Questionnaire of Understanding & information for Care Coordination

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• The Client/Recipient was exposed to controlled substances, drugs and/or alcohol during utero.

  Yes

  No

  N/A

• The Client/Recipient was born prematurely or with documented birth defects or developmental delays that have required special education or related services or therapy.

  Yes

  No

  N/A

• The Client/Recipient has used controlled substances, drugs and/or alcohol within the last three months and is currently using.

  Yes

  No

  N/A

• The Client/Recipient has been exposed to or involved in a traumatic episode (e.g. Death, violence, and accident) and or domestic violence, abuse (e.g. Physical, sexual, and/or emotional), and or neglect situations.

  Yes

  No

  N/A

• The Client/Recipient and/or PGA shared information from the client's past they consider to be a setting event or trigger contributing to the current situation or behavior.

  Yes

  No

  N/A

• Currently or within the past three months the Client has received Rehabilitation Mental Health (RMH) services.ED

  Yes

  No

  N/A

EDUCATION

• The Client/Recipient is currently receiving special education services and has a current Individualized Education Program (IEP) Note: request a copy.

  Yes

  No

  N/A

• The Client/Recipient is currently enrolled and consistently attending school (if applicable, list the name of the school, grade level or date of expulsion,suspension, and/or dies enrollment.

  Yes

  No

  N/A

• The Client/Recipient is enrolled in a vocational or higher education program (e.g. This would include course work to obtain a GED).

  Yes

  No

  N/A

• The Client/Recipient has retained several grade levels.

  Yes

  No

  N/A

• The Client/Recipient is actively engaged in extracurricular/organized sports or school activities.

  Yes

  No

  N/A

• The Client/Recipient has proven successful in his/her current educational placement (e.g. Academically, socially, and emotionally).

  Yes

  No

  N/A

CURRENT LEVEL OF FUNCTIONING

• BST_The Client/Recipient has demonstrated his/her abilities to provide the majority of his/her functional needs independent of others (e.g. Toileting, dressing, personal hygiene).

  Yes

  No

  N/A

• PSR_The Client/Recipient has established and maintained positive relationships with his PGA, teachers, and peers across settings (e.g. Home, school, and community).

  Yes

  No

  N/A

• PSR_The Client/Recipient can effectively communicate his/her likes, dislikes, needs and protest.

  Yes

  No

  N/A

• PST_The Client/Recipient can self sooth, self-regulate, his/her behavior, and can control his/her aggression within reason.

  Yes

  No

  N/A

• PSR_The Client/Recipient has a good perception of his/her self-concept (e.g. Self-esteem, confidence).

  Yes

  No

  N/A

• BST_The Client lives independently or is not in the care of a PGA.

  Yes

  No

  N/A

STRENGTHS & NEEDS (e.g. Child and Adolescent Service Intensity Instrument (CASII) and Level of Care Utilization System of Adults (LOCUS)

• The Client/Recipient status regarding his/her Intensity of Needs Determination has been established within the last 30 days.

  Yes

  No

  N/A

• The Client/Recipient's Sever Emotional Disturbance (SED)/ Seriously Mentally Impaired (SMI) Determination has been made.

  Yes

  No

  N/A

• The Client/Recipient is a member of a social/spiritual/fitness group or club and attends meetings/sessions regularly (e.g. Church, fitness club, and or fraternity/sorority).

  Yes

  No

  N/A

• The Client/Recipient has direct contact and support from his/her immediate/extended family and/or friends.

  Yes

  No

  N/A

• The Client/Recipient is homeless.

  Yes

  No

  N/A

• The Client/Recipient is unemployed and does not have any financial resources.

  Yes

  No

  N/A

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  Date

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