Site data collection personnel (client-level service utilization report)

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

ATTACHMENT 7

Registry Data

PHYSICAL HEALTH SERVICES

Since the last scheduled report….	Response Options
The total number of visits patient has attended for physical health SCREENING or ASSESSMENT.	Number of visits
Was this patient REFERRED to physical health treatment?	Yes, No, DK
The total number of visits patient has attended for physical health TREATMENT PLANNING.	Number of visits
The total number of visits this patient has attended including physical health MEDICATION MANAGEMENT.	Number of visits
The total number of HOSPITALIZATIONS for a physical health problem.	Number of hospitalizations

MENTAL HEALTH SERVICES

Since the last scheduled report….	Response Options
The total number of visits patient has attended including mental health SCREENING or ASSESSMENT.	Number of visits
Was this patient REFERRED to mental health treatment?	Yes, No, DK
The total number of visits patient has attended including mental health TREATMENT PLANNING.	Number of visits
The total number of visits this patient has attended including mental health MEDICATION MANAGEMENT.	Number of visits
The total number of visits this patient has attended including mental health COUNSELING.	Number of visits
The total number of visits this patient has attended including mental health EVIDENCE-BASED PRACTICES.	Number of visits
List all EVIDENCE-BASED PRACTICES included in patient’s treatment for mental health issues.	List EBPs
The total number of HOSPITALIZATIONS for a mental health problem.	Number of hospitalizations

SUBSTANCE ABUSE SERVICES

Since the last scheduled report…	Response Options
The total number of visits patient has attended including substance abuse SCREENING or ASSESSMENT.	Number of visits
Was this patient REFERRED to substance abuse treatment since the last report?	Yes, No, DK
The total number of visits patient has attended including substance abuse TREATMENT PLANNING.	Number of visits
The total number of visits this patient has attended including substance abuse MEDICATION MANAGEMENT.	Number of visits

The total number of visits this patient has attended including substance abuse COUNSELING.	Number of visits
The total number of visits this patient has attended including substance abuse EVIDENCE-BASED PRACTICES.	Number of visits
List all EVIDENCE-BASED PRACTICES for substance abuse included in patient’s treatment.	List EBPs
The total number of HOSPITALIZATIONS for substance abuse.	Number of hospitalizations

WELLNESS SERVICES

Since the last scheduled report…	Response Options
Was this patient REFERRED to wellness programs?	Yes, No, DK
The total number of WELLNESS SESSIONS patient has attended.	Number of sessions
List all types of WELLNESS SESSIONS this patient has attended (e.g., smoking cessation, diabetes management, stress reduction).	List wellness programs attended

PROVIDER CONTACTS

Since the last scheduled report…	Response Options
The total number of contacts this patient has had with CARE MANAGERS.	Number of contacts
The total number of contacts this patient has had with PRIMARY CARE PROVIDERS (MDs, LPNs, PAs).	Number of contacts
The total number of contacts this patient has had with PSYCHIATRISTS or PSYCHIATRIC NURSES.	Number of contacts
The total number of contacts this patient has had with COUNSELORS (LSW, Psychologist, Substance abuse counselor, etc.)	Number of contacts
The total number of contacts this patient has had with PEER SPECIALISTS.	Number of contacts
The total number of contacts this patient has had with OTHER SPECIALIST PROVIDERS (Dentists, Nutritionists, etc.)	Number of contacts

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average 8 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer