Client ID#: Primary Diagnosis: DD Diagnosis: Intake CGAS/GAF

A D A P T HSA-FSPT Checklist BEHAVIORAL SERVICES

Client Name: DOB: Intake Date: Client ID#: Primary Diagnosis: DD Diagnosis: Intake CGAS/GAF: Problems: 1: 2: 3. 4. Intake Forms (all items in regular type must be turned into the office for a case to be opened) Client Information Sheet Intake Consents form Billing Codes: No Show Policy AS=Assessment PCP Notification IHOS=In Home & On-Site Release of Information (for case managers) IndOP=Individual Outpatient Bio-Psychosocial Evaluation GrOP=Group Outpatient Progress Note for intake session (AS) Progress note for completing Bio/CFARS (AS) HSA version of MHO/CFARS HSA Client Demographic Form Client Rights Pamphlet (given to parents at intake) Health & Safety Pamphlet (give to client/parent)

Authorization: Track your units used and end dates for authorizations. Be sure to request more units/time before the previous authorization expires. Session/units used tracking: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Date Date Follow-up Forms Due Date What’s due When due Date Done Any remaining progress notes in the month 1st Monday of following month HSA Monthly Progress Summary Treatment Plan 1 month after intake date Treatment Plan Review 3 months after Intake date HSA MHO/CFARS (MHO sections only) Extension approval from Director 6 months after Intake date Treatment Plan Review (if extending past 6 months) HSA version of MHO/CFARS Extension approval by Director 9 months after Intake date Treatment Plan Review (if extending past 9 months) HSA MHO/CFARS (MHO sections only) Extension approval by Director 12 months after Intake date Treatment Plan Review (if extending past 12 months) HSA MHO/CFARS Intakes Consent No Show/Cancellation Policy Release of Information Treatment Review for Discharge Within 15 days after last session if HSA MHO/CFARS (MHO sections only) planned discharge Consumer Discharge Rating Consumer Satisfaction Survey Treatment Review for Discharge Within 15 days after decision to HSA MHO/CFARS (MHO sections only) discharge administratively Instructions: THIS IS FOR YOU TO KEEP. YOU CAN USE IT TO TRACK DUE DATES FOR THIS CASE.

Revised 12/12

A D A P T Client Information Sheet BEHAVIORAL SERVICES DEMOGRAPHIC INFORMATION

Client First Name/Last Name: Social Security#: Birth Date: Age: Sex: Male Female Address: County: City: State: FL Zip: Email: Phone: Phone #2: Bilingual needed? no yes: School: Placement: Reg Ed Emotional/Behavioral Other Exceptional Ed Race: White Black Native American/Alaskan Asian Pacific Islander Multi-racial Ethnic: None Puerto Rican Mexican Cuban Other Hispanic Haitian Legal status: Minor Dependent Minor (foster home) Delinquent Minor Competent Adult Incompetent Adult FAMILY COMPOSITION Name Relationship Age Other Information

Other Parent/Guardian: Relationship: Phone: Address: email: OTHER CONTACTS Legal Guardian(s) Name/Relationship*: Phone: Emergency Contact Name/Relationship*: Phone: Referral Source: Name/Agency: Phone: Primary Care Physician: Name/Agency: Phone: Dependency Case Mgr: Name/Agency: Phone: Other Case Manager: Name/Agency: Phone: DJJ Worker/Probation Off: Name/Agency: Phone: Other MH Counseling: Name/Agency: Phone: Psychiatric/Medication: Name/Agency: Phone: School Contact: Name/Agency: Phone: Other: Name/Agency: Phone: *include address of guardian/emergency contact, if different from above: FUNDING Funding Type: Medicaid Healthy Kids Insurance FSPT CMS Other: Funding Agency:: Subscriber #: ADMINISTRATIVE INFORMATION

Primary Clinician Name: Intake Date: Client ID#: Primary Diagnosis Code: Developmental Disability Diagnosis Code: Intake GAF: Prior Adapt record(s) for this client filed in discharge year(s): Updated 06/12

A D A P T Intake Consents & Orientation BEHAVIORAL SERVICES

Client Name: Date of Birth:

______(initial) HEALTH & SAFETY: I received a copy of the Health & Safety pamphlet (red), and it was explained to me, including wellness education; the agency’s policies on tobacco, drugs, alcohol, prescription medications, weapons, abuse reporting, agency’s responsibility to respond to client risk of danger to self/others; the agency’s emergency procedures; and after hours crisis/emergency phone numbers.

