
2 = Yes—specify _____________________
[Questions #15 and #16 are to be completed by site evaluation staff.]
15.
Is (child’s name) enrolled in the Longitudinal Outcome Study?
1 = No
2 = Yes [GO TO QUESTION #17]
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
6
CHILD ID:
16.
Enrollment and Demographic Information Form (EDIF)
Reason the child is not enrolled in the Longitudinal Outcome Study:
1 = Ineligible—sibling participating in the study
2 = Ineligible—child not selected through the site’s sampling scheme
3 = Ineligible—missed 30-day baseline data collection window
4 = Ineligible—enrolled in the Longitudinal Outcome Study at another site
5 = Caregiver or independent youth refused to consent
6 = Caregiver or independent youth not able to provide consent (e.g., mental health
conditions, substance abuser)
7 = Language (interviews cannot be conducted in the preferred language of caregiver or
youth)
8 = Never received services (e.g., inappropriate referral, no further involvement with
service system, moved prior to enrollment)
9 = Family in crisis
10 = Delay in local evaluation procedures (e.g., due to delays in national start-up, local
IRB delays, staffing issues)
11 = Other—please specify __________________________
SECTION IV. Additional Child Diagnostic Information: Revised DC:0–3 (DC:0–3R)
17.
Does (child’s name) have diagnostic information for the Revised DC:0–3 (DC:0–3R)?
[Note: The DC:0–3R codes are intended for use with children up to age 4.]
[Enter 666 if the child is aged 4 or older.]
1 = No [END OF QUESTIONNAIRE]
2 = Yes
666 = Not applicable [END OF QUESTIONNAIRE]
777 = Refused to answer [END OF QUESTIONNAIRE]
888 = Don’t know [END OF QUESTIONNAIRE]
999 = Missing [END OF QUESTIONNAIRE]
18.
Has diagnostic evaluation been done as part of the intake into the system of care program?
1 = No
2 = Yes
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
19.
Date of the most recent DC:0–3R diagnostic evaluation
________________________________
(mm/dd/yyyy)
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
7
CHILD ID:
20.
Enrollment and Demographic Information Form (EDIF)
Who provided the diagnosis?
1 = Child psychiatrist
2 = General psychiatrist
3 = Child psychologist
4 = General psychologist
5 = Licensed mental health staff (clinical social worker/professional counselor/
therapist)
6 = Primary care physician
7 = Nurse practitioner/psychiatric nurse practitioner/physician’s assistant
8 = Other licensed physical health staff
9 = Unlicensed staff (mental health assessment specialist)
10 = Other—please specify ____________________________________
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
21.
AXIS I: Clinical Disorders [Select from the attached list of DC:0–3R Axis I codes]
21a. First/primary diagnosis
____________________________________________________
[If “800 = other disorders” selected, please specify the code with the appropriate prefix, e.g.,
DSM, ICD9, ICD10]
21b. Second diagnosis
____________________________________________________
[If “800 = other disorders” selected, please specify the code with the appropriate prefix, e.g.,
DSM, ICD9, ICD10]
21c. Third diagnosis
____________________________________________________
[If “800 = other disorders” selected, please specify the code with the appropriate prefix, e.g.,
DSM, ICD9, ICD10]
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
8
CHILD ID:
Enrollment and Demographic Information Form (EDIF)
DC:0–3R Axis I codes:
100 = Posttraumatic Stress Disorder
150 = Deprivation/Maltreatment Disorder
200 = Disorders of Affect
210 = Prolonged Bereavement/Grief Reaction
220 = Anxiety Disorders of Infancy and Early Childhood
221 = Separation Anxiety Disorder
222 = Specific Phobia
223 = Social Anxiety Disorder (Social Phobia)
224 = Generalized Anxiety Disorder
225 = Anxiety Disorder NOS (Not Otherwise Specified)
230 = Depression of Infancy and Early Childhood
231 = Type 1 (type I) Major Depression
232 = Type 2 (type II) Major Depression
240 = Mixed Disorders of Emotional Expressiveness
300 = Adjustment Disorder
400 = Regulation Disorders of Sensory Processing
410 = Hypersensitive
411 = Hypersensitive—Type A: Fearful/Cautious
412 = Hypersensitive—Type B: Negative/Defiant
420 = Hyposensitive/Underresponsive
430 = Sensory Stimulation-Seeking/Impulsive
500 = Sleep Behavior Disorder
510 = Sleep-Onset Disorder (Sleep-Onset Protodyssomnia)
520 = Night-Waking Disorder (Night-Waking Protodyssomnia)
600 = Feeding Behavior Disorder
601 = Feeding Disorder of State Regulation
602 = Feeding Disorder of Caregiver–Infant Reciprocity
603 = Infantile Anorexia
604 = Sensory Food Aversions
605 = Feeding Disorder Associated With Concurrent Medical Condition
606 = Feeding Disorder Associated With Insults to the Gastrointestinal Tract
700 = Disorders of Relating and Communicating
710 = Multi-System Developmental Disorder (MSDD)
800 = Other Disorders (DSM–IV–TR or ICD10)
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
9
CHILD ID:
22.
Enrollment and Demographic Information Form (EDIF)
AXIS II: Relationship Classification: Parent–Infant Relationship Global Assessment Scale (PIR–
GAS)
22a. Parent–Infant Relationship Global Assessment Scale (PIR–GAS) Score
[Enter PIR–GAS score—valid scores range from 1 to 100]
_________________ [IF 1–100, GO TO QUESTION #23]
666 = Not applicable [GO TO QUESTION #22b]
777 = Refused to answer [GO TO QUESTION #22b]
888 = Don’t know [GO TO QUESTION #22b]
999 = Missing [GO TO QUESTION #22b]
22b. Parent–Infant Relationship Global Assessment Scale (PIR–GAS) Categories
[Choose one, only if numeric PIR–GAS score is not entered above]
1 = 91–100 = Well adapted
2 = 81–90 = Adapted
3 = 71–80 = Perturbed
4 = 61–70 = Significantly perturbed
5 = 51–60 = Distressed
6 = 41–50 = Disturbed
7 = 31–40 = Disordered
8 = 21–30 = Severely disordered
9 = 11–20 = Grossly impaired
10 = 1–10 = Documented maltreatment
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
23.
AXIS II: Relationship Classification: Relationship Problems Checklist (RPCL)
[Choose one for each relationship feature]
23a. Overinvolved
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
23b. Underinvolved
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
10
CHILD ID:
Enrollment and Demographic Information Form (EDIF)
23c. Anxious/tense
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
23d. Angry/hostile
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
23e. Verbally abusive
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
23f. Physically abusive
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
23g. Sexually abusive
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
11
CHILD ID:
24.
Enrollment and Demographic Information Form (EDIF)
AXIS III: General Medical Condition (ICD–9–CM/ICD–10 numeric code)
[Separate multiple codes with commas]
ICD–9–CM/ICD–10 numeric code
___________________________________________________________________________
25.
AXIS IV: Psychosocial and Environmental Problems [Select all that apply]
1 = Problems with primary support group
2 = Problems related to the social environment
3 = Educational/childcare problems
4 = Occupational problems
5 = Housing problems
6 = Economic problems
7 = Problems with access to health care services
8 = Problems related to interaction with the legal system/crime
9 = Other psychosocial and environmental problems
10 = Problems related to health of the child
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
26.
AXIS V: Emotional and Social Functioning: Capacities for Emotional and Social Functioning
Rating Scale
[Choose one functional rating for each emotional/functioning capacity]
26a. Attention and regulation
1 = Age-appropriate functioning, all conditions and full affect
2 = Age-appropriate functioning, vulnerable to stress or limited range of affect
3 = Functions immaturely (has the capacity but not at age-appropriate level)
4 = Functions inconsistently without special sensorimotor support
5 = Barely evidences the capacity, even with support
6 = Has not achieved this capacity
7 = N/A, child below age level
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
12
CHILD ID:
Enrollment and Demographic Information Form (EDIF)
26b. Forming relationships/mutual engagement
1 = Age-appropriate functioning, all conditions and full affect
2 = Age-appropriate functioning, vulnerable to stress or limited range of affect
3 = Functions immaturely (has the capacity but not at age-appropriate level)
4 = Functions inconsistently without special sensorimotor support
5 = Barely evidences the capacity, even with support
6 = Has not achieved this capacity
7 = N/A, child below age level
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
26c. Intentional two-way communication
1 = Age-appropriate functioning, all conditions and full affect
2 = Age-appropriate functioning, vulnerable to stress or limited range of affect
3 = Functions immaturely (has the capacity but not at age-appropriate level)
4 = Functions inconsistently without special sensorimotor support
5 = Barely evidences the capacity, even with support
6 = Has not achieved this capacity
7 = N/A, child below age level
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
26d. Complex gestures and problem-solving
1 = Age-appropriate functioning, all conditions and full affect
2 = Age-appropriate functioning, vulnerable to stress or limited range of affect
3 = Functions immaturely (has the capacity but not at age-appropriate level)
4 = Functions inconsistently without special sensorimotor support
5 = Barely evidences the capacity, even with support
6 = Has not achieved this capacity
7 = N/A, child below age level
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
13
CHILD ID:
Enrollment and Demographic Information Form (EDIF)
26e. Use of symbols to express thoughts/feeling
1 = Age-appropriate functioning, all conditions and full affect
2 = Age-appropriate functioning, vulnerable to stress or limited range of affect
3 = Functions immaturely (has the capacity but not at age-appropriate level)
4 = Functions inconsistently without special sensorimotor support
5 = Barely evidences the capacity, even with support
6 = Has not achieved this capacity
7 = N/A, child below age level
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
26f. Connecting symbols logically/abstract thinking
1 = Age-appropriate functioning, all conditions and full affect
2 = Age-appropriate functioning, vulnerable to stress or limited range of affect
3 = Functions immaturely (has the capacity but not at age-appropriate level)
4 = Functions inconsistently without special sensorimotor support
5 = Barely evidences the capacity, even with support
6 = Has not achieved this capacity
7 = N/A, child below age level
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
14
CHILD INFORMATION UPDATE FORM (CIUF)
/
CIUFDATE (Today’s date)
Month
/
Day
Year
CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)
A. Sources of information used to complete this
form [Select all that apply]
1 = Caregiver (child’s caregiver in a family,
household environment)
2 = Staff as Caregiver (staffperson who has acted
as the child’s day-to-day caregiver for the
majority of the past 6 months)
3 = Youth
4 = Case record review
5 = Other
B. Agency that the child is currently involved
with [Select all that apply]
1 = Corrections
2 = Juvenile court
3 = Probation
4 = School
5 = Mental health agency/clinic/provider
6 = Physical health care agency/clinic/provider
7 = Public child welfare
8 = Substance abuse agency/clinic/provider
9 = Family court
10 = Early care: Early Head Start program
11 = Early care: Head Start program
12 = Early care: Early intervention (Part C)
13 = Early care: Preschool special education
program (Part B)
14 = Early care: Other early care and education
programs/providers (including
childcare/providers)
15 = Other—please specify
__________________________
[If 7 = Public child welfare not selected above, go
to Question #5.]
Date last modified: December 2009
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months
B1. Child welfare involvement
1 = Receiving child abuse and neglect
investigation/assessment
2 = Court-ordered out-of-home placement—
Foster care
3 = Court-ordered out-of-home placement—
Kinship care
4 = Court-ordered out-of-home placement—
Residential treatment
5 = Voluntary out-of-home placement— Foster
care
6 = Voluntary out-of-home placement— Kinship
care
7 = Voluntary out-of-home placement—
Residential treatment
8 = Court-ordered in-home services
9 = Voluntary in-home services
CHILD ID:
SECTION I.
Child Information Update Form (CIUF)
Child Demographic Information
[Questions #1–4 are skipped, as they are not applicable at follow-up.]
5.
What is the ZIP Code of the address where (child’s name) currently lives?
_______________
[Question #6 is skipped, as it is not applicable at follow-up.]
7.
During the past 6 months, was (child’s name) the recipient of . . . ? [Select all that apply]
1 = Medicaid
2 = CHIP
3 = SSI
4 = TANF
5 = CMHS grant program funds
6 = Private insurance
7 = Other—please specify ____________________________________
Children and youth may have diagnostic codes for more than one classification system. Section II
addresses diagnostic classification for DSM–IV–R and/or ICD–9 only. Because all children and youth
served in systems of care must have diagnostic information, diagnostic codes for younger children (i.e.,
codes for the Revised DC:0–3) may be entered in Section IV.
8.
Does (child’s name) have a DSM–IV–R or ICD–9 diagnosis?
1 = No [GO TO QUESTION #13]
2 = Yes
SECTION II. Child Diagnostic Information: DSM–IV–R and ICD–9
[Question #9 is skipped, as it is not applicable at follow-up.]
In this section, please record the DSM–IV–R or ICD–9 diagnostic codes in the indicated fields.
10.
Date of the most recent multiaxial diagnostic evaluation
________________________________
(mm/dd/yyyy)
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
1
CHILD ID:
11.
Child Information Update Form (CIUF)
Who provided the diagnosis?
1 = Child psychiatrist
2 = General psychiatrist
3 = Child psychologist
4 = General psychologist
5 = Licensed mental health staff (clinical social worker/professional counselor/
therapist)
6 = Primary care physician
7 = Nurse practitioner/psychiatric nurse practitioner/physician’s assistant
8 = Other licensed physical health staff
9 = Unlicensed staff (mental health assessment specialist)
10 = Other—please specify ____________________________________
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
[Primary diagnosis should be listed as the first diagnosis on each axis (1a, 2a).]
12.
AXIS I: Clinical Disorders
Diagnostic code
DSM–IV–R name
axis_1a
_________.____
_________________________________________
axis_1b
_________.____
_________________________________________
axis_1c
_________.____
_________________________________________
AXIS II: Personality Disorders and Mental Retardation
Diagnostic code
DSM–IV–R name
axis_2a
_________.____
_________________________________________
axis_2b
_________.____
_________________________________________
AXIS III: General Medical Condition (ICD–9–CM numeric code)
[Separate multiple codes with commas]
ICD–9–CM numeric code
axis 3 ______________________________________________________________________
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
2
CHILD ID:
Child Information Update Form (CIUF)
AXIS IV: Psychosocial and Environmental Problems [Select all that apply]
1 = Problems with primary support group
2 = Problems related to the social environment
3 = Educational problems
4 = Occupational problems
5 = Housing problems
6 = Economic problems
7 = Problems with access to health care services
8 = Problems related to interaction with the legal system/crime
9 = Other psychosocial and environmental problems
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
AXIS V: Global Assessment of Functioning Scale (GAF)
[Enter current GAF score]
_______________
SECTION III. Child Enrollment Information
[Question #13 is skipped, as it is not applicable at follow-up.]
13a. System of care enrollment status of the child
1 = Child is receiving system of care services [GO TO QUESTION #13c]
2 = Formally completed services/discharged [GO TO QUESTION #13c]
3 = Family no longer receiving services, but not discharged [GO TO QUESTION
#13c]
4 = Other—please specify ____________________________________ [GO TO
QUESTION #17]
[Question #13b is skipped, as it is not applicable at follow-up.]
13c. Date of the child’s most recent assessment for the system of care
________________________________
(mm/dd/yyyy)
13d. Date of the child’s most recent service planning team meeting in the system of care
________________________________
(mm/dd/yyyy)
13e. Date of the child’s most recent service received through the system of care
________________________________
(mm/dd/yyyy)
[Questions #13f–16 are skipped, as they are not applicable at follow-up.]
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
3
CHILD ID:
Child Information Update Form (CIUF)
SECTION IV. Additional Child Diagnostic Information: Revised DC:0–3 (DC:0–3R)
17.
Does (child’s name) have diagnostic information for the Revised DC:0–3 (DC:0–3R)?
[Note: The DC:0–3R codes are intended for use with children up to age 4.]
[Enter 666 if the child is aged 4 or older.]
1 = No [END OF QUESTIONNAIRE]
2 = Yes
666 = Not applicable [END OF QUESTIONNAIRE]
777 = Refused to answer [END OF QUESTIONNAIRE]
888 = Don’t know [END OF QUESTIONNAIRE]
999 = Missing [END OF QUESTIONNAIRE]
[Question #18 is skipped, as it is not applicable at follow-up.]
19.
Date of the most recent DC:0–3R diagnostic evaluation
________________________________
(mm/dd/yyyy)
20.
Who provided the diagnosis?
1 = Child psychiatrist
2 = General psychiatrist
3 = Child psychologist
4 = General psychologist
5 = Licensed mental health staff (clinical social worker/professional counselor/
therapist)
6 = Primary care physician
7 = Nurse practitioner/psychiatric nurse practitioner/physician’s assistant
8 = Other licensed physical health staff
9 = Unlicensed staff (mental health assessment specialist)
10 = Other—please specify ____________________________________
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
21.
