Crisis Form V2 2014.Xls Computer System to Gather Crisis Data It Must Comply with This Rule: If Et, Then the Data in the Drop Downs Must Be Used Verbatim for Answers
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Summary of Telephone Crisis Contacts Total number telephone contacts Children Total number telephone contacts Adults All Encounters. Is this an Initial or Follow up Face To Face Encounter. REQUIRED. Type Of Encounter Number If an alternative spreadsheet is developed on your c there are drop downs for an item in the spreadshee All Encounters. Enter your Agencies Name from All Encounters. Select a report year from drop down. REQUIRED. drop down. REQUIRED. Agency Name Report Year Questions or concerns: Lee Richardson at 287-4591 or Julia Mason at 287-6667 Crisis Form V2_2014.xls computer system to gather Crisis Data it must comply with this rule: If et, then the data in the drop downs must be used verbatim for answers All Encounters. Select a report All Encounters. Enter All Encounters. Enter month from drop down. clients first name. clients last name. REQUIRED. REQUIRED. REQUIRED. Report Month First Name Last Name All Encounters. Select a Town from the List. All Encounters. Enter the clients REQUIRED. Medicaid ID. Town Zip Medicaid Id All Encounters. Select a Payment Source from the drop down. All Encounters. Enter an SSN with REQUIRED. no dashes. Payment Source SSN All Encounters. Select clients All Encounters. Enter the date All Encounters. Enter clients Gender from drop down. the Crisis worker met with Date Of Birth. REQUIRED. REQUIRED. client. REQUIRED. DOB Gender Date Of Encounter Initial Encounters only. New for Initial Encounters only. New for 2014. REQUIRED. 2014. REQUIRED. Housing status at time of the Who made the request for initial encounter encounter All Encounters. Select from drop down where the Crisis Worker All Encounters. New for 2015 - met with the client this encounter. REQUIRED. REQUIRED. Did the assessment from this encounter indicate the client would benefit from Site Of Face To Face Encounter substance abuse treatment. Initial Encounters only. Select from drop down a Crisis Assessment Criteria. REQUIRED Crisis Assessment Criteria All Encounters. Select Yes, No or NA from the drop down. If the client is not over 18 select NA. REQUIRED. If this client is under 18 do they have a MENTAL RETARDATION/AUTISM/PERVASIVE/Developmental DISORDER. All Encounters. Select Yes, No from the drop down. Same as on All Encounters. Select Yes, No from the old form - REQUIRED drop down. REQUIRED Is this Crisis Encounter the result Does this client have a wellness plan, crisis of an on going support for a plan, ISP or advanced directive plan previous crisis previously developed that was used for this resolution/stabilization. encounter. All Encounters. Select Yes, No or NA from the drop down. Select NA if the All Encounters. Select Yes, No client did not have a Community Support from the drop down. REQUIRED worker. REQUIRED Does this client have a Community If the client had a Community Support Support Worker (CI, CRS, ICM, Worker, was that worker notified of the ACT, TCM) crisis. Initial Encounters Only. Enter time in Initial Encounters Only. Enter time in Minutes as Hours as a whole number. Round