Form Provider-Administr Provider-Administrator

Provider/Administrator

Provider/Administrator—Instruments

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/xxxx

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 the last assessment in _________________ (mo/yr), how 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.]

CMHI National Evaluation, Follow-up Assessment
Agency Representative (A), February 2011
Phase VI

1

5.

Since the last assessment in _________________ (mo/yr), 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.)

CMHI National Evaluation, Follow-up Assessment
Agency Representative (A), February 2011
Phase VI

2

5=Attended at least 90% 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

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 the last assessment in _________________ (mo/yr), 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 the last assessment in _________________ (mo/yr), 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.]

CMHI National Evaluation, Follow-up Assessment
Agency Representative (A), February 2011
Phase VI

3

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, 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 the last assessment in _________________ (mo/yr), 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.)

CMHI National Evaluation, Follow-up Assessment
Agency Representative (A), February 2011
Phase VI

4

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

Management and Operations
12.

Since the last assessment in _________________ (mo/yr), 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

CMHI National Evaluation, Follow-up Assessment
Agency Representative (A), February 2011
Phase VI

5

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.)
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

CMHI National Evaluation, Follow-up Assessment
Agency Representative (A), February 2011
Phase VI

6

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

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 the last assessment in _________________ (mo/yr), what has been done to
ensure that services in (name of grant program) ’s service array have sufficient capacity (for

CMHI National Evaluation, Follow-up Assessment
Agency Representative (A), February 2011
Phase VI

7

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?
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 the last assessment in _________________ (mo/yr), 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 the last assessment in _________________ (mo/yr), what have been
most important achievements?

(name of grant

program) ’s

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.)
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

CMHI National Evaluation, Follow-up Assessment
Agency Representative (A), February 2011
Phase VI

8

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.]
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?

CMHI National Evaluation, Follow-up Assessment
Agency Representative (A), February 2011
Phase VI

9

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx

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.

Please briefly describe the overall goal and mission of

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 the last assessment in ______________(mo/yr)? Please describe.

4.

How many children, youth, and families have been served since the last assessment
in ______________(mo/yr)?

(name of grant program) .

(NOTE TO INTERVIEWER: Questions 5-7 skipped)

Outreach
8.

Since the last assessment in ______________(mo/yr), 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?

CMHI National Evaluation, Follow-up Assessment
Project Director (B), February 2011
Phase VI

(name of grant program)

been able to reach

1

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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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?
CMHI National Evaluation, Follow-up Assessment
Project Director (B), 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

Service Array
13.

Since the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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]

CMHI National Evaluation, Follow-up Assessment
Project Director (B), February 2011
Phase VI

3

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?
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

CMHI National Evaluation, Follow-up Assessment
Project Director (B), February 2011
Phase VI

4

18.

Since the last assessment in ______________(mo/yr), 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
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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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.

CMHI National Evaluation, Follow-up Assessment
Project Director (B), February 2011
Phase VI

5

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.]
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
CMHI National Evaluation, Follow-up Assessment
Project Director (B), February 2011
Phase VI

6

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.
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]

CMHI National Evaluation, Follow-up Assessment
Project Director (B), February 2011
Phase VI

7

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 the last assessment in ______________(mo/yr), 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]

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 the last assessment in ______________(mo/yr), 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?
[Continue to probe for examples until the respondent reports no more.]
[Data entry: code ways]

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.)

CMHI National Evaluation, Follow-up Assessment
Project Director (B), February 2011
Phase VI

8

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

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 the last assessment in ______________(mo/yr), 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?
CMHI National Evaluation, Follow-up Assessment
Project Director (B), February 2011
Phase VI

9

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 the last assessment in ______________(mo/yr), what have been the most
effective strategies or activities undertaken to develop and implement this system of
care?

39.

Since the last assessment in ______________(mo/yr), what have been the least
effective strategies or activities undertaken to implement this system of care?

Achievement of Goals
40.

Since the last assessment in ______________(mo/yr), what have been
program) ’s most important 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

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.]

CMHI National Evaluation, Follow-up Assessment
Project Director (B), February 2011
Phase VI

10

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?

CMHI National Evaluation, Follow-up Assessment
Project Director (B), February 2011
Phase VI

11

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx

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
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)?
1=No If no, go to Question 12
2=Yes If yes, continue

CMHI National Evaluation, Follow-up Assessment
Family Representative (C), February 2011
Phase VI

1

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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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.]

5=Involved in all activities of the governing body
4=Involved in most activities of the governing body
CMHI National Evaluation, Follow-up Assessment
Family Representative (C), February 2011
Phase VI

2

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 the last assessment in ______________(mo/yr), 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?