AXIS I: Clinical Disorders [Select from the attached list of DC:0–3R Axis I codes]
21a. First/primary diagnosis
____________________________________________________
[If “800 = other disorders” selected, please specify the code with the appropriate prefix, e.g.,
DSM, ICD9, ICD10]
21b. Second diagnosis
____________________________________________________
[If “800 = other disorders” selected, please specify the code with the appropriate prefix, e.g.,
DSM, ICD9, ICD10]
21c. Third diagnosis
____________________________________________________
[If “800 = other disorders” selected, please specify the code with the appropriate prefix, e.g.,
DSM, ICD9, ICD10]
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
4
CHILD ID:
Child Information Update Form (CIUF)
DC:0–3R Axis I codes:
100 = Posttraumatic Stress Disorder
150 = Deprivation/Maltreatment Disorder
200 = Disorders of Affect
210 = Prolonged Bereavement/Grief Reaction
220 = Anxiety Disorders of Infancy and Early Childhood
221 = Separation Anxiety Disorder
222 = Specific Phobia
223 = Social Anxiety Disorder (Social Phobia)
224 = Generalized Anxiety Disorder
225 = Anxiety Disorder NOS (Not Otherwise Specified)
230 = Depression of Infancy and Early Childhood
231 = Type 1 (type I) Major Depression
232 = Type 2 (type II) Major Depression
240 = Mixed Disorders of Emotional Expressiveness
300 = Adjustment Disorder
400 = Regulation Disorders of Sensory Processing
410 = Hypersensitive
411 = Hypersensitive—Type A: Fearful/Cautious
412 = Hypersensitive—Type B: Negative/Defiant
420 = Hyposensitive/Underresponsive
430 = Sensory Stimulation-Seeking/Impulsive
500 = Sleep Behavior Disorder
510 = Sleep-Onset Disorder (Sleep-Onset Protodyssomnia)
520 = Night-Waking Disorder (Night-Waking Protodyssomnia)
600 = Feeding Behavior Disorder
601 = Feeding Disorder of State Regulation
602 = Feeding Disorder of Caregiver–Infant Reciprocity
603 = Infantile Anorexia
604 = Sensory Food Aversions
605 = Feeding Disorder Associated With Concurrent Medical Condition
606 = Feeding Disorder Associated With Insults to the Gastrointestinal Tract
700 = Disorders of Relating and Communicating
710 = Multi-System Developmental Disorder (MSDD)
800 = Other Disorders (DSM–IV–TR or ICD10)
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
5
CHILD ID:
22.
Child Information Update Form (CIUF)
AXIS II: Relationship Classification: Parent–Infant Relationship Global Assessment Scale (PIR–
GAS)
22a. Parent–Infant Relationship Global Assessment Scale (PIR–GAS) Score
[Enter PIR–GAS score—valid scores range from 1 to 100]
_________________ [IF 1–100, GO TO QUESTION #23]
666 = Not applicable [GO TO QUESTION #22b]
777 = Refused to answer [GO TO QUESTION #22b]
888 = Don’t know [GO TO QUESTION #22b]
999 = Missing [GO TO QUESTION #22b]
22b. Parent–Infant Relationship Global Assessment Scale (PIR–GAS) Categories
[Choose one, only if numeric PIR–GAS score is not entered above]
1 = 91–100 = Well adapted
2 = 81–90 = Adapted
3 = 71–80 = Perturbed
4 = 61–70 = Significantly perturbed
5 = 51–60 = Distressed
6 = 41–50 = Disturbed
7 = 31–40 = Disordered
8 = 21–30 = Severely disordered
9 = 11–20 = Grossly impaired
10 = 1–10 = Documented maltreatment
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
23.
AXIS II: Relationship Classification: Relationship Problems Checklist (RPCL)
[Choose one for each relationship feature]
23a. Overinvolved
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
23b. Underinvolved
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
6
CHILD ID:
Child Information Update Form (CIUF)
23c. Anxious/tense
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
23d. Angry/hostile
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
23e. Verbally abusive
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
23f. Physically abusive
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
23g. Sexually abusive
1 = No evidence
2 = Some evidence, needs further investigation
3 = Substantive evidence
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
7
CHILD ID:
24.
Child Information Update Form (CIUF)
AXIS III: General Medical Condition (ICD–9–CM/ICD–10 numeric code)
[Separate multiple codes with commas]
ICD–9–CM/ICD–10 numeric code
___________________________________________________________________________
25.
AXIS IV: Psychosocial and Environmental Problems [Select all that apply]
1 = Problems with primary support group
2 = Problems related to the social environment
3 = Educational/childcare problems
4 = Occupational problems
5 = Housing problems
6 = Economic problems
7 = Problems with access to health care services
8 = Problems related to interaction with the legal system/crime
9 = Other psychosocial and environmental problems
10 = Problems related to health of the child
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
26.
AXIS V: Emotional and Social Functioning: Capacities for Emotional and Social Functioning
Rating Scale
[Choose one functional rating for each emotional/functioning capacity]
26a. Attention and regulation
1 = Age-appropriate functioning, all conditions and full affect
2 = Age-appropriate functioning, vulnerable to stress or limited range of affect
3 = Functions immaturely (has the capacity but not at age-appropriate level)
4 = Functions inconsistently without special sensorimotor support
5 = Barely evidences the capacity, even with support
6 = Has not achieved this capacity
7 = N/A, child below age level
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
8
CHILD ID:
Child Information Update Form (CIUF)
26b. Forming relationships/mutual engagement
1 = Age-appropriate functioning, all conditions and full affect
2 = Age-appropriate functioning, vulnerable to stress or limited range of affect
3 = Functions immaturely (has the capacity but not at age-appropriate level)
4 = Functions inconsistently without special sensorimotor support
5 = Barely evidences the capacity, even with support
6 = Has not achieved this capacity
7 = N/A, child below age level
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
26c. Intentional two-way communication
1 = Age-appropriate functioning, all conditions and full affect
2 = Age-appropriate functioning, vulnerable to stress or limited range of affect
3 = Functions immaturely (has the capacity but not at age-appropriate level)
4 = Functions inconsistently without special sensorimotor support
5 = Barely evidences the capacity, even with support
6 = Has not achieved this capacity
7 = N/A, child below age level
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
26d. Complex gestures and problem-solving
1 = Age-appropriate functioning, all conditions and full affect
2 = Age-appropriate functioning, vulnerable to stress or limited range of affect
3 = Functions immaturely (has the capacity but not at age-appropriate level)
4 = Functions inconsistently without special sensorimotor support
5 = Barely evidences the capacity, even with support
6 = Has not achieved this capacity
7 = N/A, child below age level
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
9
CHILD ID:
Child Information Update Form (CIUF)
26e. Use of symbols to express thoughts/feeling
1 = Age-appropriate functioning, all conditions and full affect
2 = Age-appropriate functioning, vulnerable to stress or limited range of affect
3 = Functions immaturely (has the capacity but not at age-appropriate level)
4 = Functions inconsistently without special sensorimotor support
5 = Barely evidences the capacity, even with support
6 = Has not achieved this capacity
7 = N/A, child below age level
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
26f. Connecting symbols logically/abstract thinking
1 = Age-appropriate functioning, all conditions and full affect
2 = Age-appropriate functioning, vulnerable to stress or limited range of affect
3 = Functions immaturely (has the capacity but not at age-appropriate level)
4 = Functions inconsistently without special sensorimotor support
5 = Barely evidences the capacity, even with support
6 = Has not achieved this capacity
7 = N/A, child below age level
666 = Not applicable
777 = Refused to answer
888 = Don’t know
999 = Missing
For all variables and data elements:
Date last modified: December 2009
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
10
Attachment E: Sector and Comparison Study
OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
COURT REPRESENTATIVE QUESTIONNAIRE
(CRQ)
/
CRQDATE (Today’s date)
Month
/
Day
Year
CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)
1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months
CRQRESP (Respondent for interview)
1 = Probation officer
2 = Case worker
3 = Other court personnel
Date last modified: January 2011
CHILD ID:
1.
Court Representative Questionnaire (CRQ)
Which, if any, of these activities was (child’s name) required to complete as part of his/her court
order or as part of participation in this program? [Select all that apply]
1 = Letter of apology
2 = Restitution
3 = Community service
4 = Drug testing
5 = Restorative justice
6 = Meet with diversion officers
7 = Obtain employment
8 = Attend school
9 = Other—please specify __________________________
2.
Which, if any, of the following services was (child’s name) referred to as part of his/her juvenile
justice involvement? [Select all that apply]
1 = Individual counseling
2 = Group counseling
3 = Family counseling
4 = Life skills classes
5 = Educational plan
6 = Assigned a mentor
7 = Substance abuse counseling
8 = Case management/treatment plan
9 = Home visits/school visits
10 = Anger management classes
11 = MST
12 = CBT
13 = Other—please specify __________________________
3.
In the past 6 months, which of the following services did (child’s name) participate in as part of
his/her juvenile justice involvement? [Select all that apply]
1 = Individual counseling
2 = Group counseling
3 = Family counseling
4 = Life skills classes
5 = Educational plan
6 = Assigned a mentor
7 = Substance abuse counseling
8 = Case management/treatment plan
9 = Home visits/school visits
10 = Anger management classes
11 = MST
12 = CBT
13 = Other—please specify __________________________
4.
Was a representative from community mental health (non-court personnel) involved in developing
the preliminary report for (child’s name)?
1 = No [GO TO QUESTION #5]
2 = Yes
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
1
CHILD ID:
Court Representative Questionnaire (CRQ)
[CARD 1]
4a.
To what extent were these recommendations followed in determining (child’s name)’s
disposition/status?
1 = Not at all
2 = Somewhat
3= A great deal
5.
In the past 6 months, was a community mental health representative involved in providing service
and progress updates about (child’s name) to you and/or other relevant court
personnel/representatives?
1 = No [GO TO QUESTION #6]
2 = Yes
[CARD 2]
5a.
In the past 6 months, how often has the community mental health representative provided you
and/or other relevant court personnel/representatives information regarding (child’s name)’s
participation in services and/or progress in services?
1 = Not at all
2 = Rarely
3 = Somewhat
4 = Often
5 = Very often
6.
In the past 6 months, have you met with (child’s name)’s mental health services provider or care
coordinator to discuss (child’s name)’s status and/or progress in this program?
1 = No
2 = Yes
7.
Did you participate in the development of (child’s name)’s mental health service plan?
1 = No
2 = Yes
8.
In the past 6 months, how many times had (child’s name) been arrested?
_____ times
8a.
What were the offenses for which (child’s name) was arrested in the past 6 months?
[Describe all offenses]
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
9.
How many times in the past 6 months did (child’s name) appear in court for something he/she was
suspected of doing (for a new offense)?
_____ times
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
2
CHILD ID:
9a.
Court Representative Questionnaire (CRQ)
What were the offenses for which (child’s name) appeared in court in the past 6 months?
[Describe all offenses]
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
10.
In the past 6 months, has (child’s name) been found guilty or adjudicated of a crime or an offense in
court?
1 = No [END OF QUESTIONNAIRE]
2 = Yes
10a. What were the offenses for which (child’s name) was found guilty or adjudicated of in the
past 6 months? [Describe all offenses]
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
3
OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
TEACHER QUESTIONNAIRE (TQ)
/
TQDATE (Today’s date)
Month
/
Day
Year
CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)
1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months
TQRESP (Respondent for interview)
1 = Classroom teacher (child’s primary instructor in a
classroom setting)
2 = Inclusion teacher (child’s special education teacher)
TQINTV (Who administered interview)
1 = Person providing services to child
2 = Data collector
TQMETH (Method of administering interview)
1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted
TQLANG (Language version of interview)
1 = English
2 = Spanish
3 = Other
Date last modified: January 2011
CHILD ID:
Teacher Questionnaire (TQ)
This set of questions deals with (child’s name)’s experiences in school. Some questions may not apply to
him/her, but we ask these questions of everyone.
[NOTE TO INTERVIEWER: “School” means preschool through post-secondary education (pre-K
through post-high school education, e.g., college, university, vocational/trade school.) “Preschool”
refers to a beginning group or class enrolling children 3 years or older that is organized to provide
educational experience under professionally qualified teachers during the year or years immediately
preceding kindergarten.]
1.
How many years have you been in the teaching profession?
_______ year(s) and _______ month(s)
2.
How many months have you known (child’s name)?
_______ month(s)
[CARD 1]
3.
How well would you say you know (child’s name)?
1 = Not well
2 = Moderately well
3 = Very well
4.
How much time does (child’s name) spend in your classroom or service a week?
_______ hour(s)
5.
What grade level(s) are the students in (child’s name)’s class?
_______
6.
How many general education students are in (child’s name)’s class?
_______ general education students
7.
How many special education students are in (child’s name)’s class?
_______ special education students
8.
What is the academic subject that you teach (child’s name)?
__________________________________________________________________
9.
To your knowledge, has (child’s name) been in school at any time in the past 6 months?
1 = No
2 = Yes [GO TO QUESTION #10]
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
1
CHILD ID:
9a.
Teacher Questionnaire (TQ)
Why was he/she not in school?
1 = Dropped out of school before reaching legal age to drop out
2 = Dropped out after reaching the legal age
3 = Expelled/suspended
4 = Graduated from high school/got GED
5 = Physical illness and/or injury
6 = Refuses to go to school
7 = In juvenile detention or jail (and schooling was not provided)
8 = Asked to leave school (e.g., due to behavior)
9 = No instruction provided while waiting for another placement
10 = Other—please specify ____________________________________________
________________________________________________________________
[GO TO QUESTION #11c]
10.
Is (child’s name) in school now?
1 = No [GO TO QUESTION #11b]
2 = Yes
11a. Which grade is (child’s name) in now? If your school does not use grade levels, please
estimate as best you can which grade he/she is in.
1 = First grade
2 = Second grade
3 = Third grade
4 = Fourth grade
5 = Fifth grade
6 = Sixth grade
7 = Seventh grade
8 = Eighth grade
9 = Ninth grade
10 = Tenth grade
11 = Eleventh grade
12 = Twelfth grade
13 = Other—please specify ____________________________________________
[GO TO QUESTION #11d]
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
2
CHILD ID:
Teacher Questionnaire (TQ)
11b. Why is he/she not in school now?
1 = Dropped out of school before reaching legal age to drop out
2 = Dropped out after reaching the legal age
3 = Expelled/suspended
4 = Graduated from high school/got GED
5 = Physical illness and/or injury
6 = Refuses to go to school
7 = In juvenile detention or jail (and schooling is not provided)
8 = Asked to leave school (e.g., due to behavior)
9 = No instruction provided while waiting for another placement
10 = Other—please specify ____________________________________________
________________________________________________________________
11c. Which grade did (child’s name) most recently complete? If your school does not use grade
levels, please estimate as best you can which grade he/she completed.
1 = First grade
2 = Second grade
3 = Third grade
4 = Fourth grade
5 = Fifth grade
6 = Sixth grade
7 = Seventh grade
8 = Eighth grade
9 = Ninth grade
10 = Tenth grade
11 = Eleventh grade
12 = Twelfth grade
13 = Other—please specify __________________________
[GO TO QUESTION #27]
11d. In the past 6 months, has (child’s name) repeated a grade in school?
1 = No
2 = Yes
For the following questions, please think about what happened while (child’s name) was in school during
the past 6 months.
12.
When school was in session, did (child’s name) ever miss school for any reason in the past 6
months? This includes excused as well as unexcused absences.
1 = No [GO TO QUESTION #13]
2 = Yes
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
3
CHILD ID:
Teacher Questionnaire (TQ)
[CARD 2]
12a. How often was he/she usually absent in the past 6 months? This includes excused and
unexcused absences.
0 = Less than 1 day per month [GO TO QUESTION #13]
1 = About 1 day a month [GO TO QUESTION #12b]
2 = About 1 day every 2 weeks [GO TO QUESTION #12b]
3 = About 1 day a week [GO TO QUESTION #12b]
4 = 2 days per week [GO TO QUESTION #12b]
5 = 3 or more days per week [GO TO QUESTION #12b]
[CARD 3]
12b. In the past 6 months, to what extent do you think (child’s name)’s school attendance was
affected by his/her behavioral or emotional problems?
1 = Not at all
2 = A little bit
3 = A moderate amount
4 = Quite a bit
5 = Extremely
12c. In the past 6 months, to what extent did the school provide support to help improve (child’s
name)’s attendance?
1 = Not at all
2 = A little bit
3 = A moderate amount
4 = Quite a bit
5 = Extremely
13.
In the past 6 months, was a pre-referral intervention team (i.e., school team) initiated to assess the
necessity of an Individualized Education Plan (IEP) for (child’s name)?
1 = No
2 = Yes
3 = School does not have a pre-referral intervention team
14.
In the past 6 months, did (child’s name) have an Individualized Education Plan?
1 = No
2 = Yes [GO TO QUESTION #14b]
[NOTE TO INTERVIEWER: If necessary, clarify that special education may be provided to many
different children for many different reasons. For example, children with developmental disabilities;
mental retardation; hearing, vision, or speech difficulties; other physical disabilities; learning
disabilities; emotional problems; and/or behavioral problems may receive special education.]
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
4
CHILD ID:
Teacher Questionnaire (TQ)
14a. What was the reason that (child’s name) did not have an IEP?
1 = Doing well and did not need an IEP
2 = Never referred, but needs to be
3 = Eligibility was under review
4 = Was assessed and found ineligible
5 = Was never assessed for special education
6 = Other special education plan (e.g., 504, behavior management, vocational training,
or transition plans)
7 = Other—please specify __________________________________________
[GO TO QUESTION #15]
14b. Did you attend the IEP planning meeting for (child’s name)?
1 = No
2 = Yes
14c. What form of modification do you use to meet (child’s name)’s needs?
1 = General education curriculum without modification
2 = General education curriculum with some modification
3 = General education curriculum with substantial modification
4 = Specialized curriculum
14d. What was the main reason that (child’s name) had an IEP?
1 = Behavioral and/or emotional problems
2 = Learning disability
3 = Physical disability (for example, an orthopedic disability such as a missing limb)
4 = Developmental disability and/or mental retardation
5 = Vision and/or hearing impairment
6 = Speech impairment
7 = Other—please specify ____________________________________________
14d2. Were there other reasons that (child’s name) had an IEP?
1 = No [GO TO QUESTION #15]
2 = Yes
14d3. What were the other reasons that (child’s name) had an IEP? [Select all that apply]
1 = Behavioral and/or emotional problems
2 = Learning disability
3 = Physical disability (for example, an orthopedic disability such as a missing limb)
4 = Developmental disability and/or mental retardation
5 = Vision and/or hearing impairment
6 = Speech impairment
7 = Other—please specify __________________________________________
[NOTE TO INTERVIEWER: If necessary, please clarify for respondent that these classes may be cotaught by a regular education instructor and special education teacher, or by a teacher and an aide. A
special education teacher may come to the class for part of the day to provide specialized instruction.]