______(initial) CLIENT RIGHTS: I received a copy of the Client Rights pamphlet (yellow), and it was explained to me, including what to expect in the assessment, treatment planning, treatment & discharge process; client rights & responsibilities; agency rights & responsibilities; grievance process; treatment philosophy; Primary Clinician name/phone number; and office hours/phone number.

______(initial) LIMITS TO CONFIDENTIALITY/PRIVACY: I understand that all information about the above-named client is considered private and will not be shared with anyone without my consent, except under the following circumstances:  Adapt is required to report suspicion of child/elder/disabled adults abuse & neglect.  Adapt is required to release information for the purpose of abuse/neglect investigations.  Adapt is allowed to warn potential victims if we believe that their lives are in danger.  Adapt is required to release a copy of records and/or testimony if subpoenaed in court. Even with your consent, Adapt will share only the information that is necessary for assessment, coordination of treatment, notification to those responsible for mandated treatment, or other specified purposes as described in the PCP Notification and Release of Information forms

______(initial) STATEMENT OF AUTHORITY TO CONSENT: I certify that I have the legal authority to consent to mental health treatment, release of information, and all legal issues involving the above-named client. If my status as legal guardian should change, I will immediately notify Adapt Behavioral Services of the name, address, and telephone number of the person who has assumed guardianship of the above- named client.

______(initial) CONSENT FOR TREATMENT AND TREATMENT LOCATION: I consent for the above- named client to participate in mental health assessment and treatment through Adapt Behavioral Services, including sharing relevant confidential information with those involved in services: School Personnel, such as teachers, counselors, behavior specialists, principal, etc. Other Family Members, such as step-parents, siblings, grandparents, foster parents, etc. Other Case Management or Treatment Professionals:

______(initial) FUNDING AUTHORIZATION: I authorize Adapt Behavioral Services to release relevant confidential information to my current funding source in order to process claims, obtain reimbursement, and comply with the funding source’s auditing requirements. **I understand that I will be responsible for any charges that this funding source does not cover, including any services provided after my insurance has lapsed, fees described on the Copayment Agreement, and fees described in the No Show/Cancellation Policy.

I understand that I may revoke consent for the above at anytime, however, I cannot revoke consent for action that has already been taken. A copy of this release shall be valid as the original. THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED.

______Client/Legal Guardian Signature Date Revised 11/12

A D A P T No Show/Cancellation Policy BEHAVIORAL SERVICES

Client: Date of Birth:

Regular attendance at scheduled appointments is very important. Our services will not be effective in helping you if you do not keep your appointments. Irregular attendance, especially a “no show,” is also inconvenient and costly for the staff assigned to help you. It is therefore your responsibility to attend all scheduled appointments.

CANCELLATION POLICY: If you call your assigned clinician at least an hour before your scheduled appointment, it is considered a “Cancellation,” although 24-hour notice is preferred. 1. After the first cancellation, the staff person will call you to reschedule. 2. After two cancellations in a row, the Director will send you a letter explaining that you must call him/her if you desire to continue services. 3. After the third cancellation in a row, services will be terminated. 4. If you cancel three times, with some attendance in between each cancellation, your therapist will discuss with you some possible solutions to the problem of irregular attendance.

NO SHOW POLICY: If you do not call to cancel at least an hour before the scheduled appointment time, it is considered a “No Show.” 1. If you fail to notify your assigned clinician prior to a missed in-home session, you will be charged a $10 travel fee to cover the staff cost of traveling to your home for the missed appointment. 2. If you fail to notify your assigned clinician prior to an in-office or in-school session, you may be charged a $10 travel fee if the staff traveled to that location specifically for that session. 3. After the first “No Show,” the staff person will call to reschedule the appointment. 4. After the second “No Show,” the Program Manager will send you a letter notifying you that services have been suspended and that you are required to pay the travel fees for both missed sessions in order to reinstate services. 5. After the third “No Show,” your case will be closed.