CMHI National Evaluation, Follow-up Assessment
Family Representative (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

CMHI National Evaluation, Follow-up Assessment
Family Representative (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:
b.

What percentage of the children, youth, and families who need these services can get
them? (B.1.b.)

CMHI National Evaluation, Follow-up Assessment
Family Representative (C), February 2011
Phase VI

5

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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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)
[Data entry: code mechanisms]

CMHI National Evaluation, Follow-up Assessment
Family Representative (C), February 2011
Phase VI

6

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 the last assessment in ______________(mo/yr), 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
1=No or almost no effort has been made toward accomplishing larger goal

CMHI National Evaluation, Follow-up Assessment
Family Representative (C), February 2011
Phase VI

7

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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), what have been the most
effective strategies or activities undertaken to develop and implement the
system/program?

30.

Since the last assessment in ______________(mo/yr), what have been the least
effective strategies or activities undertaken to implement the system/program?

Achievement of Goals
31.

Since the last assessment in ______________(mo/yr), 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?

CMHI National Evaluation, Follow-up Assessment
Family Representative (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?

CMHI National Evaluation, Follow-up Assessment
Family Representative (C), February 2011
Phase VI

9

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx

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
of grant program) ? [Probe for membership on committees, initiating special studies,
participating in data collection, reporting findings to stakeholders, etc.] (D.1.c.)
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

(NOTE TO INTERVIEWER: If early childhood site, skip to Question 7)

CMHI National Evaluation, Follow-up Assessment
Program Evaluator (D), February 2011
Phase VI

1

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?

CMHI National Evaluation, Follow-up Assessment
Program Evaluator (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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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
1=No data collected in this area; no effort to monitor quality in this area
888=Respondent unaware of quality monitoring or evaluation activities
CMHI National Evaluation, Follow-up Assessment
Program Evaluator (D), February 2011
Phase VI

3

11.

What efforts have been made, since the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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.)
Has that information been examined or analyzed?

CMHI National Evaluation, Follow-up Assessment
Program Evaluator (D), February 2011
Phase VI

4

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.

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
CMHI National Evaluation, Follow-up Assessment
Program Evaluator (D), February 2011
Phase VI

5

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 the last assessment in ______________(mo/yr), 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.
Has there been a follow-up examination to find out whether the changes led to
service or system improvements?

CMHI National Evaluation, Follow-up Assessment
Program Evaluator (D), February 2011
Phase VI

6

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 the last assessment in ______________(mo/yr), 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
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

CMHI National Evaluation, Follow-up Assessment
Program Evaluator (D), February 2011
Phase VI

7

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?

CMHI National Evaluation, Follow-up Assessment
Program Evaluator (D), February 2011
Phase VI

8

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx

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 the last assessment in ______________(mo/yr), 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

CMHI National Evaluation, Follow-up Assessment
Intake Worker (E), February 2011
Phase VI

1

4=Four agencies are able to conduct intake into the grant program
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)?
CMHI National Evaluation, Follow-up Assessment
Intake Worker (E), February 2011
Phase VI

2

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx

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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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?

CMHI National Evaluation, Follow-up 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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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.?

CMHI National Evaluation, Follow-up 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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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
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

CMHI National Evaluation, Follow-up Assessment
Care Coordinator (F), February 2011
Phase VI

3

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?

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
CMHI National Evaluation, Follow-up Assessment
Care Coordinator (F), February 2011
Phase VI

4

1=No examples of needs incorporated into service plan

13.a.

Since the last assessment in ______________(mo/yr), 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

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.]

CMHI National Evaluation, Follow-up Assessment
Care Coordinator (F), February 2011
Phase VI

5

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 the last assessment in ______________(mo/yr), 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

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?

CMHI National Evaluation, Follow-up Assessment
Care Coordinator (F), February 2011
Phase VI

6

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 the last assessment in ______________(mo/yr), have any of the public childserving 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 the last assessment in ______________(mo/yr), 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)?
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

CMHI National Evaluation, Follow-up Assessment
Care Coordinator (F), February 2011
Phase VI

7

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 the last assessment in ______________(mo/yr), 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

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?

CMHI National Evaluation, Follow-up Assessment
Care Coordinator (F), February 2011
Phase VI

8

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
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
CMHI National Evaluation, Follow-up Assessment
Care Coordinator (F), February 2011
Phase VI

9

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 the last
assessment in ______________(mo/yr) 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 the last assessment in ______________(mo/yr), have children, youth, and
families served by (name of grant program) had to pay for any of the services they received?
(G.7.e.)
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.]