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
5
CHILD ID:
15.
Teacher Questionnaire (TQ)
In the past 6 months, did (child’s name) have a one-on-one classroom aide for any reason, for any
part of the school day? For example, a child might have an aide to help him/her with schoolwork, to
help manage the child’s behavior, and/or to help the child develop behavioral and social skills.
[This does not include out-of-class visits to a counselor.]
1 = No
2 = Yes
[CARD 4]
16.
Compared to typical pupils of the same age, how hard is (child’s name) working?
1 = Much less
2 = Somewhat less
3 = Slightly less
4 = About average
5 = Slightly more
6 = Somewhat more
7 = Much more
17.
Compared to typical pupils of the same age, how disruptive is (child’s name) in class?
1 = Much less
2 = Somewhat less
3 = Slightly less
4 = About average
5 = Slightly more
6 = Somewhat more
7 = Much more
18.
In the past 6 months, were any of the following disciplinary actions taken toward (child’s name)?
1 = Suspended (in-school and out-of-school) [GO TO QUESTION #18a]
2 = Expelled [GO TO QUESTION #18a]
3 = Suspend AND expelled [GO TO QUESTION #18a]
4 = Neither suspended nor expelled [GO TO QUESTION #19]
3 = Other—please specify __________________________ [GO TO QUESTION #19]
18a. Did (child’s name) have a school disciplinary hearing or tribunal?
1 = No
2 = Yes
18b. As a result of the suspension and/or expulsion, was a plan developed to manage or improve
(child’s name)’s behavior, or was an existing plan revised or changed?
1 = No
2 = Yes
18c. [IF SUSPENDED] During the past 6 months, approximately how many days was (child’s
name) in in-school suspension?
_____ days
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
6
CHILD ID:
Teacher Questionnaire (TQ)
18d. [IF SUSPENDED] During the past 6 months, approximately how many days was (child’s
name) in out-of-school suspension?
_____ days
18e. [IF EXPELLED] During the past 6 months, approximately how many times was (child’s
name) expelled?
_____ times
19.
Now I would like to ask you about (child’s name)’s grades during this school year. Did he/she get
grades?
1 = No [GO TO QUESTION #19b]
2 = Yes
19a. Overall, across all subjects, has he/she mostly gotten . . . [READ CATEGORIES, CODE
ONE]
1 = A’s [GO TO QUESTION #20]
2 = A’s and B’s [GO TO QUESTION #20]
3 = B’s [GO TO QUESTION #20]
4 = B’s and C’s [GO TO QUESTION #20]
5 = C’s [GO TO QUESTION #20]
6 = C’s and D’s [GO TO QUESTION #20]
7 = D’s [GO TO QUESTION #20]
8 = D’s and F’s [GO TO QUESTION #20]
9 = F’s [GO TO QUESTION #20]
10 = School does not give these grades? [GO TO QUESTION #19b]
[IF RESPONSE DOES NOT FIT CATEGORIES, e.g., A’s AND F’s, SPECIFY RESPONSE = 11]
11 = Other—please specify _________________________ [GO TO QUESTION #20]
[CARD 5]
19b. Overall, would you describe his/her work at school as . . .
1 = Excellent
2 = Above average
3 = Average
4 = Below average
5 = Failing
[CARD 3]
20.
In the past 6 months, to what extent do you think (child’s name)’s grades or school performance
were affected by his/her behavioral or emotional problems?
1 = Not at all
2 = A little bit
3 = A moderate amount
4 = Quite a bit
5 = Extremely
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
7
CHILD ID:
21.
Teacher Questionnaire (TQ)
In the past 6 months, did you schedule a parent–teacher conference with (child’s name)’s parent or
guardian?
1 = No
2 = Yes
22.
In the past 6 months, did you meet with (child’s name)’s parent or guardian to discuss (child’s
name)’s progress in your class?
1 = No
2 = Yes
23.
In the past 6 months, did you meet with (child’s name)’s mental health services provider or care
coordinator to discuss (child’s name)’s progress in your class?
1 = No
2 = Yes
24.
Which of the following supports, if any, have been provided to you because this student is in your
class? [Select all that apply]
1 = Special equipment or materials to use with the student
2 = In-service training on the needs of this student
3 = Co-teaching/team teaching with special education and general education teachers
4 = Consultation services by special education or other staff
5 = Teacher aides or instructional assistants, or aides for individual students
6 = Smaller student load or class size
7 = Information about this student’s needs or abilities
8 = Other—please specify ____________________________________________
9 = None of the above have been provided
10 = None are needed
[CARD 6]
25.
In your opinion, how adequate are the supports that have been provided to you because this student
is in your class?
1 = Not applicable; none are needed
2 = Very inadequate
3 = Somewhat inadequate
4 = Somewhat adequate
5 = Very adequate
[CARD 7]
26.
In your view, how appropriate is this student’s placement in your class?
1 = Very inappropriate
2 = Somewhat inappropriate
3 = Somewhat appropriate
4 = Very appropriate
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
8
CHILD ID:
Teacher Questionnaire (TQ)
Please indicate the extent to which you agree or disagree with each of the following statements.
[CARD 8]
Strongly
disagree
Disagree
Undecided
Agree
Strongly
agree
27. I have adequate training for teaching
students with behavioral and
emotional problems.
1
2
3
4
5
28. The school leadership has high
expectations and standards for all
students and teachers.
1
2
3
4
5
29. The principal promotes instructional
improvement among staff.
1
2
3
4
5
30. This school is a safe place for
students.
1
2
3
4
5
31.
During the past 6 months, have you participated in any continuing professional development
activities totaling 8 or more hours to help you in any of the following areas? [Select all that apply]
1 = The subject matter content that you teach this student
2 = Working with students who are considered to be “at risk” for behavioral and
emotional disorders
3 = Working with students with behavioral and emotional problems
4 = Behavior management
5 = Creating positive school environment, violence prevention
6 = Collaborating with other educators
7 = Working with parents of students with behavioral and emotional problems
8 = Use of technology in instruction
9 = Considering and building on the cultural diversity of students
10 = Other—please specify ____________________________________________
11 = None
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
9
OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
SCHOOL ADMINISTRATOR QUESTIONNAIRE
(SAQ)
/
SAQDATE (Today’s date)
Month
/
Day
Year
CHILDID (National evaluation ID)
SCHOOLID (National evaluation
school ID)
TIMEFRAM (Assessment period)
1 = Intake
2 = 12 months
3 = 24 months
4 = 36 months
5 = 48 months
SAQRESP (Respondent for interview)
1 = School principal
2 = School vice principal
3 = Guidance counselor
4 = Expert teacher
5 = Other school official
SAQINTV (Who administered interview)
1 = Person providing services to child
2 = Data collector
SAQMETH (Method of administering interview)
1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted
SAQLANG (Language version of interview)
1 = English
2 = Spanish
3 = Other
Date last modified: January 2011
CHILD ID:
1.
School Administrator Questionnaire (SAQ)
Which of the following best describes this school?
1 = Comprehensive school (not including magnet or school of choice)
2 = Magnet school without a specialized academic, career, or technical theme (e.g.,
whole school, magnet program, school within a school)
3 = Magnet school with a specialized academic, career, or technical theme (e.g., a high
school for agricultural sciences)
4 = School of choice
5 = School that serves only students with disabilities
6 = Vocational–technical school
7 = Alternative/stay-in-school/dropout prevention school/continuation school
8 = Charter school
9 = Juvenile justice facility
10 = Military academy
11 = Hospital school
12 = Indian reservation school
13 = Other type of school serving an identified population or service need—please
specify ____________________________________________
2.
Is this school a/an . . . [Select all that apply]
1 = Public school
2 = Private school
3 = Faith-based school
4 = Residential/boarding school
5 = Year-round school
6 = School serving a single gender of students
7 = Other type of school—please specify __________________________
3.
What percentage of students in your school are identified as ESL (English as a Second Language)?
_______% of students
4
What percentage of students in your school are identified as Students with Interrupted Formal
Education (SIFE)?
________% of students
Note: These are students defined as immigrants who come from a home in which a language other
than English is spoken and enter a United States school after the second grade,have had at least 2
years less schooling than their peers, function at least 2 years below expected grade level in
reading and mathematics, and may be pre-literate in their first language.
5.
What percentage of students in your school are identified as receiving Special Education due to their
emotional or behavioral needs?
________% of students
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
1
CHILD ID:
6.
School Administrator Questionnaire (SAQ)
During the past 12 months, which, if any, of the following services, resources, or programs did your
school have available to students, either as part of the regular curriculum or available on school
grounds before or after school hours? [Select all that apply]
1 = Academic supports run by faculty or staff, such as homework club, tutoring or
mentoring assistance outside of regular classes during school week
2 = Saturday academies run by faculty or staff
3 = Peer-tutoring programs
4 = Home visits by teachers
5 = Special programs for pregnant teens and teenage mothers
6 = Diagnostic and prescriptive services provided by professionals to identify learning
problems and plan programs
7 = Supplemental instructional services in reading, language, arts, or math
8 = School-based health clinic
9 = Preventative mental health programs targeted at all students
10 = Targeted mental health services designed to assist students with one or more
mental health disorders
11 = Substance abuse treatment services
12 = School-based or itinerant psychological services
13 = School based or itinerant social work services
14 = Other mental health services, resources, or programs—please specify
____________________________________________________
15 = Other services, resources, or programs —please specify
____________________________________________________
[IF 9, 10, 11, 12, 13, 14, GO TO QUESTION #7. OTHERWISE, END OF QUESTIONNAIRE.]
7.
During the past 12 months, who provided mental health services in your school? [Select all that
apply]
1 = School counselor
2 = School psychologist
3 = School social worker
4 = School nurse
5 = Other—please specify __________________________
8.
During the past 12 months, what would best describe the mental health services delivery system in
your school?
1 = School-financed student support services
2 = School district mental health unit
3 = Formal connections with community mental health services
4 = Classroom-based curriculum and special “pull-out” interventions
5 = Comprehensive, multi-faceted, and integrated approaches
9.
During the past 12 months, what funding sources were utilized for mental health service provision
in your school?
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
2
CHILD ID:
9a.
School Administrator Questionnaire (SAQ)
Local funding sources: [Select all that apply]
0 = None
1 = Property taxes
2 = General sales tax
3 = Public utility tax
4 = Individual/corporate income tax
5 = All other taxes
6 = Parent government contributions
7 = Revenue from cities/counties
8 = Revenue from other school systems
9 = Tuition from parents and pupils
10 = Transportation from parents and pupils
11 = Textbook sales and rentals
12 = School lunch revenues
13 = Student activity fees
14 = Other sales and revenues
15 = Interest earnings
16 = Other—please specify __________________________
9b.
State funding sources: [Select all that apply]
0 = None
1 = General Assistance
2 = Staff improvement
3 = Special education programs
4 = Compensatory and basic skills attainment programs
5 = Bilingual education programs
6 = Gifted and talented programs
7 = Vocational education programs
8 = School lunch programs
9 = Capital outlay and debt service programs
10 = Transportation programs
11 = Other—please specify __________________________
9c.
Federal funding sources: [Select all that apply]
0 = None
1 = Children with Disabilities Act (IDEA)
2 = Medicaid
3 = Title I
4 = Title V, Part A
5 = Vocational and technical education
6 = Math, science, and professional development grants
7 = Child Nutrition Act
8 = Impact Aid (P.L. 815 and 874)
9 = Bilingual education federal aid
10 = Indian education federal aid
11 = Safe Schools/Healthy Students
12 = Safe and Drug-Free Schools
13 = Other—please specify __________________________
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
3
CHILD ID:
10.
School Administrator Questionnaire (SAQ)
During the past 12 months, which of the following services were available to students in your
school? [Select all that apply]
1 = Assessment for emotional or behavioral problems or disorders (including
behavioral observation, psychosocial assessment, and psychological testing)
2 = Behavior management consultation (with teachers, students, family)
3 = Case management (monitoring and coordination of services)
4 = Referral to specialized programs or services for emotional or behavioral problems
or disorders
5 = Crisis intervention
6 = Individual counseling/therapy
7 = Group counseling/therapy
8 = Substance abuse counseling
9 = Medication for emotional or behavioral problems
10 = Identification or school-based management of chronic or acute health conditions
11 = Referral for medication management
12 = Family support services (e.g., child/family advocacy, counseling)
13 = Pre-referral intervention team (i.e., school team to assess necessity of IEP)
14 = Other—please specify
____________________________________________________
11.
During the past 12 months, which of the following interventions were available to students in your
school? [Select all that apply]
1 = Positive Behavior Supports (PBS) or Positive Behavior and Intervention Supports
(PBIS)
2 = Crisis Prevention and Intervention (CPI)
3 = Safe Passages to School Program
4 = Good Behavior Game
5 = Social and Emotional Learning (SEL)
6 = Other—please specify
____________________________________________________
7 = None
12.
Does your school engage collaboratively with other child-serving agencies?
1 = No [GO TO QUESTION #13]
2 = Yes [GO TO QUESTION #12a]
12a. What agencies has your school collaborated with? [Select all that apply]
1 = Corrections
2 = Juvenile court
3 = Probation
4 = Other local schools
5 = Mental health agency/clinic/provider
6 = Physical health care agency/clinic/provider
7 = Public child welfare
8 = Substance abuse agency/clinic/provider
9 = Family court
10 = Other—please specify ____________________________________________
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
4
CHILD ID:
School Administrator Questionnaire (SAQ)
12b. Has this collaboration had a positive impact on the ability of students to function in the school
environment?
1 = No
2 = Yes
[CARD 1]
Never
13.
Rarely
Quarterly Monthly Weekly
How often does the following take place at your school?
13a. Mental health staff/teacher planning
1
2
3
4
5
13b. Mental health staff/special education
planning
1
2
3
4
5
13c. Mental health staff/school social worker
planning
1
2
3
4
5
13d. Other mental health service planning
meetings—please specify
_________________________
1
2
3
4
5
13e. Training to help teachers identify needs
related to a student’s behavioral and
emotional problems
1
2
3
4
5
The next set of items relates to the role of mental health service providers in your school. Please indicate
the degree to which you agree or disagree with each statement.
[CARD 2]
Neither
agree nor
Strongly
disagree Disagree disagree
14.
Agree
Strongly
agree
The school mental health provider(s) has/have
involved families to address their children’s
mental health needs.
1
2
3
4
5
The school mental health provider(s) has/have
worked collaboratively with school staff to
develop/strengthen the mental health program
at this school.
1
2
3
4
5
16.
Our school has benefitted from the services
offered by the school mental health provider(s).
1
2
3
4
5
17.
In general, students who receive services from
the school mental health provider(s) improve
their school grades.
1
2
3
4
5
In general, the behavior of students who receive
services from the school mental health
provider(s) improves.
1
2
3
4
5
15.
18.
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
5
CHILD ID:
School Administrator Questionnaire (SAQ)
Neither
Strongly
agree nor
disagree Disagree disagree
19.
The services our students receive are of the best
quality.
For all variables and data elements:
Date last modified: January 2011
1
666 = Not Applicable
777 = Refused
2
3
Agree
Strongly
agree
4
5
888 = Don’t Know
999 = Missing
6
Child Welfare Sector Study Review Form (CWSR)
This instrument is to be completed by the field research coordinators in coordination with staff at
the child welfare agencies. The field research coordinators employed by ICF will complete the
form for each child after the baseline interview has been conducted, and will update the forms
for all participants near the end of the study. The instrument will be completed for children in the
SOC and comparison sites who are enrolled in the Child Welfare Sector Study. Information will
be collected about the types of services the child, biological family, and/or foster family have
been receiving from the public child welfare agency, placement history, current child welfare
goal, existing service plans, and risk factors of the biological parent(s).
Date last modified: January 2011
OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
CHILD WELFARE SECTOR STUDY RECORD
REVIEW FORM—Intake (CWSR–I)
/
CWSRQIDATE (Today’s date)
Month
/
Day
Year
CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)
1 = Intake
Please use this form to record information located in the child’s child welfare record. Follow
these steps for each record:
Begin by reviewing the entire record.
Identify information pertaining to the most recent report of child welfare involvement,
and use the information to answer questions 1A through 1O.
Proceed to the next most recent report of child welfare involvement, and use the
information to answer questions 2A through 2O.
Repeat these steps for all additional child welfare reports.
Guidance for completing certain items on the form are included as embedded comments in
separate document. Please refer to these comments while completing the form.
CHILD ID:
1.
Child Welfare Sector Study Record Review—Intake (CWSR–I)
Please indicate the type of maltreatment that was alleged that led to (child’s name)’s current
involvement with the child welfare system. [Select all that apply]
1 = Neglect
2 = Medical neglect
3 = Physical abuse
4 = Sexual abuse
5 = Psychological maltreatment
6 = Other—please indicate the type of maltreatment or the reason for child welfare
services ____________________________________________
2.
When did (child’s name) begin receiving in-home or out-of-home placement services?
_____ month __________ year
3.
Has (child’s name) had previous episodes of involvement with a public child welfare agency?
1 = No [GO TO QUESTION #4]
2 = Yes
3a.
Please list each previous episode of involvement with a public child welfare agency.
Episode
Dates (mo/yr – mo/yr) Type of Involvement
1st episode
___/___ – ___/___
__________________________________________
2nd episode
___/___ – ___/___
__________________________________________
3rd episode
___/___ – ___/___
__________________________________________
4th episode
___/___ – ___/___
__________________________________________
5th episode
___/___ – ___/___
__________________________________________
6th episode
___/___ – ___/___
__________________________________________
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
1
CHILD ID:
4.
Child Welfare Sector Study Record Review—Intake (CWSR–I)
Did (child’s name) receive any of the following services in the past 6 months? [Select all that apply]
1 = Early Head Start services
2 = Head Start services
3 = Services through Part B of IDEA–Assistance for Education of All Children with
Disabilities [List and describe the services provided]
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
4 = Services through Part C of IDEA for Infants and Toddlers with Disabilities [List
and describe the services provided]
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
5 = Other early intervention services [List and describe the services provided]
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
6 = Primary health care [List and describe the services provided]
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
7 = Other [List and describe the services provided]
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
5.