If these services are mandated or court-ordered, the person responsible for monitoring compliance with the mandate (e.g., dependency case manager, probation officer) will be notified of repeated cancellations/no shows and suspension or termination of services.

I understand Adapt Behavioral Service’s No Show/Cancellation policy and understand that regular attendance is necessary for treatment to be effective. Therefore, I agree to attend all scheduled sessions. If I cannot keep an appointment, I will call the staff 24 hours in advance to reschedule. If I have an emergency that prevents me from attending, I will call the assigned clinician at least one hour before the appointment to cancel.

______Client Signature Date

______Parent/Caregiver Signature Date Revised 11/12

A D A P T Primary Care Physician Notification BEHAVIORAL SERVICES

Client Name: Date of Birth:

This client’s Primary Care Physician is as follows: PCP Name: Mailing Address: City, State, Zip: Phone/Fax: Email address:

Purpose of Release: FOR NOTIFICATION PURPOSES ONLY -- DO NOT SEND RECORDS This document serves as notification to the Primary Care Physician that counseling and/or behavior analysis services are being provided by Adapt Behavioral Services: Intake date: Clinician Name: Clinician phone:

Acknowledgement: By signing below, I authorize Adapt Behavioral Services to release a copy of this document to the PCP named above. I further authorize exchange of confidential information between the PCP and Adapt Behavioral Services for the purpose of coordination of care. Contact information for Adapt Behavioral Services is as follows: Orange/Seminole/Lake: 225 S. Swoope Ave. #211, Maitland, FL 32751, (407) 622-0444 Volusia/Flagler/St. John’s: 533 N. Nova Rd. #204, Ormond Beach, FL 32174, (386) 898-5003 Osceola/Polk: 3483 W. Vine St., Kissimmee, FL 34741, (407) 928-0444

. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from Adapt Behavioral Services. . I understand that I may revoke this authorization in writing at any time, however I cannot revoke authorization for action that has already been taken. . A copy of this release shall be valid as the original.

THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.

______Client/Legal Guardian Signature Date

A D A P T Consent to Release Information BEHAVIORAL SERVICES

Client Name: Date of Birth: I authorize Adapt Behavioral Services Orange/Seminole/Lake Osceola/Polk Volusia/Flagler/St. Johns 225 S. Swoope Ave. #211 3483 W. Vine St. 533 N. Nova Rd. #204 Maitland, FL 32751 Kissimmee, FL 34741 Ormond Beach, FL 32174 (407) 622-0444 (407) 928-0444 (386) 898-5003 (407) 699-0444 fax (407) 518-0808 fax (386) 675-6490 fax to exchange confidential information concerning the above-named client with the following: Agency/Contact: Mailing Address: City, State, Zip: Phone/Fax: Email: I authorize: Informal communication regarding all client information between both parties. AND/OR Copies of the following documents to be mailed/faxed to the agency listed above Copies of the following documents to be mailed/faxed to Adapt Behavioral Services Limited verbal communication (no copies) related only to the following records (Check which documents are authorized to be released) Bio-Psychosocial Evaluation Psychiatric Evaluation Report Cards/Transcripts Licensed Evaluation Medication Management Behavioral Program Treatment Plan/Reviews Medical History & Physical Individual Education Plan Progress Summary Immunization Record Other: Discharge Review Lab Results Other:

Purpose of Release: Assessment Treatment Coordination Other, specify: Notification of compliance with court-ordered treatment (e.g., DCF, DJJ)

. I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from Adapt Behavioral Services. . I understand that if I am court-ordered into treatment and refuse to allow Adapt Behavioral Services to share information with those responsible for monitoring my compliance with mandated treatment, this may result in negative consequences imposed by the court. . I understand that I may revoke this authorization in writing at any time, however I cannot revoke authorization for action that has already been taken. . A copy of this release shall be valid as the original. THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.