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
CMHI National Evaluation, Follow-up Assessment
Care Coordinator (F), February 2011
Phase VI

10

2=Three services were too expensive
1=Four or more services were too expensive

32.

Since the last assessment in ______________(mo/yr), 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
the last assessment in ______________(mo/yr), 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?
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 the last assessment in ______________(mo/yr), how have you worked with other
agencies, organizations and providers to coordinate the various services that
children youth, and families receive? (G.6.a.)

CMHI National Evaluation, Follow-up Assessment
Care Coordinator (F), February 2011
Phase VI

11

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?

CMHI National Evaluation, Follow-up 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.
CMHI National Evaluation, Follow-up 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)

CMHI National Evaluation, Follow-up Assessment
Care Coordinator (F), February 2011
Phase VI

14

Thank you for taking the time to answer my questions. Do you have any questions for
me?

CMHI National Evaluation, Follow-up Assessment
Intake Worker (E), February 2011
Phase VI

3

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx

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 the last assessment in
______________(mo/yr)?

b.

What is your function?

4.

How many of the children, youth, and families you have worked with since the last
assessment in ______________(mo/yr) 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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), what hours have you typically
worked? (G.7.b.)
Do you typically work with children, youth, and families in the evenings or weekends?

CMHI National Evaluation, Follow-up Assessment
Direct Service Provider (G), February 2011
Phase VI

1

If so, when and how frequently?
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 the last assessment in ______________(mo/yr), 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

CMHI National Evaluation, Follow-up Assessment
Direct Service Provider (G), February 2011
Phase VI

2

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
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

CMHI National Evaluation, Follow-up Assessment
Direct Service Provider (G), February 2011
Phase VI

3

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
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 the last assessment in ______________(mo/yr), how have agencies,
organizations and providers worked to coordinate the various services that
children, youth, and families receive? (G.6.a.)

CMHI National Evaluation, Follow-up Assessment
Direct Service Provider (G), February 2011
Phase VI

4

What kinds of information have you typically shared? What kinds of information have
you typically received?
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?

CMHI National Evaluation, Follow-up Assessment
Direct Service Provider (G), February 2011
Phase VI

5

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx

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 the last assessment in ______________(mo/yr), 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?

(name of care review group)

CMHI National Evaluation, Follow-up Assessment
Care Review Participant (H), February 2011
Phase VI

conduct reviews of the care of children, youth,

1

5.

Please describe how children, youth, and families are typically identified for
review by (name of care review group) .
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 the last assessment in ______________(mo/yr), 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

CMHI National Evaluation, Follow-up Assessment
Care Review Participant (H), February 2011
Phase VI

2

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.)
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.

CMHI National Evaluation, Follow-up Assessment
Care Review Participant (H), February 2011
Phase VI

3

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
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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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?

CMHI National Evaluation, Follow-up Assessment
Care Review Participant (H), February 2011
Phase VI

4

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.)
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 the last assessment in ______________(mo/yr), 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.]

CMHI National Evaluation, Follow-up Assessment
Care Review Participant (H), February 2011
Phase VI

5

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 the last assessment in ______________(mo/yr), 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?
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 the last assessment in ______________(mo/yr), 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?
CMHI National Evaluation, Follow-up 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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), what percentage of the
children, youth, and families you served have also been involved with (name of grant
program) ?

5.

Since the last assessment in ______________(mo/yr), 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]

CMHI National Evaluation, Follow-up Assessment
Other Agency Staff (L), February 2011
Phase VI

1

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?
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
[Probe for what occurs between referral and the first service
contact.]

(name of grant program) ?

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 the last assessment in ______________(mo/yr), 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
2 = Education

4 = Juvenile Justice
5 = Public Health

CMHI National Evaluation, Follow-up Assessment
Other Agency Staff (L), February 2011
Phase VI

2

3 = Child Welfare

6 = other (describe)

[circle all that apply]

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
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 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 the last assessment in ______________(mo/yr), 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)
Have staff attended service planning meetings across agencies? How frequently?

b.

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?

CMHI National Evaluation, Follow-up Assessment
Other Agency Staff (L), 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

12.

Since the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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.]

CMHI National Evaluation, Follow-up Assessment
Other Agency Staff (L), February 2011
Phase VI

4

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

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.]

CMHI National Evaluation, Follow-up Assessment
Other Agency Staff (L), February 2011
Phase VI

5

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
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 the last assessment in
______________(mo/yr) 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
the last assessment in ______________(mo/yr), 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.)

CMHI National Evaluation, Follow-up Assessment
Other Agency Staff (L), February 2011
Phase VI

6

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?
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?

CMHI National Evaluation, Follow-up 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.