What services currently are being provided or were provided to the family in the past 6 months (e.g.,
substance abuse services, therapy, respite, home visitation, etc.)? [List and describe each service]
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
2
CHILD ID:
6.
Child Welfare Sector Study Record Review—Intake (CWSR–I)
What training/parent education currently is being provided or was provided to the family in the past
6 months? [List and describe each service]
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
7.
What is (child’s name)’s current placement status?
1 = In-home placement [GO TO QUESTION #13]
2 = Out-of-home placement
8.
What is (child’s name)’s current out-of-home placement setting?
1 = Kinship care
2 = Foster care with unrelated adults
3 = Therapeutic foster care with unrelated adults
4 = Residential treatment
5 = Group home
6 = Other—please specify ____________________________________________
9.
For this current out-of-home placement, what was the date (child’s name) began living in his/her
current setting?
_____ month __________ year
10. For this current out-of-home placement, in how many different settings has (child’s name) lived?
_____ placement settings
10a. If there has been more than one living setting in the current episode of out-of-home placement,
please provide the dates and types of the previous placement settings.
Placement
Dates (mo/yr – mo/yr) Type
Reason for Ending Placement
1st placement
___/___ – ___/___
_________ ______________________________
2nd placement
___/___ – ___/___
_________ ______________________________
3rd placement
___/___ – ___/___
_________ ______________________________
4th placement
___/___ – ___/___
_________ ______________________________
5th placement
___/___ – ___/___
_________ ______________________________
6th placement
___/___ – ___/___
_________ ______________________________
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
3
CHILD ID:
Child Welfare Sector Study Record Review—Intake (CWSR–I)
11. What services currently are being provided or were provided to the out-of-home placement resource
in the past 6 months (e.g., substance abuse services, therapy, respite, home visitation, etc.)? [List
and describe each service]
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
12. What training/education currently is being provided or was provided to the out-of-home placement
resource in the past 6 months? [List and describe each service]
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
13. At the time that the current episode of child welfare involvement started, who was (child’s name)’s
primary cargiver?
1 = Biological mother
2 = Biological father
3 = Other—please specify ____________________________________________
14.
Risk factors of biological parents identified at start of current episode of involvement with the
public child welfare agency: [Indicate yes or no for each]
Risk Factor
Mother
No
Yes
Father
No
Yes
a. Mental health issue: Mood disorder (e.g., depression, bipolar)
1
2
1
2
b. Mental health issue: Anxiety disorder
1
2
1
2
c. Mental health issue: Severe mental illness (e.g., schizophrenia,
psychosis)
1
2
1
2
d. Mental retardation or borderline mental functioning
1
2
1
2
e. Substance abuse issues (drugs and/or alcohol)
1
2
1
2
f.
1
2
1
2
g. Domestic violence
1
2
1
2
h. Teen parent (19 years of age or younger when child was born)
1
2
1
2
i.
Parental history of maltreatment
1
2
1
2
j.
Child living with single parent
1
2
1
2
k. Incarcerated parent
1
2
1
2
l.
1
2
1
2
1
2
1
2
Physical health problems
Social isolation
m. Poverty
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
4
CHILD ID:
Child Welfare Sector Study Record Review—Intake (CWSR–I)
Risk Factor
Mother
No
Yes
Father
No
Yes
n. Unemployment
1
2
1
2
o. Other—please specify _______________________________
1
2
1
2
15. What types of service plans does (child’s name) have? [Select all that apply]
1 = Child welfare
2 = Early intervention
3 = System of care/mental health
4 = Head Start
5 = Other—please specify ____________________________________________
16. Were any service planning meetings held in the past 6 months for (child’s name)?
1 = No [END OF QUESTIONNAIRE]
2 = Yes
16a. How many meetings for each type of service plan were held?
Type of Planning Meeting
1 = Child welfare
2 = Early intervention
3 = System of care/mental health
4 = Head Start
5 = Other—please specify
____________________________________
# of meetings held
________
________
________
________
________
17. Please identify all who attended service planning meetings and how many meetings they attended.
Person Participating
Number of Meetings Attended
a.
Biological parent(s)
_____
b.
Non-relative foster parent(s)
_____
c.
Kin providing foster care
_____
d.
Child
_____
e.
Other family member
_____
f.
Friend(s) of the family
_____
g.
Child welfare staff (e.g., social worker/case manager, supervisor, etc.)
_____
h.
SOC care coordinator
_____
i.
Early Head Start staff
_____
j.
Early intervention services staff
_____
k.
Mental health provider
_____
l.
Other—please specify _____________________________
_____
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
5
Child Welfare Sector Study Review Form (CWSR)
This instrument is to be completed by the field research coordinators in coordination with staff at
the child welfare agencies. The field research coordinators employed by ICF will complete the
form for each child after the baseline interview has been conducted, and will update the forms
for all participants near the end of the study. The instrument will be completed for children in the
SOC and comparison sites who are enrolled in the Child Welfare Sector Study. Information will
be collected about the types of services the child, biological family, and/or foster family have
been receiving from the public child welfare agency, placement history, current child welfare
goal, existing service plans, and risk factors of the biological parent(s).
Date last modified: January 2011
OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
CHILD WELFARE SECTOR STUDY RECORD
REVIEW FORM—Follow-Up (CWSR–F)
/
CWSRQFDATE (Today’s date)
Month
/
Day
Year
CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months
Please use this form to record information located in the child’s child welfare record. Follow
these steps for each record:
Begin by reviewing the entire record.
Identify information pertaining to the most recent report of child welfare involvement,
and use the information to answer questions 1A through 1O.
Proceed to the next most recent report of child welfare involvement, and use the
information to answer questions 2A through 2O.
Repeat these steps for all additional child welfare reports.
Guidance for completing certain items on the form are included as embedded comments in
separate document. Please refer to these comments while completing the form.
CHILD ID:
1.
Child Welfare Sector Study Record Review—Follow-Up (CWSR–F)
Did (child’s name) receive any of the following services in the past 6 months? [Select all that apply]
1 = Early Head Start services
2 = Head Start services
3 = Services through Part B of IDEA–Assistance for Education of All Children with
Disabilities [List and describe the services provided]
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
4 = Services through Part C of IDEA for Infants and Toddlers with Disabilities [List
and describe the services provided]
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
5 = Other early intervention services [List and describe the services provided]
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
6 = Primary health care [List and describe the services provided]
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
7 = Other [List and describe the services provided]
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
2.
What services currently are being provided or were provided to the family in the past 6 months (e.g.,
substance abuse services, therapy, respite, home visitation, etc.)? [List and describe each service]
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
1
CHILD ID:
3.
Child Welfare Sector Study Record Review—Follow-Up (CWSR–F)
What training/parent education currently is being provided or was provided to the family in the past
6 months? [List and describe each service]
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
4.
Is (child’s name) currently involved with the child welfare system?
1 = No
2 = Yes [GO TO QUESTION #5]
4a.
When did (child’s name)’s involvement with the child welfare system end?
_____ month __________ year [END OF QUESTIONNAIRE]
5.
Is this the same episode of involvement with child welfare indicated at the previous record
review/interview?
1 = No
2 = Yes [GO TO QUESTION #8]
6.
Please indicate the type of maltreatment that was alleged that led to (child’s name)’s current
involvement with the child welfare system. [Select all that apply]
1 = Neglect
2 = Medical neglect
3 = Physical abuse
4 = Sexual abuse
5 = Psychological maltreatment
6 = Other—please indicate the type of maltreatment or the reason for child welfare
services ____________________________________________
7.
When did (child’s name) begin receiving the current in-home or out-of-home placement services?
_____ month __________ year
8.
At the time that the current episode of child welfare involvement started, who was (child’s name)’s
primary cargiver?
1 = Biological mother
2 = Biological father
3 = Other—please specify ____________________________________________
9.
What is (child’s name)’s current placement status?
1 = In-home placement [GO TO QUESTION #15]
2 = Out-of-home placement
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
2
CHILD ID:
Child Welfare Sector Study Record Review—Follow-Up (CWSR–F)
10. What is (child’s name)’s current out-of-home placement setting?
1 = Kinship care
2 = Foster care with unrelated adults
3 = Therapeutic foster care with unrelated adults
4 = Residential treatment
5 = Group home
6 = Other—please specify ____________________________________________
11. How many different settings has (child’s name) had in the past 6 months?
1 = 1 placement setting [GO TO QUESTION #12]
2 = More than 1 placement setting
11a. Please indicate the number of placement settings (child’s name) has had in the past 6 months.
_____ placement settings
11b. Please provide the dates and types of the previous placement settings.
Placement
Dates (mo/yr – mo/yr) Type
Reason for Ending Placement
1st placement
___/___ – ___/___
_________ ______________________________
2nd placement
___/___ – ___/___
_________ ______________________________
3rd placement
___/___ – ___/___
_________ ______________________________
4th placement
___/___ – ___/___
_________ ______________________________
5th placement
___/___ – ___/___
_________ ______________________________
6th placement
___/___ – ___/___
_________ ______________________________
12. What is the current child welfare goal for (child’s name)?
1 = Reunification
2 = Kinship guardianship
3 = Non-kin guardianship
4 = Adoption
5 = Other—please specify ____________________________________________
13. What services currently are being provided or were provided to the out-of-home placement resource
in the past 6 months (e.g., substance abuse services, therapy, respite, home visitation, etc.)? [List
and describe each service]
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
3
CHILD ID:
Child Welfare Sector Study Record Review—Follow-Up (CWSR–F)
14. What training/education currently is being provided or was provided to the out-of-home placement
resource in the past 6 months? [List and describe each service]
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
15. Were any service planning meetings held in the past 6 months for (child’s name)?
1 = No [END OF QUESTIONNAIRE]
2 = Yes
15a. How many meetings for each type of service plan were held?
Type of Planning Meeting
1 = Child welfare
2 = Early intervention
3 = System of care/mental health
4 = Head Start
5 = Other—please specify
____________________________________
# of meetings held
________
________
________
________
________
16. Please identify all who attended service planning meetings and how many meetings they attended.
Person Participating
Number of Meetings Attended
a.
Biological parent(s)
_____
b.
Non-relative foster parent(s)
_____
c.
Kin providing foster care
_____
d.
Child
_____
e.
Other family member
_____
f.
Friend(s) of the family
_____
g.
Child welfare staff (e.g., social worker/case manager, supervisor, etc.)
_____
h.
SOC care coordinator
_____
i.
Early Head Start staff
_____
j.
Early intervention services staff
_____
k.
Mental health provider
_____
l.
Other—please specify _____________________________
_____
For all variables and data elements:
Date last modified: January 2011
666 = Not Applicable
777 = Refused
888 = Don’t Know
999 = Missing
4
Attachment F: Services and Costs Study
OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 20 minutes per record, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.
FLEXIBLE FUNDS DATA DICTIONARY
Variable
Name
Variable Description
Format
Field
Length
Formats & Codes
CHILDID
National Evaluation Child ID. The child
identification number assigned for the
national evaluation. This number is 9
digits. The first 3 digits represent the
program, the fourth and fifth digits are
determined by local evaluators, and
the final 4 digits are unique child
identifiers.
NUM
9
100000000 – 199999999
Range will be more specific to
each community.
CATEGORY
Expenditure Category. The numeric
code and description for the
expenditure for which the flexible
funds were spent. (Refer to
Appendix D: Flexible Funds
Expenditure Category Definitions
for additional clarification and
examples of the different categories.)
TEXT
52
1=Housing
2=Utilities
3=Environmental Modification
4=Furnishings/Appliances
5=Supplies
6=Food/Groceries
7=Clothing
8=Activities
9=Educational Support
10=Day Care and Support
11=Automobile
12=Transportation
14=Incentive
15=Legal
16=Medical
17=Mental Health Services (Child)
18=Mental Health Services
(Caregiver / Family Member)
19=Camp
20=Training (Caregiver / Family
Member)
21=Training (Child)
22=Other (Specify)
If “22=Other” is selected, details
should be provided in the “Expenditure
Details/Notes/Comments” field.
Note: Code number 13 has been
deleted.
DETAILS
Expenditure Details/Notes/
Comments. A description of the
specific item, service, or activity the
flexible funds were used to purchase
that would help clarify the expenditure.
Use this field to describe any
expenditure listed in the Expenditure
Category field as “22=Other.”
TEXT
70
EXPDATE
Expenditure Date. The date the
flexible funds were disbursed.
DATE
10
mm/dd/yyyy
A data validation rule requires
that this date be between
10/01/2005 and 09/30/2016.
AMTPAID
Total Amount Paid by Flexible Funds.
The total amount of flexible funds
spent on this item, service, or activity.
NUM
8.2
0.00 – 999,999.99
Comprehensive Community Mental Health Services for Children and Their Families Program
A – Z; 0 – 9
OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB
control number for this project is 0930-0307. Public reporting burden for this collection of information is estimated to average 20 minutes per record, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road,
Room 7-1044, Rockville, Maryland, 20857.
National Evaluation of the Comprehensive Community Mental Health Services
for Children and Their Families Program
SERVICES AND COSTS DATA DICTIONARY
Variable
Name
CHILDID*
Variable Description
Child/youth identification number assigned for the
national evaluation. First three digits indicate the site
number, fourth digits and fifth digits are determined by
the local evaluation, final four digits are unique child
identifiers. This is the same Child ID used for the
national evaluation’s Cross-Sectional Descriptive
Study and Longitudinal Child and Family Outcome
Study. *This is a required field for all data records.
SERVICE ENROLLMENT DATES
ENROLL1
Date the child was first enrolled in system of care and
eligible for services.
DISCHRG1
Date of first discharge from system of care services.
ENROLL2
Date the child was re-enrolled in system of care (2nd
enrollment) and again eligible for services. This field
may be left blank if there is no second episode of
enrollment and discharge.
DISCHRG2
Date of second discharge from system of care
services. This field may be left blank if there is no
second episode of enrollment and discharge.
ENROLL3
Date the child was re-enrolled in system of care (3rd
enrollment) and again eligible for services. This field
may be left blank if there is no third episode of
enrollment and discharge.
DISCHRG3
Date of third discharge from system of care services.
This field may be left blank if there is no third episode
Format
NUM
Field
Length
9
DATE
10
MM/DD/YYYY
DATE
DATE
10
10
MM/DD/YYYY
MM/DD/YYYY
DATE
10
MM/DD/YYYY
DATE
10
MM/DD/YYYY
DATE
10
MM/DD/YYYY
Comprehensive Community Mental Health Services for Children and Their Families Program
Codes
100000000 – 199999999
(range will be more specific to each community)
Variable
Name
Variable Description
of enrollment and discharge.
DATE OF SERVICE
START*
Start date of service. If length of service is 1 day or
less, enter the date of service in START and leave
END blank. * This is a required field for all data
records.
END
End date of service. If length of service is more than 1
day, enter the first date of service in START and the
last date of service in END. This field may be left
blank if length of service is 1 day or less.
SERVICE TYPE*
* This is a required field for all data records.
CPT
Current Procedural Terminology (CPT-4): Level I
codes. Official definitions for CPT-4 codes commonly
used for systems of care services are provided in
Attachment A.
or
HCPCS
Healthcare Common Procedure Coding System
(HCPCS): Level II codes. Official definitions for
HCPCS codes commonly used for systems of care
services are provided in Attachment A.
or
ICD9
International Classification of Diseases, 9th Revision,
Clinical Modification (ICD-9-CM)—Procedure Codes.
Official definitions for ICD-9-CM procedure codes
commonly used for systems of care services are
provided in Attachment A.
or
SVCTYPE
Type of service. Further definitions of service
categories are provided in Attachment B.
Format
Field
Length
DATE
10
MM/DD/YYYY (may precede the child’s first enrollment date into system
of care by one year)
DATE
10
MM/DD/YYYY
TEXT
5
0 – 9; i.e., 96150
TEXT
5
A – Z; 0 – 9; i.e., H0002
NUM
5
0 - 9; 4 digits with an explicit decimal, i.e., 94.42
NUM
2
General Community-based / Episodic Services
1=Intake / screening / diagnosis / assessment
2=Evaluation
3=Consultation / meeting
4=Case management / clinical coordination
5=Service planning
6=Crisis intervention / crisis stabilization / crisis hotline
7=Emergency room psychiatric service
8=Early intervention / prevention
9=Caregiver support / family support
10=Respite care
11=Advocacy
12=Legal service
13=Recreational activity / recreational therapy
Comprehensive Community Mental Health Services for Children and Their Families Program
Codes
Variable
Name
Variable Description
Format
Field
Length
Codes
14=After-school program or childcare
15=Training / tutoring / education / mentoring
16=Behavioral / therapeutic aide service
17=Medication treatment / administration / monitoring
18=Medical care / physical health care / laboratory related to mental health
19=Day treatment / partial-day treatment
20=Individual therapy / counseling / psycho-social therapy / play therapy
21=Group therapy / group counseling
22=Family therapy / family counseling
23=Psycho-social rehabilitation / cognitive rehabilitation
24=Tribal healing service
25=Social work service
26=Vocational / life skills training / independent living skills / youth transition
27=Transportation
Services Specific to Child Welfare
28=Child protective service
29=Case evaluation and monitoring
30=Family preservation
31=Adoption service
32=Therapeutic foster care / therapeutic group home
33=Family foster care, with non-relative / non-therapeutic foster care
34=Group foster care
35=Relative care
Services Specific to Juvenile Justice
36=Diversion / prevention service
37=Court services
38=Juvenile detention
39=Jail or prison
40=Parole / aftercare service
41=Probation / monitoring
Services Specific to Special Education and Early Care Programs
42=Early Head Start Program
43=Early Intervention (Part C)
44=Head Start Program
45=Preschool Special Education Program (Part B)
46=Other Early Care and Education Programs
47=Special education class, self contained
48=Special education resource service
49=Special education, inclusion
Comprehensive Community Mental Health Services for Children and Their Families Program
Variable
Name
Variable Description
Format
Field
Length
Codes
50=Physical, occupational, speech, hearing, or language service
51=Teacher aide service / other paraprofessional service
Informal, Natural Support, In-Kind, Volunteer Services
52=Self-help group / peer counseling / support group
53=Counseling from clergy
54=Informal transportation
Inpatient and Residential Services (Other than Foster Care)
55=Inpatient evaluation
56=Inpatient consultation
57=Inpatient behavioral health service
58=Residential therapeutic camp / wilderness program
59=Residential treatment service, non-hospital
60=Residential care / custodial care
61=Shelter placement
SVCOTH
Description of other service type in SVCTYPE=62. If
other is unknown, enter “-999”.