______Client/Legal Guardian Signature Date

A D A P T Bio-Psychosocial Evaluation BEHAVIORAL SERVICES

Client: Date of Birth: Age: Sex: Race: Primary Clinician: Intake Date: PSYCHOSOCIAL STRESSORS (circle descriptors or, if typing, delete descriptors that do not apply) Family changes: divorce/remarriage, death/birth, estranged, caregiver changes, other: Family conflict: between siblings, parent-child, couple/marital, extended family, other: Social/Relationships: lack of friends, peer conflict/rejection, death/loss of friend, other: Placement/Housing: crowded, moves, unsafe, homeless, risk of eviction/foreclosure, other: Educational: school changes, academic delays, poor grades, discipline, other: Financial/Work: low income, unemployed, supervisor conflict, retirement, other: Legal: protective services, arrest, incarceration, probation, litigation, police called, other: Disability/disorder: SSI, injury, chronic illness, physical limitation, developmental, other: Trauma/abuse: sexual abuse, physical abuse, foster care, crime victim, natural disaster, other: Current safety threat (written safety plan required): Other stressor: Describe: ______BEHAVIORAL HEALTH/MENTAL STATUS (rating of 4+ requires intervention on MTP or rationale for omission) Severity: 1=no problem; 2-3=slight problem; 4-6=needs treatment; 7-9=hospitalization may be needed; P=past problem (>3 mo ago) Depression: sad, withdrawn, flat affect, hopeless, apathetic, lethargic, other: Anxiety: worries, fearful, phobic, panic, OCD, PTSD symptoms, sleepless, other: Hyper-manic: inattentive, disruptive, overactive, impulsive, distractible, sleepless, other: Psychosis: hallucinations, delusions, disoriented, loose associations, other: Substance use*: alcohol, tobacco, illegal, prescription, binges, cravings, other: Peer problems: argues, provokes, verbal abuse, physical aggression, rejected, other: Authority problems: defiant, argues, verbal abuse/cursing, physical aggression, other: Family conflict: conflict with sibling, parent, child, partner, extended family, other: Sexuality issues: sexual acting out, sexual preference issues, gender confusion, other: Self-care problems: poor hygiene, needs assistance, daytime enuresis, encopresis, other: Antisocial: breaks societal rules, lies, truant, curfew violations, firesetting, theft, other: Danger to self**: risk-taking, suicidal ideation/plan, self injury, suicide attempt, other: Danger to others**: violent, causes injury, weapons, homicidal ideation/threats, other: Sleep issues: resists bedtime, wakes frequently, wakes early, wets bed, other: Other symptom: Average hours sleep at night: *Rating of 7+ on substance use requires referral to substance abuse assessment/treatment **Rating of 7+ on danger to self or danger to others requires a written safety plan/crisis assessment Details & history of symptoms: ______Revised 11/12

A D A P T Bio-Psychosocial Evaluation – page 2 BEHAVIORAL SERVICES Client: MENTAL HEALTH TREATMENT HISTORY (include treatment type, provider/agency name, dates of treatment) Outpatient: Inpatient/crisis unit: Current psychotropic medications/dosages: Results/side effects of current medications: Prior medications/results/side effects: Prior diagnoses: Family mental health, substance abuse issues: Client has psychiatric advance directive? Yes No (if yes, attach a copy of written advance directive) Additional information: EDUCATIONAL HISTORY Highest grade completed: Learning/academic delays? Yes No Reading level? School performance: School behavior: EMPLOYMENT HISTORY Currently employed? Yes No Employer: Work performance/issues: MEDICAL/PHYSICAL HISTORY Developmental history (children only): delays in crawling walking speech other: Immunizations up-to-date (children only): yes no, explain: Current & past medical issues (check all that apply & provide details below): none Seizure disorder Hypertension Gross motor problem Headaches Diabetes Heart problem Fine motor problem Stomach aches HIV/AIDS Kidney problem Prenatal drug exposure Bowel problem Brain injury Thyroid problem Life-threatening illness*** Allergies Paraplegia Vision impairment ***(requires safety plan) Asthma Dental problem Hearing impairment Other: Details: ______Current medications for physical conditions: Current health needs: Other/need for assistive technology in service provision: ADAPTIVE FUNCTIONING/STRENGTHS Self care skills: age-appropriate, verbal prompting, physical assistance, dependent, other: Communication level: age appropriate, articulation, nonverbal, speech delay, echoic, other: Intellectual/developmental abilities: IQ low/average/high, Autism/ASD, learning disability, other: Leisure/recreation interests: Support network/current resources: Client strengths: Family strengths: Other strengths: Revised 11/12