minutes a whole number. REQUIRED off. Must be at least 1. REQUIRED Time in MINUTES between determination of need for initial face to face contact or when client Time in HOURS from initial Face to Face was ready and able to be seen, to initial face to Encounter to Disposition of Crisis. face contact Follow Up Encounters Only. Enter time in All Encounters. Select Yes, No or Hours as a whole number. Round minutes NA from the drop down. off. Must be at least 1. REQUIRED REQUIRED Time in HOURS for Non Initial Face to If this client is under 18 are they Face Encounter in State Custody? Initial Encounters only. Select from drop down a Crisis Resolution. REQUIRED Crisis Resolution (Mutually Exclusive and Exhaustive) Form Data Site Of Face To Face Encounter Primary Residence (Home) Family/Relative/Other Residence Other Community Setting (Work, School, Police Dept, Public Place) SNF, Nursing Home, Boarding Home Residential Program (Congregate Community Residence, Apartment Program) Homeless Shelter Provider Office Crisis Office Emergency Department Other Hospital Location Incarcerated (Local Jail, State Prison, Juvenile Correction Center) Crisis Assessment Criteria Depression Anxiety Behavioral Issues--youth Suicidal Ideation Suicidal Act Psychosis Homicidal Ideation Homicidal Act Self-Injury/Assaultive Behavior Substance Abuse Medical Attention needed Mental Health Symptom Decompensating Grief and Loss Domestic Abuse Acute Stress No medical Based Change in Mental Status Sexual Assault Overdose Inability to care for self Crisis Resolution. Crisis Stabilization with no referrals for Mental health/substance abuse follow-up. Crisis Stabilization with referral to new provider for Mental Health/Substance Abuse follow-up. Crisis Stabilization with referral back to current provider for Mental Health/Substance Abuse follow-up. Admission to Crisis Stabilization unit. Inpatient Hospitalization - Medical. Voluntary Psychiatric Hospitalization. Involuntary Psychiatric Hospitalization. Admission to Detox Unit. Town Zip Agency Name ABBOT VILLAGE 04406 AMHC ACTON 04001 Community Health and Counseling ADDISON 04606 Maine Behavioral Healthcare - Biddeford ALBANY 04267 Crisis & Counseling Centers, Inc. ALBANY 04231 Evergreen Behavioral Services ALBION 04910 Oxford County Mental Health Services ALFRED 04002 Maine Behavioral Healthcare - Rockland ALLENS MILLS 04938 Sweetser ALNA 04535 The Opportunity Alliance ALTON 04468 Tri-County Mental Health Services AMHERST 04605 AMITY 04465 ANDOVER 04216 ANSON 04911 APPLETON 04862 ARROWSIC 04530 ARUNDEL 04005 ARUNDEL 04046 ASHLAND 04759 ASHLAND 04737 ASHLAND 04732 ASHVILLE 04607 ATHENS 04912 ATKINSON 04410 ATKINSON 04426 ATKINSON CORNER 04426 AUBURN 04210 AUGUSTA 04330 AURORA 04408 AURORA 04605 AVON 04966 AYERS 04666 BAILEY ISLAND 04003 BAILEYVILLE 04694 BALDWIN 04024 BANCROFT 04497 BANCROFT 04424 BANGOR 04401 BAR HARBOR 04609 BAR MILLS 04004 BARING 04694 BARNARD 04414 BASS HARBOR 04653 BATH 04530 BAYSIDE 04605 BAYSIDE 04915 BAYVILLE 04536 BEAR ISLAND 04683 BEDDINGTON 04622 BELFAST 04915 BELGRADE 04917 BELGRADE LAKES 04918 BELMONT 04952 BELMONT 04915 BELMONT CORNER 04915 BENEDICTA 04733 BENTON 04910 BENTON 04936 BENTON FALLS 04901 BENTON STATION 04937 BERNARD 04612 BERWICK 03901 BETHEL 04217 BIDDEFORD 04005 