CMHI National Evaluation, Follow-up 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)

CMHI National Evaluation, Follow-up Assessment
Other Agency Staff (L), February 2011
Phase VI

9

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx

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]

CMHI National Evaluation, Follow-up 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

CMHI National Evaluation, Follow-up 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

CMHI National Evaluation, Follow-up 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

CMHI National Evaluation, Follow-up 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

CMHI National Evaluation, Follow-up 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

CMHI National Evaluation, Follow-up Assessment
Case Record Review (M), February 2011
Phase VI

6

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx

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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), what percentage of children,
youth, and families served by your organization have also been involved with (name of
grant program) ?

5.

Since the last assessment in ______________(mo/yr), 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?

6.

Has your or your organization’s involvement with

CMHI National Evaluation, Follow-up Assessment
Other Agency Staff (N), February 2011
Phase VI

(name of grant program)

changed

1

--your operations, how your organization does business?
--how your organization serves children, youth, and families?
7.

Since the last assessment in ______________(mo/yr), 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?

CMHI National Evaluation, Follow-up 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)

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?

CMHI National Evaluation, Follow-up Assessment
Debriefing Document (O), February 2011
Phase VI

1

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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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?
CMHI National Evaluation, Follow-up 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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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.]

CMHI National Evaluation, Follow-up Assessment
Youth Coordinator (Q), February 2011
Phase VI

2

[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

8.

Since the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr) what has been the process of
engaging and informing youth about (name of grant program) and the services available to them
through it?

CMHI National Evaluation, Follow-up Assessment
Youth Coordinator (Q), February 2011
Phase VI

3

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?
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 the last assessment in ______________(mo/yr) has (name of
children and youth in planning and developing their own plans of care?

grant program)

involved

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?

CMHI National Evaluation, Follow-up Assessment
Youth Coordinator (Q), February 2011
Phase VI

4

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?

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?

CMHI National Evaluation, Follow-up 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 the last assessment in ______________(mo/yr), 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

CMHI National Evaluation, Follow-up 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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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

CMHI National Evaluation, Follow-up 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 the last assessment in ______________(mo/yr), 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.)

CMHI National Evaluation, Follow-up 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?

CMHI National Evaluation, Follow-up 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 the last assessment in ______________(mo/yr), 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?

CMHI National Evaluation, Follow-up 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 the last assessment in ______________(mo/yr), 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 the last assessment in ______________(mo/yr), 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

CMHI National Evaluation, Follow-up Assessment
Social Marketing Manager (S), February 2011
Phase VI

2

13.

Since the last assessment in ______________(mo/yr), 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? 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 the last assessment in ______________(mo/yr), 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?

CMHI National Evaluation, Follow-up 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: September 2013

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: September 2013

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-TR and/or ICD-9 system and for the DSM-5 system.
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-TR, ICD-9, or DSM-5 diagnosis?
1 = No [GO TO QUESTION #13]
2 = Yes, a DSM-IV-TR or ICD-9 diagnosis [GO TO SECTION II-A, Child Diagnostic
Information: DSM-IV-TR and ICD-9]
3 = Yes, a DSM-5 diagnosis [GO TO SECTION II-B, Child Diagnostic Information:
DSM-5]

SECTION II-A.

Child Diagnostic Information: DSM-IV-R and ICD-9

In this section, please record the DSM-IV-TR 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-TR — DSM
ICD-9 — ICD

Examples: A DSM-IV-TR 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-A.

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-A. Date of the most recent multiaxial diagnostic evaluation
________________________________
(mm/dd/yyyy)

For all variables and data elements:
Date last modified: September 2013

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
3

CHILD ID:

Enrollment and Demographic Information Form (EDIF)

11-A. 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-A. 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: September 2013

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]

_______________

[GO TO SECTION III]
SECTION II-B.

Child Diagnostic Information: DSM-5

In this section, please record the DSM-5 diagnostic codes in the indicated fields. When entering
diagnostic codes, please use the following prefix in front of the codes without spaces:
•

DSM-5 — DSM5

Example: A DSM-5 diagnosis of Oppositional Defiant Disorder (313.81) should be entered as
DSM5313.81.
The entire list of diagnostic codes is available in PDF format for your reference.
9-B.