A D A P T Bio-Psychosocial Evaluation – page 3 BEHAVIORAL SERVICES Client: INTERPRETIVE SUMMARY (include significant findings in all areas, relationship between issues, factors affecting outcome) ______INITIAL TREATMENT PLAN Client statement of presenting issues: Client/family goals in treatment: Religious/cultural sensitive issues: Gender sensitive issues: Current services/social supports: Service recommendations/support needs: Client willingness to participate: Caregiver willingness to participate: Other preferences: PROVISIONAL DIAGNOSES (Clinical Impressions) Axis I: ICD-9: ICD-9: Axis II: ICD-9: Axis III: Axis V: GAF: Axis IV: Discussion of Diagnoses with Licensed Supervisor: Date: I agree with the treatment recommendations and provisional diagnoses contained in this evaluation.

______Primary Clinician/Credentials Date Completed Licensed Supervisor/Credentials Date Discussed

Revised 11/12

A D A P T Progress Note BEHAVIORAL SERVICES Instructions: Write note within 24 hours after session. Turn in to office for filing in client record within 1 week.

Client Name: Date: Units of Service: Location: Start Time: am/ pm End Time: am/ pm SERVICE: TBOS-T (assessment; individual/family therapy; engagement of client’s support system; develop/implement/monitor behavior program) Individual & Family Therapy (insight oriented, cognitive behavioral, or supportive therapy to an individual or family--not school personnel) 90791-Intake Psychotherapy: 90834-45min OR 90832-30min Family Therapy: 90847-WITH client OR 90846-W/OUT client Assessment (FSPT-AS) In-Home & On-Site (FSPT-IHOS) Individual Outpatient (FSPT-IndOP) Funding ineligibility notification No show Cancellation Week without service (EXPLAIN) Other:

Problem #1: PROGRESS: Problem #2: PROGRESS: Problem #3: PROGRESS: Problem #4: PROGRESS:

PARTICIPANTS: Client Other(s): Relationship/Name PRESENTING ISSUES: INTERVENTIONS: ______1. Initial session with client and family ______1. Began developing rapport and creating positive expectations ______for treatment success. Oriented client and family to treatment. ______2. ______2. . ______

REFERRAL INFORMATION GIVEN FOR: Agency: Service Type: LEVEL OF PARTICIPATION/RESPONSE TO INTERVENTION: Client: Participation/response by other: Follow through on homework: PLAN: Next session scheduled for @ am/ pm. Homework assigned: Focus of next session: Signature: Name: Credentials: Date: Abbreviation Legend: Clt=client Tch=Teacher =increase =decrease mgmt=management Mx=mother SF=step-father Dx=diagnosis Tx=treatment +=positive wk=week GF=girlfriend Fx=father GM=grandmother Hx=history Bx=behavior x=times w/=with BF=boyfriendProgress Note Revised 01/13

Instructions: Write note within 24 hours after session. Turn in to office for filing in client record within 1 week.

Client Name: Date: Units of Service:

A D A P T BEHAVIORAL SERVICES Location: office Start Time: am/ pm End Time: am/ pm SERVICE: TBOS-T (assessment; individual/family therapy; engagement of client’s support system; develop/implement/monitor behavior program) Individual & Family Therapy (insight oriented, cognitive behavioral, or supportive therapy to an individual or family--not school personnel) 90791-Intake Psychotherapy: 90834-45min OR 90832-30min Family Therapy: 90847-WITH client OR 90846-W/OUT client Assessment (FSPT-AS) In-Home & On-Site (FSPT-IHOS) Individual Outpatient (FSPT-IndOP) Funding ineligibility notification No show Cancellation Week without service (EXPLAIN) Other:

Problem #1: PROGRESS: Problem #2: PROGRESS: Problem #3: PROGRESS: Problem #4: PROGRESS:

PARTICIPANTS: Client Other(s): Relationship/Name PRESENTING ISSUES: INTERVENTIONS: ______Documented assessment of client and family is needed in ______Completed Biopsychosocial Evaluation and Children's ______order to formulate an effective plan for treatment.. ______Functional Assessment Rating Scale following intake ______assessment session. ______