PROVIDER AGENCY / SERVICE SECTOR
AGENCY
The service sector or type of agency providing the
service. This might include both public agencies and
private providers.
TEXT
50
NUM
2
AGENOTH
TEXT
50
NUM
2
Description of other service sector or agency type
providing the service in AGENCY=8. If other is
unknown, enter “-999”.
PROVIDER TYPE
PROVIDER
Type of individual providing the service. Further
definitions of provider categories are provided in
Attachment B.
Comprehensive Community Mental Health Services for Children and Their Families Program
Other Service Type
62=Other service type, please specify
A – Z; 0 – 9; or -999
1=Mental health
2=Child welfare / social services
3=Juvenile justice (juvenile court, corrections, probation)
4=Education / school / early childhood program / childcare organization
5=Pediatrician / physical health care provider
6=Family organization
7=Youth organization
8=Other, please specify
A – Z; 0 – 9; or -999
1=Case manager / care coordinator
2=Psychologist (Ph.D. or similar credential)
3=Mental health professional / licensed professional counselor
4=Social worker
5=Recreational therapist / behavioral aide / respite worker / other mental
health staff
6=Tribal healer
Variable
Name
PROVOTH
Variable Description
Description of other in PROVIDER=32. If other is
unknown, enter “-999”.
SERVICE LOCATION
LOCATION
Location where service was provided. Further
definitions of location categories are provided in
Attachment B.
Format
Field
Length
TEXT
50
NUM
2
Comprehensive Community Mental Health Services for Children and Their Families Program
Codes
7=Faith-based professional
8=Psychiatrist (M.D. or similar credential)
9=Physical health care physician / pediatrician
10=Nurse practitioner / physician’s assistant
11=Nurse / psychiatric nurse
12=Alternative health care practitioner
13=Medical technician / laboratory
14=Child protective services worker / child protective investigator / foster
care case worker
15=Foster family / foster parent
16=Teacher / special education teacher / resource teacher
17=School counselor / school psychologist
18=Speech, language therapist / audiologist / occupational or
physical therapist
19=Teacher aide / educational paraprofessional
20=Tutor
21=Childcare provider
22=Court services worker
23=Detention / corrections staff
24=Probation / parole officer
25=Youth coordinator
26=Youth
27=Family member / relative / friend / neighbor / volunteer
28=Advocate / family advocate / education advocate / court advocate
29=Mentor
30=Program support staff
31=Driver
32=Other, please specify
A – Z; 0 – 9; or -999
1=Office / independent clinic
2=Public health clinic / rural health clinic / federally qualified health center
3=Indian health service / Tribal 638 facility
4=Community mental health center
5=Social service center or agency
6=Ambulance
7=Mobile unit
8=Urgent care facility
9=Inpatient hospital
10=Outpatient hospital
11=Emergency room – hospital
Variable
Name
Variable Description
LOCATOTH
Description of other in LOCATION=24. If other is
unknown, enter “-999”.
SERVICE UNITS
NUMBER
Number of service units
SVCUNIT
Unit of service
COSTS AND PAYMENT SOURCE
Amounts Charged
CHGMEDCD Total amount charged for this service to Medicaid
CHGSCHIP
Total amount charged for this service to SCHIP
CHGCMHI
Total amount charged for this service to SAMHSA
CMHI cooperative agreement
CHGMH
Total amount charged for this service to a mental
health agency or provider
CHGCW
Total amount charged for this service to a child
welfare or social services agency
CHGJJ
Total amount charged for this service to juvenile
justice (juvenile court, corrections, or probation)
CHGEDUC
Total amount charged for this service to education,
early childhood program, or childcare organization
Format
Field
Length
TEXT
50
NUM
NUM
8.2
1
NUM
NUM
NUM
8.2
8.2
8.2
0.00 – 999999.99
0.00 – 999999.99
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
Comprehensive Community Mental Health Services for Children and Their Families Program
Codes
12=Inpatient psychiatric hospital / facility
13=Psychiatric facility-partial hospitalization
14=Residential psychiatric treatment center
15=Correctional facility
16=Homeless shelter / temporary lodging
17=School
18=Home
19=Group home / custodial care facility
20=Pharmacy
21=Independent laboratory
22=Other community location / public place (i.e., Boys/Girls Club,
YMCA, library, place of worship)
23=Phone
24=Other place of service, please specify
A – Z; 0 – 9; or -999
1.00 – 999999.99
1=minute
2=hour
3=day
4=week
5=month
6=year
7=visit / session
8=call / contact
9=report
Variable
Name
CHGTRIBE
CHGIHS
CHGFAM
CHGYOUTH
CHGFDTN
CHGPRIV
CHGCLIEN
CHGOTHER
CHGOTH
PAYMEDCD
PAYSCHIP
PAYCMHI
PAYMH
PAYCW
PAYJJ
PAYEDUC
PAYTRIBE
PAYIHS
PAYFAM
Variable Description
Total amount charged for this service to a Tribal
government, agency, or organization
Total amount charged for this service to the Indian
Health Service
Total amount charged for this service to a family
organization
Total amount charged for this service to a youth
organization
Total amount charged for this service to a foundation
or other private funding
Total amount charged for this service to private
insurance
Total amount charged for this service to client out-ofpocket
Total amount charged for this service to other payer.
Please specify type of other payer in CHGOTH. If
charge data are available, but source of payment is
not available, enter charge amounts in this
CHGOTHER variable and enter “payment source
unknown” in CHGOTH,
Description of other payer in CHGOTHER. If other is
unknown, enter “-999”.
Amounts Paid
Total amount paid for this service by Medicaid
Total amount paid for this service by SCHIP
Total amount paid for this service by SAMHSA CMHI
cooperative agreement
Total amount paid for this service by a mental health
agency or provider
Total amount paid for this service by a child welfare or
social services agency
Total amount paid for this service by juvenile justice
(juvenile court, corrections, or probation)
Total amount paid for this service by education, early
childhood program, or childcare organization
Total amount paid for this service by a Tribal
government, agency, or organization
Total amount paid for this service by the Indian Health
Service
Total amount paid for this service by a family
organization
Format
NUM
Field
Length
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
TEXT
50
A – Z; 0 – 9; or -999
NUM
NUM
NUM
8.2
8.2
8.2
0.00 – 999999.99
0.00 – 999999.99
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
Comprehensive Community Mental Health Services for Children and Their Families Program
Codes
Variable
Name
PAYYOUTH
Variable Description
Total amount paid for this service by a youth
organization
PAYFDTN
Total amount paid for this service by a foundation or
other private funding
PAYPRIV
Total amount paid for this service by private insurance
PAYCLIEN
Total amount paid for this service by client out-ofpocket
PAYOTHER
Total amount paid for this service by other payer.
Please specify type of other payer in PAYOTH. If
payment data are available, but source of payment is
not available, enter payment amounts in this
PAYOTHER variable and enter “payment source
unknown” in PAYOTH,
PAYOTH
Description of other payer in PAYOTHER. If other is
unknown, enter “-999”.
PAYESTIM
Flag to indicate whether any of the payment amounts
represent an estimated amount, rather than actual
amount.
UNPAID SERVICE ESTIMATES
ESTIMATE
Total amount estimated as the value of the unpaid
informal, natural support, in-kind, or volunteer service.
If the service is not an unpaid service, enter “-666” in
this field to identify it as not applicable.
Format
NUM
Field
Length
8.2
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
NUM
NUM
8.2
8.2
0.00 – 999999.99
0.00 – 999999.99
NUM
8.2
0.00 – 999999.99
TEXT
50
A – Z; 0 – 9; or -999
NUM
2
1=Actual
2=Estimated
NUM
8.2
Comprehensive Community Mental Health Services for Children and Their Families Program
Codes
0.00 – 999999.99 or -666
SERVICES AND COSTS DATA DICTIONARY— ATTACHMENT A
CODE DEFINITIONS FOR CPT-4 CODES, HCPCS CODES, AND ICD-9-CM PROCEDURE CODES
CPT-4 codes are assigned and maintained by the American Medical Association. HCPCS codes are assigned and maintained by the Centers for
Medicare and Medicaid Services. ICD-9-CM procedure codes are maintained jointly by the National Center for Health Statistics (NCHS) and the
Centers for Medicare & Medicaid Services (CMS).
Note: Procedure codes approved for reimbursement vary by State; not all procedure codes are approved for reimbursement through Medicaid in all
States. The codes listed in this attachment are representative of most codes in use for behavioral health and related care, but are not intended to be
exhaustive or definitive.
Code
Description
Current Procedural Terminology (CPT-4): Level I - Psychiatric Codes
90801
Psychiatric diagnostic interview examination
90802
Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication
90804
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face
with the patient
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face
with the patient; with medical evaluation and management services
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face
with the patient
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face
with the patient; with medical evaluation and management services
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face
with the patient
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face
with the patient; with medical evaluation and management services
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an
office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an
office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient with medical evaluation and management services
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an
office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an
office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an
office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient
90805
90806
90807
90808
90809
90810
90811
90812
90813
90814
Comprehensive Community Mental Health Services for Children and Their Families Program
Code
Description
90815
90845
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an
office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting,
approximately 20 to 30 minutes face-to-face with the patient
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting,
approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting,
approximately 45 to 50 minutes face-to-face with the patient
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting,
approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting,
approximately 75 to 80 minutes face-to-face with the patient
Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting,
approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an
inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an
inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and
management services
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an
inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an
inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and
management services
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an
inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an
inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and
management services
Psychoanalysis
90846
Family psychotherapy (without the patient present)
90847
Family psychotherapy (conjoint psychotherapy) (with patient present)
90849
Multiple family group psychotherapy
90853
Group psychotherapy (other than of a multiple-family group)
90857
Interactive group psychotherapy
90862
Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy
90816
90817
90818
90819
90821
90822
90823
90824
90826
90827
90828
90829
Comprehensive Community Mental Health Services for Children and Their Families Program
Code
Description
90875
90880
Individual psycho-physiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (e.g., insight
oriented, behavior modifying or supportive psychotherapy); (approx. 20-30 minutes)
Individual psycho-physiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (e.g., insight
oriented, behavior modifying or supportive psychotherapy); (approx. 45-50 minutes)
Hypnotherapy
90882
Environmental intervention for medical management purposes on a psychiatric patient's behalf with agencies, employers, or institutions
90885
Psychiatric evaluation of hospital records, other psychiatric reports, psychometric and/or projective tests, and other accumulated data for medical diagnostic
purposes
Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible
persons, or advising them how to assist patient
Preparation of report of patient's psychiatric status, history, treatment, or progress (other than legal or consultative purposes) for other physicians, agencies, or
insurance carriers
Unlisted psychiatric service or procedure
90876
90887
90889
90899
Current Procedural Terminology (CPT-4): Level I - Health Behavior Assessment & Intervention (HBAI) Codes
These codes typically apply to mental health procedures used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the
prevention, treatment, or management of physical health problems. They are intended for use by specific mental health care professionals who provide mental health
services related to a physical, not a mental health, diagnosis.1
96101 Psychological testing (includes psycho-diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology (e.g., MMPI, Rorschach,
WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and
preparing the report
96102 Psychological testing (includes psycho-diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology (e.g., MMPI and WAIS),
with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face
96103 Psychological testing (includes psycho-diagnostic assessment of emotionality, intellectual abilities, personality and psychopathology (e.g., MMPI), administered
by a computer, with qualified health care professional interpretation and report
96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability,
reading, spelling, writing (e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour
96111 Developmental testing; extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental
instruments) with interpretation and report
96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment (e.g., acquired knowledge, attention, language, memory, planning and
problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test
results and preparing the report
96118 Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the
psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report
96119
96120
96150
Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified
health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face
Neuropsychological testing (e.g., Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report
Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psycho-physiological monitoring, health-oriented
questionnaires), each 15 minutes face-to-face with the patient; initial assessment
Comprehensive Community Mental Health Services for Children and Their Families Program
Code
Description
96151
96152
Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psycho-physiological monitoring, health-oriented
questionnaires), each 15 minutes face-to-face with the patient; re-assessment
Health and behavior intervention, each 15 minutes, face-to-face; individual
96153
Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients)
96154
Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present)
96155
Health and behavior intervention, each 15 minutes, face-to-face; family (without the patient present)
Current Procedural Terminology (CPT-4): Level I - Evaluation & Management (EM) Codes
These codes typically apply to services unique to medical management, such as laboratory results, medical diagnostic evaluations, and medication management,
performed by physicians, nurse practitioners, clinical nurse specialists, and physician assistants, but not clinical psychologists and clinical social workers.1
99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a
problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians
typically spend 10 minutes face-to-face with the patient and/or family.
99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused
history; an expanded problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to
moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.
99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed
examination; medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with
the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30
minutes face-to-face with the patient and/or family.
99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a
comprehensive examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high
severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family.
99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a
comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity.
Physicians typically spend 60 minutes face-to-face with the patient and/or family.
99211 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the
presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.
99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem
focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or
minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded
problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coordination of care with
other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s)
Comprehensive Community Mental Health Services for Children and Their Families Program
Code
99214
99215
99241
99242
99243
99244
99245
99251
99252
99253
Description
are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed
history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high
severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a
comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers
or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of
moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.
Office consultation for a new or established patient, which requires these 3 key components: a problem focused history; a problem focused examination; and
straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the
problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-toface with the patient and/or family.
Office consultation for a new or established patient, which requires these 3 key components: an expanded problem focused history; an expanded problem
focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically
spend 30 minutes face-to-face with the patient and/or family.
Office consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision
making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and
the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the
patient and/or family.
Office consultation for a new or established patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and
medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend
60 minutes face-to-face with the patient and/or family.
Office consultation for a new or established patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and
medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of
the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80
minutes face-to-face with the patient and/or family.
Inpatient consultation for a new or established patient, which requires these 3 key components: a problem focused history; a problem focused examination; and
straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the
problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 20 minutes at the
bedside and on the patient's hospital floor or unit.
Inpatient consultation for a new or established patient, which requires these 3 key components: an expanded problem focused history; an expanded problem
focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically
spend 40 minutes at the bedside and on the patient's hospital floor or unit.
Inpatient consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision
making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and
the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on
the patient's hospital floor or unit.
Comprehensive Community Mental Health Services for Children and Their Families Program
Code
Description
99254
Inpatient consultation for a new or established patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and
medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend
80 minutes at the bedside and on the patient's hospital floor or unit.
Inpatient consultation for a new or established patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and
medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of
the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 110
minutes at the bedside and on the patient's hospital floor or unit.
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history;
An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to
moderate severity.
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history;
An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers
or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of
moderate severity.
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed
examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent
evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.
Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high
complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's
and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.
Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a
problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are
provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physicians
typically spend 20 minutes with the patient and/or family or caregiver.
Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused
history; an expanded problem focused examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers
or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of
moderate severity. Physicians typically spend 30 minutes with the patient and/or family or caregiver.
Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed
examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided
consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity.
Physicians typically spend 45 minutes with the patient and/or family or caregiver.
Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a
comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are
provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Physicians
typically spend 60 minutes with the patient and/or family or caregiver.
Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a
99255
99282
99283
99284
99285
99324
99325
99326
99327
99328
Comprehensive Community Mental Health Services for Children and Their Families Program
Code
99334
99335
99336
99337
99341
99342
99343
99344
99345
99371
Description
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are
provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new
problem requiring immediate physician attention. Physicians typically spend 75 minutes with the patient and/or family or caregiver.
Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem
focused interval history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers
or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited
or minor. Physicians typically spend 15 minutes with the patient and/or family or caregiver.
Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded
problem focused interval history; an expanded problem focused examination; medical decision making of low complexity. Counseling and/or coordination of
care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting
problem(s) are of low to moderate severity. Physicians typically spend 25 minutes with the patient and/or family or caregiver.
Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed
interval history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or
agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate
to high severity. Physicians typically spend 40 minutes with the patient and/or family or caregiver.
Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a
comprehensive interval history; a comprehensive examination; medical decision making of moderate to high complexity. Counseling and/or coordination of care
with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting
problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician
attention. Physicians typically spend 60 minutes with the patient and/or family or caregiver.
Home visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused
examination; and straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with
the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 20
minutes face-to-face with the patient and/or family
Home visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an
expanded problem focused examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate
severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.
Home visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and
medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend
45 minutes face-to-face with the patient and/or family.
Home visit for the evaluation and management of a new patient, which requires these three components: a comprehensive history; a comprehensive
examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity. Physicians typically
spend 60 minutes face-to-face with the patient and/or family.
Home visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive
examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent
with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant new problem requiring
immediate physician attention. Physicians typically spend 75 minutes face-to-face with the patient and/or family.
Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care
Comprehensive Community Mental Health Services for Children and Their Families Program
Code
99372
99373
Description
professionals (e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists); simple or brief (e.g., to report on tests and/or laboratory results, to
clarify or alter previous instructions, to integrate new information from other health professionals into the medical treatment plan, or to adjust therapy)
Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care
professionals (e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists); intermediate (e.g., to provide advice to an established patient on a
new problem, to initiate therapy that can be handled by telephone, to discuss test results in detail, to coordinate medical management of a new problem in an
established patient, to discuss and evaluate new information and details, or to initiate new plan of care)
Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care
professionals (e.g., nurses, therapists, social workers, nutritionists, physicians, pharmacists); complex or lengthy (e.g., lengthy counseling session with anxious
or distraught patient, detailed or prolonged discussion with family members regarding seriously ill patient, lengthy communication necessary to coordinate
complex services of several different health professionals working on different aspects of the total patient care plan)
Current Procedural Terminology (CPT-4): Level I - Other Codes
36415
Collection of venous blood by venipuncture
80053
Comprehensive metabolic panel
80061
Lipid panel
80076
Hepatic function panel
80101
Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class
80164
Dipropylacetic acid (valproic acid)
80178
Lithium
81000
82043
Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of
these constituents; non-automated, with microscopy
Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of
these constituents; non-automated, without microscopy
Albumin; urine, microalbumin, quantitative
82055
Alcohol (ethanol); any specimen except breath
82565
Creatinine; blood
82570
Creatinine; other source
82947
Glucose; quantitative, blood (except reagent strip)
83036
Hemoglobin; glycosylated (A1C)
83655
Lead
83721
Lipoprotein, direct measurement; LDL cholesterol
84146
Prolactin
81002
Comprehensive Community Mental Health Services for Children and Their Families Program
Code
Description
84439
Thyroxine; free
84443
Thyroid stimulating hormone (TSH)
84520
Urea nitrogen; quantitative
85007
Blood count; blood smear, microscopic examination with manual differential WBC count
85025
Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count
85027
Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)
88262
Chromosome analysis; count 15-20 cells, 2 karyotypes, with banding
92507
Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508
Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals
92588
92700
Evoked otoacoustic emissions; comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple
levels and frequencies)
Unlisted otorhinolaryngological service or procedure
93000
Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report
93005
Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report
93010
Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only
93303
Transthoracic echocardiography for congenital cardiac anomalies; complete
93320
94664
Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging);
complete
Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device
94760
Noninvasive ear or pulse oximetry for oxygen saturation; single determination
97003
Occupational therapy evaluation
97110
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97150
Therapeutic procedure(s), group (2 or more individuals)
97530
Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
98966
Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian
not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service
or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian
not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service
or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
98967
Comprehensive Community Mental Health Services for Children and Their Families Program
Code
Description
98968
Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian
not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service
or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion
1
Kautz, C., Mauch, D., & Smith, S. A. Reimbursement of mental health services in primary care settings (HHS Pub. No. SMA-08-4324). Rockville, MD: Center for
Mental Health Services, Substance Abuse and Mental Health Services Administration, 2008.
Health Care Current Procedure Coding System (HCPCS): Level II Codes
A0080
Non emergency transportation, per mile. Vehicle provided by volunteer (individual or organization), with no vested interest
A0090
Non emergency transportation, per mile. Vehicle provided by individual (family member, self, neighbor) with vested interest
A0100
Non emergency transportation services, taxi
A0110
Non-emergency transportation and bus, intra or interstate carrier
A0120
Non-emergency transportation: mini-bus, mountain area transports, or other transportation systems
A0130
Non emergency transportation: wheel-chair van
A0140
Non emergency transportation and air travel (private or commercial) intra or interstate
A0160
Non emergency transportation, per mile- case worker or social worker
A0170
Transportation ancillary: parking fees, tolls, other
A0425
Ground Mileage, per statute mile
A0426
Ambulance service, advanced life support, non-emergency transport, level 1 (Als1)
A0427
Ambulance service, advanced life support, emergency transport, level 1 (Als1_emergency)
A0428
Ambulance service, basic life support, non-emergency transport, (Bls)
H0001
Alcohol and/or drug assessment
H0002
Behavioral health screening to determine eligibility for admission to treatment program
H0003
Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol and or drugs
H0004
Behavioral health counseling and therapy, per 15 minutes
H0017
Behavioral health; residential (hospital residential treatment program), without room and board, per diem
H0018
Behavioral health; short term residential (non-hospital residential treatment program), without room and board, per diem
H0019
Behavioral health; long term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 30 days),
without room and board, per diem
Comprehensive Community Mental Health Services for Children and Their Families Program
H0023
Behavioral health outreach service (planned approach to reach a targeted population)
H0024
H0025
Behavioral health prevention information dissemination service (one-way direct or non-direct contact with service audiences to affect knowledge and
attitude)
Behavioral health prevention education services (delivery of services with target population to affect knowledge, attitude and/or behavior)
H0030
Behavioral health hotline service
H0031
Mental health assessment by non-physician
H0032
Mental health service plan development by non-physician
H0033
Oral medication administration, direct observation
H0034
Medication training and support, per 15 minutes
H0035
Mental health partial hospitalization treatment, less than 24 hours
H0038
Self-help/ peer services per 15 minutes
H0039
Assertive community treatment, face to face, per 15 minutes
H0040
Assertive community treatment program, per diem
H0041
Foster care, child, non-therapeutic, per diem
H0042
Foster care, child, non-therapeutic, per month
H0045
Respite care services, not in the home, per diem
H0046
Mental health services, not otherwise specified
H2000
Comprehensive multidisciplinary evaluation
H2001
Rehabilitation program, per 1/2 day
H2010
Comprehensive medication services, per 15 minutes
H2011
Crisis intervention service, per 15 minutes
H2012
Behavioral health day treatment, per hour
H2014
Skills training and development, per 15 minutes
H2015
Comprehensive community support services, per 15 minutes
H2016
Comprehensive community support services, per diem
H2017
Psychosocial rehabilitation services, per 15 minutes
Comprehensive Community Mental Health Services for Children and Their Families Program
H2018
Psychosocial rehabilitation services, per diem
H2019
Therapeutic behavioral services, per 15 minutes
H2020
Therapeutic behavioral services, per diem
H2021
Community based wrap around services, per 15 minutes
H2022
Community based wrap around services, per diem
H2025
Ongoing support to maintain employment, per 15 minutes
H2026
Ongoing support to maintain employment, per diem
H2027
Psycho-educational service, per 15 minutes
H2030
Mental health clubhouse services, per 15 minutes
H2032
Activity therapy per 15 minutes
H2033
Multi-systemic therapy for juveniles, per 15 minutes
H2037
Developmental delay prevention activities, dependent child of client, per 15 minutes
J0515
Injection benztropine mesylate, per 1 mg
J1200
Injection, diphenhydramine HCL injection up to 50 mg
J1630
Injection, haloperidol, up to 5 mg
J1631
Injection, haloperidol decanoate, per 50 mg
J2680
Injection, fluphenazine decanoate, up to 25 mg
J2794
Injection, risperidone, long acting, 0.5 mg
J3410
Injection, hydroxyzine HCL, up to 25 mg
M0064
S0163
Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality
disorders
Injection, risperidone, Long Acting, 12.5 mg
S0201
Partial hospitalization services, less than 24 hours, per diem
S0215
Non emergency transportation, mileage per mile
S0316
Disease management program, follow-up/reassessment
S5110
Home care training, family; per 15 minutes
S5125
Attendant care services, per 15 minutes
Comprehensive Community Mental Health Services for Children and Their Families Program
S5126
Attendant care services, per diem
S5140
Foster care, adult, per diem
S5145
Foster care, therapeutic, child; per diem
S5146
Foster care, therapeutic, child; per month
S5150
Unskilled respite care, not hospice; per 15 minutes
S5151
Unskilled respite care, not hospice; per diem
S9445
Patient education, not otherwise classified, non-physician provider, individual, per session
S9446
Patient education, not otherwise classified, non-physician provider, group, per session
S9482
Family stabilization services, per 15 minutes
S9484
Crisis intervention, mental health services, per hour
S9485
Crisis intervention, mental health services, per diem
T1005
Respite care services, up to 15 minutes
T1013
Sign language or oral interpretive services, per 15 minutes
T1015
Clinic visit/encounter, all-inclusive
T1016
Case management, each 15 minutes
T1017
Targeted case management each 15 minutes
T1023
T2001
Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol, per
encounter
Non-emergency transportation; patient attendant / escort
T2002
Non emergency transportation; per diem
T2003
Non emergency transportation; encounter/trip
T2004
Non emergency transportation; commercial carrier, multi pass
T2005
Non emergency transportation; stretcher van
T2007
Transportation waiting time, air ambulance and non-emergency vehicle, one-half (1/2) hour increments
T2034
Crisis intervention, waiver; per diem
T2036
Therapeutic camping overnight, waiver each session
Comprehensive Community Mental Health Services for Children and Their Families Program
T2037
Therapeutic camping day, waiver, each session
T2038
Community transition, waiver, per service
T2048
Behavioral health; long-term care residential (non-acute care in a residential treatment program where stay is typically longer than 30 days), with room
and board, per diem
Non emergency transportation; stretcher van, mileage, per mile
T2049
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)—Procedure Codes
94.01
94.03
Administration of intelligence test designed primarily for school children to predict school performance and the ability to adjust to everyday demands or
standardized tests that measure the present general ability of aptitude for intellectual performance (Stanford-Binet, Wechsler Adult Intelligence Scale,
Wechsler Intelligence Scale for Children).
Administration of standardized psychologic test designed to measure abilities, aptitude, and achievement, or to evaluate personality traits (Bender VisualMotor Gestalt Test, Benton Visual Retention Test, Minnesota Multiphasic Personality Inventory, Wechsler Memory Scale)
Character analysis
94.08
Other psychologic evaluation and testing
94.09
94.13
Psychologic mental status determination, not otherwise specified
Psychiatric mental status determination; clinical psychiatric mental status determination; evaluation for criminal responsibility; evaluation for testamentary
capacity; medico-legal mental status determination; mental status determination NOS
Routine psychiatric visit, not otherwise specified
Psychiatric commitment evaluation; pre-commitment interview
94.19
Other psychiatric interview and evaluation; follow-up psychiatric interview NOS
94.02
94.11
94.12
94.21
Narcoanalysis; narcosynthesis
94.22
Lithium therapy
94.23
Neuroleptic therapy
94.24
Chemical shock therapy
94.25
Other psychiatric drug therapy
94.26
Sub-convulsive electroshock therapy
94.27
Other electroshock therapy; electroconvulsive therapy (ECT); EST
94.29
Other psychiatric somatotherapy (biologic treatment of mental disorders)
94.31
Psychoanalysis
94.32
Hypnotherapy; hypnodrome; hypnosis
Comprehensive Community Mental Health Services for Children and Their Families Program
94.33
Behavior therapy; aversion therapy; behavior modification; desensitization therapy; extinction therapy; relaxation training; token economy
94.34
Individual therapy for psychosexual dysfunction. Excludes that performed in group setting
94.35
94.36
Crisis intervention; actions performed to sustain a person dealing with a condition, event, or radical change in status. Brief therapeutic approach which is
ameliorative rather than curative of acute psychiatric emergencies. Used in contexts such as emergency rooms of psychiatric or general hospitals, or in the
home or place of crisis occurrence, this treatment approach focuses on interpersonal and intra-psychic factors and environmental modification.
Play psychotherapy
94.37
Exploratory verbal psychotherapy
94.38
Supportive verbal psychotherapy
94.39
Other individual psychotherapy; biofeedback
94.41
Group therapy for psychosexual dysfunction
94.42
Family therapy; a form of group psychotherapy. It involves treatment of more than one member of the family simultaneously in the same session.
94.43
94.44
Psychodrama; primarily a technique of group psychotherapy which involves a structure, directed, and dramatized acting out of the patient's personal and
emotional problems.
Other group therapy; transactional group therapy; encounter group therapy
94.49
Other counseling; family counseling
94.51
Referral for psychotherapy
94.52
Referral for psychiatric aftercare: that in halfway house or outpatient (clinic) facility
94.53
Referral for alcoholism rehabilitation
94.54
Referral for drug addiction rehabilitation
94.55
Referral for vocational rehabilitation
94.59
Referral for other psychologic rehabilitation
Comprehensive Community Mental Health Services for Children and Their Families Program
SERVICES AND COSTS DATA DICTIONARY— ATTACHMENT B
GLOSSARY OF TERMS
Definitions for the services and concepts specified in this data dictionary are provided in the glossary provided in this attachment. For services that
are associated with CPT-4, HCPCS codes, or ICD-9-CM—Procedure Codes, the specific codes associated with each service type are listed in this
glossary. This glossary can be particularly helpful when information technology staff are recoding the data, and may not be as knowledgeable
about mental health services as program staff may be.
Note: Definitions listed here are intended to provide guidance in coding data consistently across grant communities, but are not intended to provide
definitive meanings to these concepts. If definitions listed here differ from those used locally, follow the definitions that are used locally. Procedure
codes approved for reimbursement vary by State; not all procedure codes are approved for reimbursement through Medicaid in all States. Procedure
codes provided here represent examples of codes that are possibly associated with each service type.
ENROLLMENT DATES
Enrollment Date 1
Discharge Date 1
Enrollment Date 2
Discharge Date 2
Enrollment Date 3
Discharge Date 3
The official date of the child or youth’s first enrollment into system of care services.
The definition of clinical discharge may be defined by the grantee. However, the child or youth can be considered discharged if he
/ she is lost to contact for 90 calendar days or more, or has died.
For children or youth who have re-enrolled into system of care services after previously being discharged. The official date of the
child or youth’s second enrollment into system of care services.
For children or youth who have re-enrolled into system of care services after previously being discharged. The definition of clinical
discharge may be defined by the grantee. However, the child or youth can be considered discharged if he / she is lost to contact
for 90 calendar days or more, or has died.
For children or youth who have re-enrolled into system of care services after twice being previously discharged. The official date of
the child or youth’s third enrollment into system of care services.
For children or youth who have re-enrolled into system of care services after twice being previously discharged. The definition of
clinical discharge may be defined by the grantee. However, the child or youth can be considered discharged if he / she is lost to
contact for 90 calendar days or more, or has died.
SERVICE TYPE – General Community-based / Episodic Services
Intake / Screening / Diagnosis /
Assessment
Evaluation
The process of gathering and documenting information about a child’s psychological, social, learning, and behavioral strengths
and challenges in order to determine the extent and nature of a child or youth’s condition. These are typically performed by a
psychologist, psychiatrist, or other clinical professional. Types of diagnostic assessment may include neurological, psychosocial,
educational, and vocational. Includes CPT-4 codes: 90801 90802 90885 96101 96102 96103 96105 96111 96116 96118 96119
96120 96150 96151. Includes HCPCS codes: H0001 H0002 H0003 H0031 T1023.
The process of collecting and interpreting information about a child. An evaluation may include a variety of tests, observations, and
background information and is typically conducted by a multi-disciplinary team of clinical or educational professionals. The purpose
of an evaluation is to determine whether the child needs mental health treatment and, if so, what type of treatment, for preparing
reports, or making recommendations for the most appropriate and least restrictive treatment for the child. Includes CPT-4 code:
97003 99205. 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99341 99342 99343 99344 99345. Includes
HCPCS codes: H2000. Includes ICD-9-CM Procedure Codes: 94.0 94.01 94.02 94.03 94.08 94.09 94.1 94.11 94.12 94.13 94.19
Comprehensive Community Mental Health Services for Children and Their Families Program
Consultation / Meeting
Case Management / Clinical
Coordination
Service Planning
Crisis Intervention / Crisis
Stabilization / Crisis Hotline
Emergency Room Psychiatric
Service
Early Intervention / Prevention
Caregiver Support / Family
Support
Respite Care
Advocacy
Legal Service
Recreational Activity /
Recreational Therapy
After-school Program or Childcare
Training / Tutoring / Education /
Mentoring
Behavioral / Therapeutic Aide
Service
Medication Treatment /
These services include providing information, education, and support on how to work more effectively with children and youth.
Includes CPT-4 codes: 99241 99242 99243 99244 99245 99251 99371 99372 99373.
The procedures that a trained service provider uses to access and coordinate services for a child and the child’s family. These
services may include establishing and facilitating interagency treatment teams; preparing, monitoring, and revising individual
service plans; and identifying and coordinating multiple treatment and support services. Includes CPT-4 codes: 90882 90889
98966 98967 98968. Includes HCPCS codes: G9007 H2021 H2022 T1016 T1017.
Service planning assists individuals and their families in planning, developing, choosing, or gaining access to needed services and
supports. Services and supports that are planned may be formal (provided by the human services system) or informal (available
through the strengths and resources of the family or community). Services and supports include discharge planning, advocacy and
monitoring the well being of children, youth, and families, and supporting them to make their own service decisions.
Includes HCPCS code: H0032.
Interventions designed to provide immediate, short-term help, and to stabilize a child or youth experiencing acute emotional or
behavioral difficulties. Services may include the development of crisis plans, 24-hour telephone support, short-term counseling,
mobile outreach services, intensive in-home support during crisis, and short-term emergency residential services. Includes
HCPCS codes: H2011 S9484 S9485 T2034. Includes ICD-9-CM Procedure Code: 94.35
Includes triage, psychiatric evaluation, and extended observation within an emergency room setting. Includes CPT-4 codes:
99282 99283 99284 99285.
Services used to recognize warning signs for mental health problems and to take early action against factors that put individuals at
risk, aimed to help children get better more quickly and to prevent problems from becoming worse. Includes CPT-4 codes: 96152
96153 96154 96155. Includes HCPCS codes: H0023 H0024 H0025 H2037.
Non-therapeutic and support services provided to caregivers or siblings. These may include family activities, behavior
management training, parent classes, and support groups, but does not include respite care, recreational activities, or
transportation services. Includes HCPCS codes: H2015 H2016 S5110.