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-B. Date of the most recent diagnostic evaluation
________________________________
(mm/dd/yyyy)

For all variables and data elements:
Date last modified: September 2013

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
5

CHILD ID:

Enrollment and Demographic Information Form (EDIF)

11-B. 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]
12-B. Clinical Disorders
Diagnostic code

DSM-5 name

_________.____

________________________________________

_________.____

________________________________________

_________.____

________________________________________

_________.____

________________________________________

_________.____

________________________________________

_________.____

________________________________________

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
Global Assessment of Functioning Scale (GAF) [Enter
current GAF score]
For all variables and data elements:
Date last modified: September 2013

666 = Not Applicable
777 = Refused

_______________

888 = Don’t Know
999 = Missing
6

CHILD ID:

Enrollment and Demographic Information Form (EDIF)

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.]
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, DSM-5 or the 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 ____________________________________

For all variables and data elements:
Date last modified: September 2013

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
7

CHILD ID:

14.

Enrollment and Demographic Information Form (EDIF)

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]

16.

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 __________________________

For all variables and data elements:
Date last modified: September 2013

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
8

CHILD ID:

Enrollment and Demographic Information Form (EDIF)

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)

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]

For all variables and data elements:
Date last modified: September 2013

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
9

CHILD ID:

Enrollment and Demographic Information Form (EDIF)

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: September 2013

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
10

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: September 2013

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
11

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: September 2013

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
12

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: September 2013

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
13

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: September 2013

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
14

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: September 2013

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
15

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: September 2013

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
16

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: 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.

GEN

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 for additional clarification and
examples of the different categories.)

GEN

52

1=Housing
2=Utilities
3=Environmental modification
4=Furnishings/appliances
5=Supplies
6=Food/groceries
7=Clothing
8=Activities
9=Educational support
10=Daycare and support
11=Automobile
12=Transportation
14=Incentive
15=Legal
16=Medical
17=Mental health services
(child/youth)
18=Mental health services
(caregiver/family member)
19=Camp
20=Training (caregiver/family
member)
21=Training (child/youth)
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.” Do not include
child or caregiver’s actual name.

GEN

70

A–Z; 0–9

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.

GEN

8.2

0.00–999,999.99

Date last modified: September 2012

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

Format

Field
Length

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 CrossSectional Descriptive Study and Longitudinal Child
and Family Outcome Study. *This is a required field
for all data records.

GEN

9

100000000–199999999
(range will be more specific to each community)

Codes

SERVICE ENROLLMENT DATES
ENROLL1

Date the child was first enrolled in the system of
care and eligible for services.

DATE

10

MM/DD/YYYY

DISCHRG1

Date of first discharge from system of care services.

DATE

10

MM/DD/YYYY

ENROLL2

Date the child was re-enrolled in system of care
(second enrollment) and again eligible for services.
This field may be left blank if there is no second
episode of enrollment and discharge.

DATE

10

MM/DD/YYYY

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.

DATE

10

MM/DD/YYYY

ENROLL3

Date the child was re-enrolled in system of care
(third enrollment) and again eligible for services.
This field may be left blank if there is no third
episode of enrollment and discharge.

DATE

10

MM/DD/YYYY

Services and Costs Data Dictionary

| Page 1

Variable
Name
DISCHRG3

Variable Description
Date of third discharge from system of care
services. This field may be left blank if there is no
third episode of enrollment and discharge.

Format

Field
Length

DATE

10

MM/DD/YYYY

Codes

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.

DATE

10

MM/DD/YYYY (may precede the child’s first enrollment date into
system of care by 1 year)

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.

DATE

10

MM/DD/YYYY

Current Procedural Terminology (CPT-4): Level I
codes. Official definitions for CPT-4 codes
commonly used for system of care services are
provided in attachment A.

GEN

5

0–9; i.e., 96150

Healthcare Common Procedure Coding System
(HCPCS): Level II codes. Official definitions for
HCPCS codes commonly used for system of care
services are provided in attachment A.

GEN

5

A–Z; 0–9; i.e., H0002

International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM)—
Procedure Codes. Official definitions for ICD-9-CM
Procedure Codes commonly used for system of
care services are provided in attachment A. ICD-9
Procedure Codes are not to be confused with ICD-9
Diagnostic Codes.

GEN

5

0–9; 4 digits with an explicit decimal, i.e., 94.42

Type of service. Further definitions of service types
are provided in attachment B.

GEN

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

SERVICE TYPE*
CPT

* This is a required field for all data records.

or
HCPCS

or
ICD9

or
SVCTYPE

Services and Costs Data Dictionary

| Page 2

Variable
Name

Variable Description

Format

Field
Length

Codes
9=Caregiver support/family support
10=Respite care
11=Advocacy
12=Legal service
13=Recreational activity/recreational therapy
14=Afterschool 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/psychosocial therapy/play therapy
21=Group therapy/group counseling
22=Family therapy/family counseling
23=Psychosocial 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 support services
43=Early Intervention (Part C) support services
44=Head Start Program support services
45=Preschool Special Education Program (Part B)
46=Other Early Care and Education Programs
Services and Costs Data Dictionary

| Page 3

Variable
Name

Variable Description

Format

Field
Length

Codes
47=Special education class, self contained
48=Special education resource service
49=Special education, inclusion
50=Physical therapy, occupational, speech, hearing, or language svc
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
Other Service Type
62=Other service type, please specify

SVCOTH

Description of other service type in SVCTYPE=62. If
other is unknown, enter -999.