CHILDREN’S MENTAL HEALTH OUTCOME/CFARS FORM

*Client Name: Last First Middle [PRINT NAME] Section 1 : If purpose of evaluation is 4-Administative discharge complete areas with paper/pencil picture only. **Provider Initial Evaluation Date from MH Outcome Form at Admission: ***HSA Initial Evaluation Date from MH Form at Admission: 1. *Social Security#: - - 2. *Contractor ID: 59-3174674

1- Admission to agency 4- Administrative Discharge (Complete areas with 3.*Provider Purpose of Evaluation: 2- 3 month Interval paper/pencil picture only ) (Select a choice, then complete the sections associated with that choice) 3- Discharge from Agency 5-Immediate Discharge 1- Admission to agency 4- Administrative Discharge (Complete areas 3.(a) *HSA Purpose of Evaluation: 2- 3 month Interval with paper/pencil picture only ) 3- Discharge from Agency 5-Immediate Discharge 4.*Evaluation Date: - - 5. *Provider ID: MM / DD / YYYY 5(a).*HSA Provider ID: 59-374674

Section 2 : 6. *Provider Site ID: 7. Client ID: 6(a) .*HSA Site ID:

8. *Mental Health (799.9) = Unknown Cause For ICD-9 code enter the first three digits from DSM-IV Code (i.e. Major depression disorder, Diagnosis: recurrent – DSM-IV (296.30) / ICD-9 (296)

9. Substance Abuse (799.9) = Unknown Cause For ICD-9 code enter the first three digits from DSM-IV Code (i.e. Major depression disorder, Diagnosis recurrent – DSM-IV (296.30) / ICD-9 (296)

10. **CFARS _ Rater ID: Note: Rater Education Specialty Rater FMHI Certification # Full Rater ID is Definition for first two digits: 03 – BA/BS 06 – PhD/PsyD/EdD – Licensed required 01 – Non-Degree Trained Technician 04 – MA/MS Psychologist 02 – AA Degree Trained Technician 05 – MA/MS Licensed Practitioner 07 – MD/DO – Board Certified

CFARS Section: Note: If completing at the 3 or 9 month interval choose “6- None of the Above” on Question 1. 1- Admission to Agency 4-Administrative Discharge 1.* Purpose of CFARS Evaluation: 2- 6 month Interval 5-None of the Above 3- Discharge from Agency 2. *Substance Abuse History: 0-No 1-Yes (Abused Drugs or Alcohol in the last 6 months)

3. *Problem Severity Rating Scales: Assign a severity Rating Number to each Section to describe the consumer’s problems or assets during the last 3 weeks. Mark an “X” through this section if completing this form at the 3 or 9-month interval

1 2 3 4 5 6 7 8 9 No Less Slight Slight to Moderate Moderate Severe Severe to Extreme Problem Than Slight Problem Moderate Problem to Severe Problem Extreme Problem i. Interpersonal m. Select: a. Depression: e. Cognitive Performance: Relationships: Work/School: j. Home Setting b. Anxiety: f. Medical/Physical: n. Danger to Self: Behavior k. ADL o. Danger to c. Hyper Activity: g. Traumatic Stress: Functioning: Others: p. Security d. Thought Process: h. Substance Abuse: l. Socio-Legal: Management HSA Form #4: Children MH Outcome/CFARS Page 1 of 4 Effective: 7/01/2010 Revised 4/11/2007, 5/29/2008, 7/30/2008, 3/18/2010,6/17/10, 06/25/10 HUMAN SERVICES ASSOCIATES, INC. Family Service Planning Team & Title XXI Intervention

Client Name [PRINT]

Section 2 Cont.