A planned break for families who are caring for a child or youth with a serious emotional or behavioral disturbance, where trained
parents or counselors assume the duties of care giving for a brief time to provide a break for the parent or caregiver. The service
may be provided in the child’s home or in other community locations. Includes HCPCS codes: H0045 S5150 S5151 T1005.
An individual or group acting on behalf of a child or youth. This can be a parent, friend, relative, or a concerned private or
professional individual or group. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
Services provided to ensure the protection and maintenance of a child or family’s legal rights. These services may include
preparation of reports for court, representing a client in court, and providing follow-up documents to the court. No applicable CPT-4
codes, HCPCS codes, or ICD-9-CM Procedure Codes.
Use of recreational projects or community recreation resources, such as YMCA or other physical fitness activities, youth sports
programs, karate classes, or summer camps (with no treatment component). Includes HCPCS codes: H2030 H2032 G0176
T2037.
After-school programs are programs designed to provide care for and educational enhancement to children in the hours
immediately following school classes. Childcare may occur at any time and is primarily for providing supervision of children. No
applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
A range of child-focused educational services from basic literacy through the General Equivalency Diploma and college courses.
Includes special education at the pre-primary, primary, secondary, and adult levels. Includes CPT-4 code: 90887.
Supervision of a child by trained adults in home, school, or other community locations. The treatment aide might provide support
and may assist with behavior management or recreational activities. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM
Procedure Codes.
Prescription of psychoactive medications by a physician or other qualified health care specialist to a child/youth designed to
Comprehensive Community Mental Health Services for Children and Their Families Program
Administration / Monitoring
Medical Care /
Physical Health Care/ Laboratory
Related to Mental Health
Day Treatment / Partial-Day
Treatment
Individual Therapy / Counseling /
Psycho-social Therapy / Play
Therapy
Group Therapy / Group
Counseling
Family Therapy / Family
Counseling
Psycho-Social Rehabilitation /
Cognitive Rehabilitation
Tribal Healing Service
Social Work Service
Vocational / Life Skills Training /
Independent Living Services /
Youth Transition
alleviate symptoms and promote psychological growth. Treatment includes prescription, administration, assessment of drug
effectiveness, and periodic assessment and monitoring of the child’s reaction(s) to the drug. Includes CPT-4 code: 90862.
Includes HCPCS codes: H2010 H0033 H0034 J0515 J1200 J1630 J1631 J2680 J2794 J3410 S0163 M0064. Includes ICD-9-CM
Procedure Codes: 94.2 94.21 94.22 94.23 94.24 94.25 94.26 94.27 94.29
Includes professional mental health medical services including physical health care or laboratory services in an inpatient or
outpatient setting, specific to services required for direct support of mental health care or medication management. Includes CPT-4
codes: 36415 80053 80061 80076 80101 80164 80178 81000 81002 82043 82565 82570 82947 83036 83655 83721 84146
84439 84443 84520 85007 85025 85027 88262 90899 93000 93005 93010 93303 93320 94664 94760.
Intensive, non-residential service that provides an integrated array of counseling, education, and/or vocational training which
involves a child or youth for at least 5 hours a day, for at least 3 days a week. Day treatment may be provided in a variety of
settings including: schools, mental health centers, hospitals or in other community locations. Includes HCPCS code: H2012
Therapeutic intervention with a child or youth that is administered one-on-one and that relies on interaction between
therapist/clinician and child or youth to promote psychological and behavior change. Includes a variety of approaches (e.g.,
behavior, psychodynamic, cognitive, family systems) provided outside of the home. Includes CPT-4 codes: 90804 90805 90806
90807 90808 90809 90810 90811 90812 90813 90814 90815 90816 90817 90818 90819 90821 90822 90823 90824 90826
90827 90828 90829 90845 90875 90876 90880. Includes HCPCS codes: H0004 H0039 H0040 H2019 H2020 H2027 H2033
S9445. Includes ICD-9-CM Procedure Codes: 94.3 94.31 94.32 94.33 94.34 94.36 94.37 94.38 94.39
Therapeutic intervention with a child or youth that relies on interaction among a group of children or youth, facilitated by a
clinician/therapist to promote psychological and behavior change. This form of therapy involves groups of usually 4 to 12 people
who have similar problems and who meet regularly with a therapist. The therapist uses the emotional interactions of the group's
members to help them get relief from distress and possibly modify their behavior.
Includes CPT-4 codes: 90853 90857. Includes HCPCS code: S9446. Includes ICD-9-CM Procedure Codes: 94.41 94.43 94.44
Therapeutic family oriented services provided to caregivers and/or siblings with or without the child or youth present (e.g.,
individual/group therapy, family therapy, multi-family therapy). Includes CPT-4 codes: 90846 90847 90849. Includes ICD-9-CM
Procedure Codes: 94.42 94.49
Therapeutic activities or interventions provided individually or in groups that may include development and maintenance of daily
and community-living skills, self-care, skills training includes grooming, bodily care, feeding, social skills training, development of
basic language skills, and management of specific problems in perception, memory, thinking and problem solving. Includes
HCPCS codes: H2001 H2017 H2018.
Traditional tribal healing practices performed with or for a child or youth to support emotional and behavioral needs. Includes
healing ceremonies, sweat lodges, herbal remedies, healing hands, prayer, cleansing, song and dance, traditional plant
medicines, and culturally sensitive counseling. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
Social work services include diagnostic or active clinical treatments provided with the intent to reasonably improve the child’s
physical or mental condition or functioning. Includes global evaluation to determine a child’s developmental status and need for
early intervention services, making home visits to assess a child’s living conditions and patterns of parent-child interaction to
determine the need for social work or other counseling services; preparing a social or emotional developmental assessment of the
child within the family context to determine the need for social work or other counseling services; working with issues in the child’s
and family’s living situation (e.g., home, community, etc.) and identifying, mobilizing, and coordinating community resources and
services to enable the child and family to receive maximum benefit from early intervention services. No applicable CPT-4 codes,
HCPCS codes, or ICD-9-CM Procedure Codes.
Services designed to prepare older adolescents to live independently and reduce reliance on the family or service system.
Services teach youth how to handle financial, medical, housing, transportation, and other daily living needs, as well as how to get
along with others. Services may include social and community living skills development (e.g., look for job, pay bills), peer support
Comprehensive Community Mental Health Services for Children and Their Families Program
Transportation
and counseling. Designed for older adolescents to facilitate the move from the child system to the adult mental health system.
Includes HCPCS codes: G0177 H2014 H2025 H2026 T2038.
Transportation to appointments and other scheduled services and activities. Includes HCPCS codes: A0080 A0090 A0100 A0110
A0120 A0130 A0140 A0160 A0170 S0215 T2001 T2002 T2003 T2004 T2005 T2007 T2049.
SERVICE TYPE—Services Specific to Child Welfare
Child Protective Service
Case Evaluation and Monitoring
Family Preservation
Adoption Service
Therapeutic Foster Care /
Therapeutic Group Home
Family Foster Care, with NonRelative / Non-Therapeutic Foster
Care
Group Foster Care
Relative Care
Includes investigation of maltreatment allegations and validation of the child maltreatment report; assessment of child safety, early
intervention and prevention, and alleged risk (alternative response). Develops a safety plan, if needed, to assure the child's
protection and determines services needed. Includes removal and placement of child, court services, and reunification activities.
No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
Assessing the need for child welfare services; providing or arranging for services; and coordinating and evaluating child welfare
services provided to a child and family. Includes referring a child and family to other services, as needed; documenting client
progress and adherence to the plan; and providing casework contacts. Also includes measuring the extent to which treatment
goals have been, or are being attained. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
An intensive combination of therapeutic and support services provided to the child, youth, or family within the home to prevent outof-home placement. These services may include 24-hour access to support services, intensive in-home support during crisis when
a child is at risk of out-of-home placement or when the child is returning from out-of-home placement. These are distinct from crisis
stabilization services as they may continue for several months during transition or crisis. Includes reunification services, family
intervention, parent mentoring, therapy, enhancement of conflict resolution and communication skills, parenting skills, and visiting
nurses. Includes HCPCS code: S9482
Finding the adoptive family, supporting the child through the process, etc. Service to post-placement, pre-finalization adoptive
family and post-adoption services. Could also include services to biological family to voluntarily terminate parental rights or open
adoption agreement, etc. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
A therapeutic foster care or group home is a 24-hour residential placement in a home or home-like setting with caregivers who are
especially trained to care for children and youth with emotional and/or behavioral problems in behavior management and social
and independent living skills development. These homes provide an environment conducive to learning social and psychological
skills, and employ a variety of treatment approaches that includes supportive counseling, crisis back-up, behavior management,
and social development. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
Non-treatment oriented living arrangements with a non-relative for children and youth who cannot live with their families. Includes
recruiting, training and licensing foster parents; placement; foster family assistance; family team meetings; periodic home visits.
Includes HCPCS codes: H0041 H0042 S5140 S5145 S5146.
Non-treatment oriented living arrangements in a group foster care facility, where caregivers provide care to children and youth in a
24-hour residential setting. These facilities may be community residential facilities, comprehensive residential facilities, enhanced
residential facilities, or highly structured residential facilities. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure
Codes.
24-hour care provided by the child or youth's relatives in the relative's home. No applicable CPT-4 codes, HCPCS codes, or ICD-9CM Procedure Codes.
SERVICE TYPE—Services Specific to Juvenile Justice (Juvenile Court, Corrections, and Probation)
Diversion / Prevention Service
Alternatives to formal judicial processing and adjudication through the juvenile court. Those efforts that support youth who are “at
risk” of becoming involved in the juvenile justice system through formal case processing and help prevent a juvenile from being
labeled in the juvenile justice system as a delinquent. Prevention includes arbitration, diversionary or mediation programs, and
community service work or other treatment available subsequent to a child committing a delinquent act. No applicable CPT-4
codes, HCPCS codes, or ICD-9-CM Procedure Codes.
Comprehensive Community Mental Health Services for Children and Their Families Program
Court Services
Juvenile Detention
Jail / Prison
Parole / Aftercare Service
Probation / Monitoring
Includes the preparation of statutory required legal documents, court orders, and court docket entries; reviewing and processing
professional vouchers, witness fees, victim/witness surcharges, restitution and recoupment; processing appeals; and preparing
and maintaining the court and maintaining court files for these matters. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM
Procedure Codes.
Temporary confinement (generally not more than 21 days) of a child/youth (under the age of 18) alleged to be delinquent pending
pretrial release, juvenile court proceedings, or disposition. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure
Codes.
Jails and prisons are secure facilities. Jail refers to the confinement of persons accused of crimes and awaiting trial, serving short
sentences (typically 365 days or less), or awaiting transfer to another State or Federal authority. Jails are managed and operated
at the local or county level. Prison refers to the confinement of convicted criminals. Prisons are managed and operated by State or
Federal authorities. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
Discretionary release of a convicted or adjudicated delinquent juvenile from detention or custody prior to the expiration of their
sentence, upon a finding that the person is sufficiently rehabilitated and not a threat to society. The parole period is defined as a
certain length of time and is subject to conditions imposed by the releasing authority and to its supervision, including a term of
supervised release. Parole monitoring and re-integrative services that prepare out-of-home placed juveniles for re-entry into the
community by re-establishing the necessary collaborative arrangements with the community to ensure the delivery of prescribed
services and supervision. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
A juvenile disposition where the youth serves out his sentence through supervised community-release as opposed to being
confined in juvenile detention. Monitoring youth who are placed on informal/voluntary or formal/court-ordered probation or
supervision. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
SERVICE TYPE—Services Specific to Education and Early Care Programs
Early Head Start Program
Early Intervention (Part C)
Head Start Program
Preschool Special Education
Program (Part B)
Other Early Care and Education
Programs
Special Education Class, Self
Contained
Early Head Start Program provides comprehensive, year-round, child and family development services to low-income families with
children, prenatal to 3 years old. Program approaches for delivering services in Early Head Start include: center-based programs,
home-based programs and mixed-approach programs. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure
Codes.
Part C of the Individuals with Disabilities Education Act (IDEA) authorizes the creation of early intervention programs for babies
and toddlers with disabilities, and provides Federal assistance for States to maintain and implement statewide systems of services
for eligible children, ages birth through 2 years, and their families. States and jurisdictions participating in Part C must provide early
intervention services to any child below age 3 who is experiencing developmental delays, has a diagnosed physical or mental
condition that has a high probability of resulting in a developmental delay, and some States serve children who are at-risk for
serious developmental problems. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
A federally-funded program for low-income children and their parents (preschoolers), designed to promote school readiness by
enhancing the social and cognitive development of children through the provision of educational, health, nutritional, and other
social services. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
Individuals with Disabilities Education Act (IDEA) provides Federal funds to States and local communities to assist in their efforts
to provide a free appropriate public education to students with disabilities. Part B of IDEA contains provisions relating to the
education of school-aged and preschool-aged children with disabilities. The preschool program is often referred to as the Section
619 program, referring to the section of the law describing services for this age group. No applicable CPT-4 codes, HCPCS codes,
or ICD-9-CM Procedure Codes.
Special education and related services provided to children under the age of 5. No applicable CPT-4 codes, HCPCS codes, or
ICD-9-CM Procedure Codes.
A segregated classroom only for special education students. Class sizes are usually very small, and students have severe
disabilities. Some self-contained classes are for students classified as emotionally disturbed. No applicable CPT-4 codes, HCPCS
Comprehensive Community Mental Health Services for Children and Their Families Program
Special Education, Resource
Service
Special Education, Inclusion
Physical, Occupational, Speech,
Hearing, or Language Service
Teacher Aide Service / Other
Paraprofessional Service
codes, or ICD-9-CM Procedure Codes.
This instructional arrangement/setting is for providing special education instruction and related services in a setting other than
regular education for less than 50% of the regular school day. No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM
Procedure Codes.
Practice of educating children with special needs in regular education classrooms. No applicable CPT-4 codes, HCPCS codes, or
ICD-9-CM Procedure Codes.
Includes therapy to remediate gross motor skills, fine motor skills, or sensory processing disorders; identification and diagnosis of
speech or language impairments; speech or language therapy. Includes CPT-4 codes: 92507 92508 92588 92700 97110 97150
97530. Includes HCPCS code: T1013.
Services provided by individuals who work either with individual students or a program to meet the requirements of individualized
education plans (IEP). Teacher aides are often assigned to inclusion students. No applicable CPT-4 codes, HCPCS codes, or
ICD-9-CM Procedure Codes.
SERVICE TYPE—Informal / Natural Support Services
Self-Help Group / Peer Counseling
/ Support Group
Counseling from Clergy
Informal Transportation
Self-help generally refers to groups or meetings that: involve people who have similar needs; are facilitated by a consumer,
survivor, or other layperson; assist people to deal with a "life-disrupting" event, such as a death, abuse, serious accident,
addiction, or diagnosis of a physical, emotional, or mental disability, for oneself or a relative; are operated on an informal, free-ofcharge, and nonprofit basis; provide support and education; and are voluntary, anonymous, and confidential. Includes HCPCS
code: H0038.
Include counseling services provided by pastoral counselors or counselors working within traditional faith communities to
incorporate psychotherapy, and/or medication, with prayer and spirituality to effectively help some people with mental disorders.
No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
Transportation provided by family, friends, neighbors that is not paid or reimbursed. No applicable CPT-4 codes, HCPCS codes, or
ICD-9-CM Procedure Codes.
SERVICE TYPE—Inpatient and Residential Services
Inpatient Evaluation
Inpatient Consultation
Inpatient Behavioral Health
Service
Residential Therapeutic Camp /
Wilderness Program
Residential Treatment Service,
The process of collecting and interpreting information about a child in an inpatient or residential setting. An evaluation consists of a
variety of tests, observations, and background information and is conducted by a multi-disciplinary committee or team of
educational professionals. Examination or evaluation of a child for the purpose of determining whether the child needs mental
health treatment and, if so, what type of treatment and for the purpose of preparing reports or making recommendations for the
most appropriate and least restrictive treatment for the child. Includes CPT codes: 99324 99325 99326 99327 99328 99334 99335
99336 99337.
Provides psychiatric evaluation within an inpatient or residential setting, collaboration with medical specialists, and arrangement for
follow-up behavioral health care when needed. Includes CPT codes: 99252 99253 99254 99255.
Mental health treatment provided in a hospital setting 24 hours a day. Inpatient hospitalization provides: (1) short-term treatment in
cases where a child is in crisis and possibly a danger to his/herself or others, and (2) diagnosis and treatment when the patient
cannot be evaluated or treated appropriately in an outpatient setting. Placement of child/youth in inpatient hospital setting for
observation, evaluation and/or treatment. This treatment is characterized by a strong medical orientation and 24-hour nursing
supervision and is often used for short-term treatment and crisis stabilization or to conduct comprehensive evaluations where
specialized medical tests are warranted. Includes HCPCS codes: H0017 H0035 S0201.
Involves children or youth and staff living together in a wilderness or other camp environment often located outside of the
community in which the child resides. Treatment focuses on group process and social skills development. Includes HCPCS code:
T2036.
Treatment provided in secure non-hospital residential facilities that typically serve 10 or more children or youth, provide 24-hour
Comprehensive Community Mental Health Services for Children and Their Families Program
Non-Hospital
Residential Care / Custodial Care
Shelter Placement
staff supervision, and can provide a full array of treatment interventions and approaches including individual therapy, group and
family therapy, behavior modification, skills development, education and recreational services. Includes HCPCS codes: H0018
H0019 T2048.
Supervision of a child or youth with serious emotional or behavioral challenges by trained adults out-of-home who offer supervision
and support and may assist with other household chores, tutoring, or recreational activities where no treatment are provided.
Includes HCPCS codes: S5125 S5126.
This placement, also known as an emergency shelter placement, is used for children or youth when an unanticipated placement
need arises for a child and no regular contracted placement exists. Shelter placements generally do not exceed 30 days. During
the placement a caseworker attempts to return the child home, to foster care, or other appropriate substitute care resource. No
applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.