GEN

50

A–Z; 0–9; or -999 Leave blank if not applicable.

PROVIDER AGENCY/SERVICE SECTOR
AGENCY

The service sector or type of agency providing the
service. This might include both public agencies
and private providers.

GEN

2

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

AGENOTH

Description of other service sector or agency type
providing the service in AGENCY=8. If other is
unknown, enter -999.

GEN

50

A–Z; 0–9; or -999 Leave blank if not applicable.

GEN

2

PROVIDER TYPE
PROVIDER

Type of individual providing the service. Further
definitions of provider categories are provided in
attachment B. Leave blank if provider type is
unknown.

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

Services and Costs Data Dictionary

| Page 4

Variable
Name

Variable Description

Format

Field
Length

Codes
health staff
6=Tribal healer
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/pharmacist
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

PROVOTH

Description of other in PROVIDER=32. If other is
unknown, enter -999. No actual provider names.

GEN

50

A–Z; 0–9; or -999 Leave blank if not applicable.

GEN

2

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

SERVICE LOCATION
LOCATION

Location where service was provided. Further
definitions of location categories are provided in
attachment B. Leave blank if service location is
unknown.

Services and Costs Data Dictionary

| Page 5

Variable
Name

Variable Description

Format

Field
Length

Codes
11=Emergency room – hospital
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

LOCATOTH

Description of other in LOCATION=24. If other is
unknown, enter -999.

GEN

50

A–Z; 0–9; or -999 Leave blank if not applicable.

SERVICE UNITS
NUMBER

Number of service units

GEN

8.2

SVCUNIT

Unit of service

GEN

1

1.00–999999.99 Leave blank if unknown.
1=Minute
2=Hour
3=Day
4=Week
5=Month
6=Year
7=Visit/session
8=Call/contact
9=Report
10=E-mail

COSTS AND PAYMENT SOURCE
Amounts Charged
CHGMEDCD

Total amount charged for this service to Medicaid.

GEN

8.2

0.00–999999.99 Leave blank if unknown or not applicable.

CHGSCHIP

Total amount charged for this service to SCHIP.

GEN

8.2

0.00–999999.99 Leave blank if unknown or not applicable.

CHGCMHI

Total amount charged for this service to SAMHSA
CMHI cooperative agreement.

GEN

8.2

0.00–999999.99 Leave blank if unknown or not applicable.

CHGMH

Total amount charged for this service to a mental
health agency or provider, at State or local level

GEN

8.2

0.00–999999.99 Leave blank if unknown or not applicable.

CHGCW

Total amount charged for this service to a child
welfare or social services agency

GEN

8.2

0.00–999999.99 Leave blank if unknown or not applicable.

CHGJJ

Total amount charged for this service to juvenile

GEN

8.2

0.00–999999.99 Leave blank if unknown or not applicable.

Services and Costs Data Dictionary

| Page 6

Variable
Name

Variable Description

Format

Field
Length

Codes

justice (juvenile court, corrections, or probation)
CHGEDUC

Total amount charged for this service to education,
early childhood program, or childcare organization

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

CHGTRIBE

Total amount charged for this service to a Tribal
government, agency, or organization

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

CHGIHS

Total amount charged for this service to the Indian
Health Service

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

CHGFAM

Total amount charged for this service to a family
organization

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

CHGYOUTH

Total amount charged for this service to a youth
organization

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

CHGFDTN

Total amount charged for this service to a
foundation or other private funding.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

CHGPRIV

Total amount charged for this service to private
insurance.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

CHGCLIEN

Total amount charged for this service to client outof-pocket.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

CHGOTHER

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.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

CHGOTH

Description of other payer in CHGOTHER. If other
is unknown, enter -999.

GEN

50

A–Z; 0–9; or -999 Leave blank if not applicable.

PAYMEDCD

Total amount paid for this service by Medicaid.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

PAYSCHIP

Total amount paid for this service by SCHIP.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

PAYCMHI

Total amount paid for this service by SAMHSA
CMHI cooperative agreement.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

PAYMH

Total amount paid for this service by a mental
health agency or provider, at State or local level.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

PAYCW

Total amount paid for this service by a child welfare
or social services agency.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

PAYJJ

Total amount paid for this service by juvenile justice
(juvenile court, corrections, or probation).