1 - Salary 3 - Retirement/Pension/SSI 5 - Other 11. * Primary Source of Income: 7 – Unknown 2 – WAGES/TANF 4 - Disability 6 - None

0-No 0-No 12. *Psychiatric Disability Income: 13. *Service to Exceed or has Exceeded 12 Months 1-Yes 1-Yes Non-Adjudicated Children Adjudicated Children 08 - Other DCF program status 01 – Delinquent – In physical custody 09 - Under custody & supervision of 02 - Delinquent – not in physical custody family/guardian 14.*Dependency/ 03 - Dependent, in physical custody Criminal Status: 04 - Dependent, not in physical custody Incompetent to Proceed 05 - Dependent & Delinquent, in physical custody 27 - Incompetent to Proceed–Ages 0-17 06 - Dependent & Delinquent, not in physical custody 28- Incompetent to Proceed – Ages 18-20 07 – CINS, not in physical custody

15. *Admission Type: 1 - Voluntary Competent 3 - Involuntary Competent 2 – Voluntary Incompetent 4 - Involuntary Incompetent Performance Measures 16. *Days Spent in the Community in Last 30 Days: 17. *Rx? Is client taking atypical antipsychotic medication in past 90 days: 0-No 1-Yes 18. *Total School Days Available (last 30 days): NOTE: Max. Number is 22 due to weekends

19. *School Days Attended (last 30 days): NOTE: Max. number is 22 due to weekends 20. *Current CGAS Rating: (Must have an entry between 01 and 99) 21. *Committed to DJJ (last 90 days): 0-No 1-Yes 0-No 1-Yes 22. *Risk Factor: (No MH diagnosis, but risk factors for Emotion Disturbance)

07 - Foster Care/Home 01 - Independent – alone 08 - Group Home 02- Independent – shares costs with relatives 13 - Correctional Facility 09 - Homeless 03 - Independent – shares costs with non-relatives 14 - DJJ Facility 23. *Residential Status: 10 - Hospital 04 - Dependent – not sharing costs with relatives 99 - Not Available or Unknown 11 - Nursing Home 05 - Dependent – not sharing costs with non-relatives 12 - Supported Housing 06 - Assisted Living Facility (ALF) 1-Single 4-Divorced 7-Registered Domestic Partner 24. *Marital Status: 2-Married 5-Separated 8-Legally Separated 3-Widowed 6-Unreported

10 – Active military, overseas 50 – Leave of Absence 83 – Disabled 20 – Active military, USA 60 – Retired 84 – Criminal Inmate 25. * Employment Status: 30 – Full Time 70 – Terminated (unemployed) 85 – Other Inmate 31-Employed in Family Run Business 81 – Homemaker 86-Not Authorized to work 40 – Part Time 82 – Student (illegal alien and some children) 26. *County of Residence: (88 - Homeless, 99 - Out of State)

32 - Master’s Degree (MA, MS, MSW, 20 - No Schooling 26 - 11th Grade etc.) 21 - Nursery Schooling to 4th Grade 27 - 12th Grade, No Diploma 33 - Prof. Degree (MD, DDS, JD, etc.) 27.*Highest Education: 22 - 5th to 6th Grade 28 - High School Graduate-Diploma 34 - Doc. Degree (PhD, EDD, etc.) 23 - 7th to 8th Grade 29 - 1 or > year College, No Degree 35 - Special School 24 - 9th Grade 30 - Associate’s Degree (AA, AS, 36 -Vocational School 25 - 10th Grade etc.) HSA Form #4: Children MH Outcome/CFARS Page 2 of 4 Effective: 7/01/2010 Revised 4/11/2007, 5/29/2008, 7/30/2008, 3/18/2010,6/17/10, 06/25/10 HUMAN SERVICES ASSOCIATES, INC. Family Service Planning Team & Title XXI Intervention

Client Name [PRINT]

Section 3 28. ** IDENTIFY DISABILITY FACTORS: a.*Developmental Disability: 0-No 1-Yes b.*Physical Disability: 0-No 1-Yes c.*Non-ambulatory (bedridden, wheelchair): 0-No 1-Yes d. *Visually Impaired 0-No 1-Yes e.*Hearing Impaired 0-No 1-Yes f. *Person’s English Language understanding and speaking are severely limited 0-No 1-Yes g. *ADL Function: (Difficulty performing independently in day-to-day living) 0-No 1-Yes 29. *Zip Code: 88888 – Homeless 99999 – Unknown 30. *Mental Health Problem: 1 - Shows evidence of recent severe stressful event and problems with coping 2 - Displays symptomatology placing person at risk of more restrictive intervention if untreated 3 – Both (1 & 2) 4 – None 31. *TANF Status: 1 - Temporary Cash Assistance 2 - Diversion Family Program 3 - Not a TANF Client 32. *Family Size: Number living in home (1-9) 9 = 9 or more

33. *Annual Personal Income (00-99): $ (98) - Income over $98,000 (99) – Unknown [Last 12 months]

34.*Primary 01 - Individual (Self-Referral) 08 - Other social 14 - Other court order/legal entity 22 - Physician/Dr 02 - SA Care Provider service/health/Community Ref. 16 - CINS/FINS 23 - Law enforcement Referral Source: 03 - MH Care Provider 09 - TASC 17 - ARF 24 - Fam Safe: Foster 04 - Juvenile Justice 10 - Probation/Parolee 18 - Outreach Program Care 05 - County Public Health Unit 11 - DUI/DWI 19 – DCF/ADM 25 - Fam Safe: Prof. 06 - School (Education) 12 - Pretrial 20 - Community Hospital Services 07 - Employer /EAP 13 - Prison/Jail 21 - State Hospital 99 - None of the Above 35. *Baker Act: (Meets criteria for admission to Baker Act facility) 0-No 1-Yes 36. *Did client receive medication through Indigent Psychiatric Medication Program in the past 90 days? 0-No 1-Yes

37. *Is client taking any medication through Patient Assistance Program in the past 90 days? (e.g. 0-No 1-Yes Zyprexa, Risperdol, Seroquel, Geodon, Clozaril, etc.) 38.* SAMH Contract #: GHG19 (T-21) 39.*Contractor NPI # 1407813405 40.*Provider NPI #: 1356532584 40(a). HSA Provider NPI #: 1407813405 41. *Veteran of US 0-No 1-Yes Armed Services? 01- No attendance in the past month 05- 16-30 Times in past month 42.*Social Connectedness 02- 1-3 Times in past month 06- Some attendance in past month, (attended self-help group) 03- 4-7 times in past month but frequency unknown. 04- 8-15 times in past month 43.*Number of Times Client was arrested in the past 30 days (0-9) Use 9 if arrested more than 9 times: 44.*Was the client suspended and/or expelled within the 1- Suspended 3- Suspended and Expelled last 30 days? 2- Expelled 4- Not Applicable

HSA Representative: [PRINT NAME]

HSA Representative Signature: Date: HSA Form #4: Children MH Outcome/CFARS Page 14 of 4 Effective: 7/01/2010 Revised 4/11/2007, 5/29/2008, 7/30/2008, 3/18/2010,6/17/10, 06/25/10 HUMAN SERVICES ASSOCIATES, INC. Family Services Planning Team & Title XXI Intervention For Providers Only

DEMOGRAPHIC FORM

1. Client Social Security Number: - - (If unknown create Pseudo SS# using guidelines below)

2. Contractor ID: 59-3174674

3. Provider ID: 20-5708619

4. Client ID:

5. *Client LAST Name: [PRINT LAST NAME]

6. *Client FIRST Name: [PRINT FIRST NAME]

7. *Client MIDDLE Name: PRINT MIDDLE NAME or N/A if none or unknown]

8. Client Suffix (i.e Jr. or III):

9. *Date of Birth: - - MM / DD / YYYY 10. *Gender: 1. Male 2. Female 1. White 7. Asian 11. *Race: 2. Black 8. Native Hawaiian/Other Pacific Islander 3. American Indian/Alaskan Native 9. Multi-Racial 1. Puerto Rican 5. Haitian 2. Mexican 6. None of the Above 12. *Ethnicity: 3. Cuban 7. Mexican American 4. Other Hispanic 8. Spanish/Latino

13. *Contractor NPI#: 1407813405

14. *Subcontractor NPI#: 1356532584

(*Mandatory Fields) Pseudo SS# Guidelines (i.e. John M. Doe) First letter of FIRST name J First letter of MIDDLE name M NOTE: If the client does not have a middle name, the letter “X” is used for the second character in the Pseudo SS#. First letter of LAST name D DOB in MMDDYY 041378 New Pseudo SSN JMD041378

HSA Representative: [PRINT NAME]

HSA Representative Signature: Date:

HSA Form FSPT-T21-C18-01 Page 1 of 1 Effective: 7/1/07