PROVIDER AGENCY / SERVICE SECTOR
Mental Health
Child Welfare / Social Services
Juvenile Justice (Juvenile Court,
Corrections, Probation)
Education / School / Early
Childhood Program / Childcare
Organization
Pediatrician / Physical Health Care
Provider
Family Organization
Youth Organization
Includes mental health agencies that provide leadership and collaboration for the planning, monitoring, managing, and provision of
mental health related services to children, youth, and families. Also includes private or public offices, clinics, inpatient and
residential organizations that provide mental health related services.
Child welfare and social services agencies that work to ensure the safety, protection, well-being, and self-sufficiency of children
and youth. These agencies provide and manage an array of services including but not limited to child support, child protection,
foster care, adoption, child care, family services, family assistance, and food assistance.
Juvenile justice agencies, including courts, detention facilities, jails, and prison, that provide supervision, prevention, diversion,
detention, probation, parole, aftercare services, and a wide range of treatment and educational services for at-risk children and
youth.
Education, school, and early childhood organizations or agencies that promote student academic achievement and encourage
students to learn under the supervision of teachers. Childcare organizations that provide care for and supervise children and
youth.
Pediatricians and other physical health care providers, laboratories, physical health care clinics, hospitals, agencies or
organizations that diagnose, treat, and help prevent children's diseases and injuries.
Family organizations at the national or local level that promote healthy families providing support particularly for families that
include children and youth with emotional, behavioral, and mental health challenges. Family organizations typically provide crisis
services, family supports, self-help groups, peer counseling, self-sufficiency programs, advocacy.
Youth organizations at the national or local level that are devoted to improving or providing services and systems that support
positive growth and development of youth with emotional, behavioral, and mental health challenges. Youth organizations
typically provide services that support children and youth’s positive mental health and development through a sense of
competence. Services might include advocacy for youth rights, supports that empower youth to become equal partners in their
care, after-school programs, independent living skills, literacy, mentoring, tutoring, workforce partnerships, health and fitness
activities.
PROVIDER TYPE
Case manager / care coordinator
Psychologist (Ph.D. or similar
credential)
Mental Health Professional
/Licensed Professional Counselor
Social worker
An individual who organizes and coordinates services and supports for children with mental health problems and their families.
(Alternate terms: service coordinator, advocate, and facilitator.)
A professional with a doctoral degree in psychology who specializes in assessment and therapy. Includes Ph.D., or similar
credential.
A professional with an advanced degree in mental health or other social services trained in assessment and treatment.
Social workers are health professionals trained in client-centered advocacy that assist clients with information, referral, and direct
Comprehensive Community Mental Health Services for Children and Their Families Program
Recreational Therapist /Behavioral
Aide / Respite Worker / Other
Mental Health Staff
Tribal Healer
Faith-Based Professional
Psychiatrist (M.D. or similar
credential)
Physical Health Care Physician /
Pediatrician
Nurse Practitioner / Physician
Assistant
Nurse / Psychiatric Nurse
Alternative Health Care
Practitioner
Medical Technician / Laboratory
Child Protective Services Worker /
Child Protective Investigator /
Foster Care Case Worker
Foster Family / Foster Parent
help in dealing with local, State, or Federal Government agencies. A social worker helps individuals deal with a variety of mental
health and daily living problems to improve overall functioning. A social worker usually has a master's degree in social work and
has studied sociology, growth and development, mental health theory and practice, human behavior/social environment,
psychology, research methods.
A recreational therapist plans, directs, or coordinates medically-approved recreation programs for patients in hospitals or other
institutions. Activities may include sports, trips, dramatics, social activities, and arts and crafts. May assess a patient’s condition
and recommend appropriate recreational activity. Behavioral aides address behavioral needs; help with life-style choices; assist
children, youth, and families; provide group or individual counseling. Behavioral aides typically have an associates degree or
bachelor’s degree. Respite workers provide relief to caregivers and community-based emotional, practical, and social support to
families in which mental illness has impacted family functioning.
A tribal healer is an individual who uses culturally traditional healing practices such as plant medicines and foods, prayer,
ceremony and song healing hands, cleansing, and culturally sensitive counseling.
Counselors working within traditional faith communities to incorporate psychotherapy, and/or medication, with prayer and
spirituality to effectively help some people with mental disorders. Some people prefer to seek help for mental health problems from
their pastor, rabbi, or priest, rather than from therapists who are not affiliated with a religious community.
A professional who completed both medical school and training in psychiatry and is a specialist in diagnosing and treating mental
illness. Includes M.D., or similar credential.
A medical doctor who diagnoses, treats, and helps prevent diseases and injuries. Includes M.D., D.O., or similar credential.
A nurse practitioner is an advanced practice nurse who works in an expanded role and manages patients' medical conditions.
They focus on health promotion, disease prevention, health education, diagnosis and treatment of a wide range of health
conditions; order perform and interpret diagnostic tests; prescribe medications; and manage patients’ over all care. A physician
assistant is a certified and licensed health professional who practice medicine as members of a team with their supervising
physicians, deliver a broad range of medical and surgical services to diverse populations in rural and urban settings, conduct
physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, and
prescribe medications.
A nurse can be either a licensed practical nurse (L.P.N.), registered nurse (R.N.), or an advanced practice nurse. Nurses develop
and implement nursing care plans, and maintain medical records, administer medications and therapeutic treatments to patients,
and advise patients on health maintenance and disease prevention. A psychiatric nurse can be either R.N. or an advanced
practice nurse who diagnose, treat individuals or families with psychiatric problems or disorders, or potential for such disorders.
An alternative health care practitioner is an individual who provides complementary and alternative health care services such as
acupressure, aromatherapy, bodywork, massage and massage therapy, detoxification practices and therapies, homeopathy, and
meditation. An alternative health care practitioner differs from a tribal healer in that the alternative health care practitioner does not
necessarily provide services that are culturally relevant to the patient.
An individual who performs routine medical laboratory tests for the diagnosis, treatment, and prevention of disease. May work
under the supervision of a medical technologist.
Child protective services workers and investigators investigate reports of child abuse or neglect in order to determine whether any
child in a referred family has been abused or neglected or is at risk of abuse or neglect, and initiate protective services for children
who need protection. Foster care case workers provide many services including intake, assessment, behavioral management
services, crisis intervention, referral, report writing, family reunification, emancipation, discharge planning, maintain case files, and
recruits, certifies, trains and provides on-going support to foster parents.
Foster families and parents provide daily care and nurturing of children and youth in foster care, help children learn daily life skills,
are advocates for children in their schools and communities, inform caseworkers about adjustments in the home, school, and
Comprehensive Community Mental Health Services for Children and Their Families Program
Teacher / Special Education
Teacher / Resource Teacher
School Counselor / School
Psychologist
Speech, Language Therapist /
Audiologist / Occupational or
Physical Therapist
Teacher Aide /Educational
Paraprofessional
Tutor
Childcare provider
Court Services Worker
Detention / Corrections Staff
Probation / Parole Officer
Youth Coordinator
Youth
Family Member / Relative / Friend
/ Neighbor / Volunteer
Advocate / Family Advocate /
Education Advocate / Court
Advocate
Mentor
Program Support Staff
Driver
community, provide positive role model for birth families, and participates with caseworkers’ efforts to reunify the child or youth
with their birth families.
A teacher is an individual who teaches basic academic, social, and other formative skills to students in a preschool, day care
center, or public or private school at the preschool, elementary, intermediate, or high school level. Special education teachers
teach academic, social, and other formative skills to emotionally and behaviorally challenged students, educationally and
physically handicapped students, audibly and visually handicapped students, and the mentally impaired. Special education
resource teachers help teachers meet the needs of students with special needs while maintaining a traditional classroom
atmosphere.
An individual with an advanced degree in psychology who assesses children for the presence of learning and emotional problems,
diagnoses, and treats children in the school system. Roles of school psychologists will vary by location.
Speech and language therapists and audiologists assess and treat persons with speech, language, voice, and fluency disorders;
may select alternative communication systems for patients and teach their use; may perform research related to speech and
language problems. Occupational therapists assess, plan, organize, and provide rehabilitative services that help restore
vocational, homemaking, and daily living skills, as well as general independence, to disabled persons. Physical therapists assess,
plan, organize, and provide rehabilitative services that improve mobility, relieve pain, increase strength, and decrease or prevent
deformity of patients suffering from disease or injury.
Performs duties that are instructional in nature or delivers direct services to students, under direct supervision of a teacher. Serve
in a position for which a teacher or another professional has ultimate responsibility for designing and implementing educational
programs and services.
Provides professional academic or educational instruction in a given subject or field. Instruction may be given one-on-one or in a
group setting.
Attends to children at schools, businesses, private households, and child care facilities. Perform a variety of tasks, such as play
supervision and custodial care.
Prepares statutory required legal documents, court orders, and court docket entries; reviews and processes professional
vouchers, witness fees, victim/witness surcharges, restitution and recoupment; processes appeals; and prepares and maintains
the court and maintains court files for these matters.
Guards detainees in detention, correctional, or rehabilitative institutions in accordance with established regulations and
procedures. May guard prisoners in transit between jail, courtroom, prison, or other point.
Provides monitoring of adjudicated youth who have been released to the community. Provides social services to assist in
rehabilitation of offenders in custody or on probation or parole. Recommends actions for rehabilitation and treatment plans,
including conditional release and education and employment stipulations.
Provides services and general supervision specific to youth participating system of care programs. Coordinates and implements a
wide variety of recreational activities for youth participants in group settings.
Child or youth, ages 22 years or younger, participating in system of care programs.
A family member, relative, friend, or neighbor of a child or youth participating in systems of care programs; a volunteer providing
services to a child, youth, or family who are participating in system of care programs.
These individuals provide a voice for a child or youth in general or more specifically in the context of their family, their education, or
in situations where the child or youth is involved in the judiciary process.
A trusted friend, counselor, or teacher, usually a more experienced person who serves as a role model or provides guidance and
support to a child or youth.
Provides general administrative or program assistance to system of care programs.
Drives automobiles, vans, or buses to transport passengers.
Comprehensive Community Mental Health Services for Children and Their Families Program
SERVICE LOCATION
Office / Independent Clinic
Public Health Clinic / Rural Health
Clinic / Federally Qualified Health
Center
Indian Health Service / Tribal 638
Facility
Community Mental Health Center
Social Service Center or Agency
Ambulance
Mobile Unit
Urgent Care Facility
Inpatient Hospital
Outpatient Hospital
Emergency Room-Hospital
Inpatient Psychiatric Hospital /
Facility
Psychiatric Facility-Partial
Hospitalization
Residential Psychiatric Treatment
Center
Correctional Facility
Homeless Shelter / Temporary
Lodging
An office is a location, other than a hospital, skilled nursing facility, military treatment facility, community health center, State or
local public health clinic, or intermediate care facility, where the health professional routinely provides health examinations,
diagnosis, and treatment of illness or injury on an ambulatory basis. An independent clinic is a location, not part of a hospital and
not described by any other service location, which is organized and operated to provide preventive, diagnostic, therapeutic,
rehabilitative, or palliative services to outpatients only.
A public health clinic is a facility maintained by either State or local health departments that provides ambulatory primary medical
care under the general direction of a physician. A rural health clinic is a certified facility which is located in a rural medically
underserved area that provides ambulatory primary medical care under the general direction of a physician. A federally qualified
health center is a facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical
care under the general direction of a physician.
A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives
admitted as inpatients or outpatients. A tribal 638 facility is owned and operated by a federally recognized American Indian or
Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members admitted as inpatients or outpatients.
A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly,
individuals who are chronically ill, and residents of the center’s mental health services area who have been discharged from
inpatient treatment at a mental health facility: 24 hour a day emergency care services; day treatment, other partial hospitalization
services, or psycho-social rehabilitation services; screening for patients being considered for admission to State mental health
facilities to determine the appropriateness of such admission; and consultation and education services.
A center or agency that provides basic human aid to individuals with emergency needs or living in poverty. These centers make
referrals to other agencies for additional support and to encourage children and youth toward self-sufficiency.
A land, air, or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.
Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for
unscheduled, ambulatory patients seeking immediate medical attention.
A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation
services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
A portion of a hospital which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or
injured persons who do not require hospitalization or institutionalization.
A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.
A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or
under the supervision of a physician.
A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not
require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or
hospital-affiliated facility.
A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally
staffed group living and learning environment.
A secure facility that confines persons accused of crimes and awaiting trial or confines criminals convicted or adjudicated of
crimes. This includes juvenile detention facilities, reformatories, work farms, jails, and prisons.
A homeless shelter is a facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g.,
emergency shelters, individual or family shelters). Temporary lodging is short term accommodation such as a hotel, camp ground,
Comprehensive Community Mental Health Services for Children and Their Families Program
School
Home
Group Home / Custodial Care
Facility
hostel, ship, or resort where the patient receives care.
A facility whose primary purpose is education.
Location, other than a hospital or other facility, where the patient receives care in a private residence.
A group home is a residence, with shared living areas, where clients receive supervision and other services such as social and/or
behavioral services, custodial service, and minimal services (e.g., medication administration). A custodial care facility provides
room, board, and other personal assistance services, generally on a long-term basis, and which does not include a medical
component.
Pharmacy
A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise
provided directly to patients.
Independent Laboratory
Other Community Location /
Public Place
Phone
A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician’s office.
Other community location or public place not included in any other service location definitions, including Boys/Girls Club, YMCA,
library, place of worship, etc.
A conversation over the telephone between a child, youth, or family member and a service provider.
Costs And Payment Source
Amount Charged
Amount Paid
Medicaid
SCHIP
SAMHSA CMHI Cooperative
Agreement
Other Government Funds
Mental Health Agency or Provider
Child Welfare Agency
Juvenile Justice Agency
Education
Family Organization
Youth Organization
Foundation Funds
Private Insurance
Client Out-of-Pocket
Amount originally charged by provider prior to any adjustments that may be applied.
Amount actually paid to the provider for the service, not the amount the provider originally lists on the bill as the charge. If the
amount actually paid is not known, but the value of that payment can be estimated, you may provide the estimated value of
payment. The amount recorded should represent the payer’s total payment for the service, not the payment per unit of service.
Includes Federal, State, and local Medicaid funds; includes the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
program. EPSDT is Medicaid's comprehensive and preventive child health program for individuals under the age of 21.
State Children’s Health Insurance Program (SCHIP) is a Federal Government program that gives funds to States in order to
provide health insurance to families with children. The program was designed to cover uninsured children in families with incomes
that are modest but too high to qualify for Medicaid.
Includes any service funded through, or provided by a staff funded through, the Cooperative Agreement for the Comprehensive
Community Mental Health Services for Children and Their Families Program.
Includes other Federal, State, local funds, Temporary Assistance for Needy Families (TANF), and title funds, but does not include
Medicaid, EPSDT, or SCHIP.
The service sector that is responsible for the planning, monitoring, and managing of mental health care to children or youth and
their families.
Includes child welfare agencies and social service agencies or organizations in the child service sector that focuses on child
protection, foster care, and the overall care of children’s health and living conditions.
The service sector that is responsible for serving children accused of or judged to have committed unlawful or delinquent acts..
Includes juvenile court, juvenile detention facilities, other corrections facilities, and probation organizations.
Includes education, early childhood, or child care organizations.
Advocacy and support organizations that are led by family members with expertise / experience in the field of mental health.
Includes Federation of Families for Children’s Mental Health chapters and similar organizations.
Includes any funding from youth organizations (e.g., Youth Move, YMCA, Big Brothers Big Sisters, Girl Scouts, Boys and Girls
Club).
Includes any funding from private foundations (e.g., Annie E. Casey Foundation).
A contract between an insurance company and an individual to pay for physical and mental health care services. Private health
insurance includes managed care, preferred provider organization, point-of-service, and fee-for-service arrangements.
The portion of the service expenses that are paid for by the recipient or recipient’s family.
Comprehensive Community Mental Health Services for Children and Their Families Program
Other Source of Payment
Estimate For Informal, Natural
Support, In-Kind, or Volunteer
Service
General category to be used when source of payment does not match other payment source categories or if payment source is
unknown. If charge or payment data are available, but source of payment is not available, enter charge or payment amounts in this
other category.
Cost estimates calculated to assign a value to informal, natural support, in-kind, or volunteer services for which no payment is
actually made.
The following references represent primary resources that informed the definitions in Attachment B.
1. SAMHSA’s National Mental Health Information Center. Glossary of Terms Child and Adolescent Mental Health.
http://mentalhealth.samhsa.gov/publications/allpubs/CA-0005/default.asp.
2. SAMHSA’s National Mental Health Information Center. Mental Health Dictionary. http://mentalhealth.samhsa.gov/resources/dictionary.aspx.
3. Bureau of Labor Statistics (BLS) http://www.bls.gov
4. Centers for Medicare and Medicaid’s Place of Service Codes http://www.cms.hhs.gov/MedHCPCSGenInfo/Downloads/Place_of_Service.pdf
5. The Free Dictionary http://legal-dictionary.thefreedictionary.com/Prison
6. Merriam Webster Dictionary http://www.merriam-webster.com/dictionary/jail
7. National Federation of Families for Children’s Mental Health http://www.ffcmh.org
8. Youth Move http://www.youthmove.us
9. Testimony on Access to Medical Treatment Act http://www.hhs.gov/asl/testify/t960730b.html
10. American Association of Nurse Practitioners www.aanp.org
11. American Academy of Physician Assistants www.aapa.org
12. American Psychiatric Nurses Association www.apna.org
Comprehensive Community Mental Health Services for Children and Their Families Program
| File Type | application/pdf |
| File Title | Microsoft Word - Cover pages - Provider Administrator |
| Author | 21988 |
| File Modified | 2012-08-29 |
| File Created | 2012-06-20 |