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

PAYEDUC

Total amount paid for this service by education,
early childhood program, or childcare organization.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

Amounts Paid

Services and Costs Data Dictionary

| Page 7

Variable
Name

Variable Description

Format

Field
Length

Codes

PAYTRIBE

Total amount paid for this service by a Tribal
government, agency, or organization.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

PAYIHS

Total amount paid for this service by the Indian
Health Service.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

PAYFAM

Total amount paid for this service by a family
organization.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

PAYYOUTH

Total amount paid for this service by a youth
organization.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

PAYFDTN

Total amount paid for this service by a foundation or
other private funding.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

PAYPRIV

Total amount paid for this service by private
insurance.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

PAYCLIEN

Total amount paid for this service by client out-ofpocket.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

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.

GEN

8.2

0.01–999999.99 Leave blank if unknown or not applicable.

PAYOTH

Description of other payer in PAYOTHER. If other is
unknown, enter -999.

GEN

50

A–Z; 0–9; or -999 Leave blank if not applicable.

PAYESTIM

Flag to indicate whether any of the payment
amounts represent an estimated amount, rather
than actual amount.

GEN

2

1=Actual
2=Estimated
Leave blank if no payment amount is entered.

GEN

8.2

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.

0.01–999999.99 or -666

Services and Costs Data Dictionary

| Page 8

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 20–30
minutes face-to-face with the patient
90805 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20–30
minutes face-to-face with the patient; with medical evaluation and management services
90806 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45–50
minutes face-to-face with the patient
90807 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45–50
minutes face-to-face with the patient; with medical evaluation and management services
90808 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75–80
minutes face-to-face with the patient
90809 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75–80
minutes face-to-face with the patient; with medical evaluation and management services
90810 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal
communication, in an office or outpatient facility, approximately 20–30 minutes face-to-face with the patient
90811 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal
communication, in an office or outpatient facility, approximately 20–30 minutes face-to-face with the patient with medical evaluation and
management services
90812 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal
communication, in an office or outpatient facility, approximately 45–50 minutes face-to-face with the patient
Services and Costs Data Dictionary

| Page 9

Code Description
90813 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal
communication, in an office or outpatient facility, approximately 45–50 minutes face-to-face with the patient; with medical evaluation and
management services
90814 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal
communication, in an office or outpatient facility, approximately 75–80 minutes face-to-face with the patient
90815 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal
communication, in an office or outpatient facility, approximately 75–80 minutes face-to-face with the patient; with medical evaluation and
management services
90816 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential
care setting, approximately 20–30 minutes face-to-face with the patient
90817 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential
care setting, approximately 20–30 minutes face-to-face with the patient; with medical evaluation and management services
90818 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential
care setting, approximately 45–50 minutes face-to-face with the patient
90819 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential
care setting, approximately 45–50 minutes face-to-face with the patient; with medical evaluation and management services
90821 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential
care setting, approximately 75–80 minutes face-to-face with the patient
90822 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential
care setting, approximately 75–80 minutes face-to-face with the patient; with medical evaluation and management services
90823 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 20–30 minutes face-to-face with the
patient
90824 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 20–30 minutes face-to-face with the
patient; with medical evaluation and management services
90826 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 45–50 minutes face-to-face with the
patient
90827 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 45–50 minutes face-to-face with the
patient; with medical evaluation and management services

Services and Costs Data Dictionary

| Page 10

Code Description
90828 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 75–80 minutes face-to-face with the
patient
90829 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 75–80 minutes face-to-face with the
patient; with medical evaluation and management services
90845 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
90875 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)
90876 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)
90880 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
90887 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
90889 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
90899 Unlisted psychiatric service or procedure

Services and Costs Data Dictionary

| Page 11

Code Description

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
96110 Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report
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 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-toface
96120 Neuropsychological testing (e.g., Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional
interpretation and report
96150 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
96151 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
96152 Health and behavior intervention, each 15 minutes, face-to-face; individual

Services and Costs Data Dictionary

| Page 12

Code Description
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)
96372 Therapeutic, prophylactic or diagnostic injection (specify drug or substance); subcutaneous or intramuscular
97537 Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work
environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one
contact by provider, each 15 minutes

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-toface 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.