BIDDEFORD POOL 04006 BINGHAM 04920 BIRCH HARBOR 04613 BIRCH ISLAND 04011 BLAINE 04758 BLANCHARD 04406 BLUE HILL 04614 BLUE HILL FALLS 04615 BOLSTERS MILLS 04040 BOOTHBAY 04549 BOOTHBAY 04537 BOOTHBAY HARBOR 04536 BOOTHBAY HARBOR 04570 BOOTHBAY HARBOR 04538 BOWDOIN 04350 BOWDOINHAM 04252 BOWDOINHAM 04008 BOWERBANK 04426 BOYD-LAKE 04463 BRADFORD 04410 BRADFORD CENTER 04410 BRADLEY 04412 BREWER 04412 BREWER LAKE 04474 BRIDGEWATER 04735 BRIDGTON 04009 BRIGHTON 04912 BRIGHTON 04990 BRISTOL 04539 BROOKLIN 04616 BROOKS 04921 BROOKSVILLE 04617 BROOKTON 04413 BROWNFIELD 04010 BROWNVILLE 04414 BRUNSWICK 04053 BRUNSWICK 04011 BRUNSWICK NAVAL AIR STATION 04011 BRYANT POND 04219 BUCKFIELD 04220 BUCKS HARBOR 04618 BUCKSPORT 04416 BUNKERS HARBOR 04613 BURKETTVILLE 04574 BURLINGTON 04417 BURNHAM 04922 BUSTINS ISLAND 04013 BUXTON 04093 BUXTON CENTER 04093 BYRON 04275 CALAIS 04619 CAMBRIDGE 04923 CAMDEN 04843 CAMDEN 04847 CAMP ELLIS 04072 CANAAN 04924 CANTON 04221 CANTON POINT 04221 CAPE COTTAGE 04107 CAPE ELIZABETH 04107 CAPE JELLISON 04981 CAPE NEDDICK 03902 CAPE PORPOISE 04014 CAPE ROSIER 04642 CAPE SPLIT 04606 CAPITOL ISLAND 04538 CARATUNK 04925 CARDVILLE 04418 CARIBOU 04736 CARMEL 04419 CARRABASSET VALLEY 04947 CARRABASSETT 04947 CARROLL 04487 CARSON 04786 CARTHAGE 04224 CARY PLANTATION 04465 CASCO 04015 CASTLE HILL 04732 CASTLE HILL 04757 CASWELL 04750 CEDAR GROVE 04342 CENTER LEBANON 04027 CENTER LOVELL 04016 CENTER MONTVILLE 04941 CENTER VASSALBORO 04989 CENTERVILLE 04623 CENTRAL M E POWER CO 04336 CHAMBERLAIN 04541 CHAPMAN 04757 CHARLESTON 04422 CHARLOTTE 04666 CHEBEAGUE ISLAND 04017 CHELSEA 04345 CHELSEA 04330 CHERRYFIELD 04622 CHESTER 04458 CHESTERVILLE 04352 CHESTERVILLE 04938 CHESTERVILLE 04955 CHESUNCOOK DAM 04441 CHESUNCOOK VILLAGE 04441 CHINA 04358 CHISHOLM 04239 CHRISTMAS COVE 04568 CLARK ISLAND 04859 CLAYTON LAKE 04737 CLAYTON LAKE 04732 CLIFF ISLAND 04019 CLIFTON 04428 CLIFTON CORNERS 04428 CLINTON 04927 COBURN GORE 04936 CODYVILLE 04490 COLBY 04736 COLBY COLLEGE 04901 COLES CORNER 04496 COLUMBIA 04623 COLUMBIA 04643 COLUMBIA FALLS 04623 CONCORD 04979 CONNORS 04736 COOKS CORNER 04011 COOPERS MILLS 04341 COPLIN 04982 COREA 04624 CORINNA 04928 CORINNA CENTER 04928 CORINTH 04427 CORNISH 04020 CORNVILLE 04976 COSTIGAN 04423 COUSINS ISLAND 04096 CRAWFORD 04694 CROUSEVILLE 04786 CRYSTAL 04747 CUMBERLAND 04021 CUMBERLAND CENTER 04021 CUMBERLAND FORESIDE 04110 CUMBERLAND MILLS 04092 CUNDYS HARBOR 04011 CUPSUPTIC 04964 CUSHING 04563 CUTLER 04626 CUTLER NAVAL COMMUNICATIONS 04630 CUTTS ISLAND 03905 CYR PLANTATION 04785 DAIGLE 04743 DALLAS 04970 DAMARISCOTTA 04543 DAMASCUS 04419 DANFORTH 04492 DANFORTH 04424 DANVILLE 04223 DAYTON 04005 DEBLOIS 04622 DEDHAM 04429 DEER ISLE 04627 DENMARK 04022 DENNISTOWN 04945 DENNYSVILLE 04628 DERBY 04463 DETROIT 04929 DEXTER 04930 DICKEY 04774 DIXFIELD 04224 DIXMONT 04932 DIXMONT CENTER 04932 DOLBY 04430 DORMAN 04643 DOUGLAS HILL 04024 DOVER 04426 DOVER-FOXCROFT 04426 DRESDEN 04342 DREW 04497 DRY MILLS 04039 DRYDEN 04225 DUCKTRAP 04849 DURHAM 04032 DURHAM 04252 DURHAM 04069 DURHAM 04210 DYER BROOK 04747 E PLANTATION 04758 EAGLE ISLAND 04683 EAST ANDOVER 04226 EAST AUBURN 04210 EAST BALDWIN 04024 EAST BENTON 04910 EAST BETHEL 04217 EAST BOOTHBAY 04544 EAST BUCKFIELD 04220 EAST CORINTH 04427