Services and Costs Data Dictionary

| Page 13

Code Description
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) are of low to moderate severity. Physicians
typically spend 15 minutes face-to-face with the patient and/or family.
99214 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.
99215 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.
99217 Observation care discharge day management (This code is to be utilized by the physician to report all services provided to a patient on
discharge from “observation status” if the discharge is on other than the initial date of “observation status.”)
99218 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: a detailed or
comprehensive history, a detailed or comprehensive examination, and medical decision making that is straightforward.
99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: a
comprehensive history, a comprehensive examination, and medical decision making of moderate complexity. Counseling and/or
coordination.
99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: a
comprehensive history, a comprehensive examination, and medical decision making of high complexity. Counseling and/or coordination.
99221 Initial hospital care, per day, for the evaluation and management of a patient which requires these 3 key components: a detailed or
comprehensive history—a detailed or comprehensive examination—and medical decision making that is straightforward.
99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive
history, a comprehensive examination, and medical decision making of moderate complexity. Counseling and/or coordination.

Services and Costs Data Dictionary

| Page 14

Code Description
99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive
history, a comprehensive examination, and medical decision making of high complexity. Counseling and/or coordination.
99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key
components: a problem-focused interval history, a problem-focused examination, medical decision making that is straightforward.
99232 Subsequent hospital care, per day, for the evaluation and management of a 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.
99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key
components: a detailed interval history, a detailed examination, medical decision making of high complexity. Counseling and/or
coordination.
99234 Observation or inpatient hospital care, for the evaluation and management of a patient, including admission and discharge on the same
date which requires these 3 key components; a detailed or comprehensive history; a detailed or comprehensive exam; & med decision
making that is straightforward.
99235 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same
date which requires these 3 key components: a comprehensive history, a comprehensive exam, and medical decision making of
moderate complexity. Counseling and/or coordination.
99238 Hospital discharge day management; 30 minutes or less.
99239 Hospital discharge day management; more than 30 minutes.
99241 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-to-face with the patient and/or family.
99242 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.
99243 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.
99244 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.

Services and Costs Data Dictionary

| Page 15

Code Description
99245 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.
99251 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.
99252 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.
99253 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.
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.
99255 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.
99281 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a problemfocused history, a problem-focused examination, and straightforward medical decision making. Counseling and/or coordination.
99282 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.
99283 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.
Services and Costs Data Dictionary

| Page 16

Code Description
99284 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.
99285 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.
99324 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.
99325 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.
99326 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.
99327 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.
99328 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 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.

Services and Costs Data Dictionary

| Page 17

Code Description
99334 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.
99335 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.
99336 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.
99337 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.
99341 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.
99342 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.
99343 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.

Services and Costs Data Dictionary

| Page 18

Code Description
99344 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.
99345 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.
99354 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual
service (e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour.
99361 Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to
coordinate activities of patient care (patient not present); approximately 30 minutes.
99362 Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to
coordinate activities of patient care (patient not present); approximately 60 minutes.
99371 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); 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)
99372 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)
99373 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)
99383 Initial preventive medicine evaluation and management of an individual including a comprehensive history, a comprehensive
examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic
procedures.
99393 Periodic preventive medicine reevaluation and management of an individual including a comprehensive history, comprehensive
examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/ diagnostic
procedures.

Services and Costs Data Dictionary

| Page 19

Code Description
99394 Periodic preventive medicine reevaluation and management of an individual including a comprehensive history, comprehensive
examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/ diagnostic
procedures.

Current Procedural Terminology (CPT-4): Level I - Other Codes
36415 Collection of venous blood by venipuncture
71020 Radiologic examination, chest, two views, frontal and lateral
80048 Basic metabolic panel (calcium, total)
80050 General health panel
80053 Comprehensive metabolic panel
80061 Lipid panel
80076 Hepatic function panel
80100 Drug, screen; multiple drug classes, each procedure
80101 Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class
80102 Drug, confirmation, each procedure
80164 Dipropylacetic acid (valproic acid)
80178 Lithium
80196 Pathology, salicylate
81000 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
81001 Pathology, urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific
gravity, urobilinogen, any number of these constituents; automated, with microscopy
81002 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
81003 Pathology, urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific
gravity, urobilinogen, any number of these constituents; automated, without microscopy
81025 Pathology, urine pregnancy test, by visual color comparison methods
82003 Pathology, acetaminophen
82043 Albumin; urine, microalbumin, quantitative
82055 Alcohol (ethanol); any specimen except breath

Services and Costs Data Dictionary

| Page 20

Code Description
82487 Chromatography, qualitative; paper, 1-dimensional, analyte not elsewhere specified
82550 Creatine kinase (CK), (CPK); total
82565 Creatinine; blood
82570 Creatinine; other source
82803 Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation)
82947 Glucose; quantitative, blood (except reagent strip)
82977 Glutamyltransferase, gamma (GGT)
83036 Hemoglobin; glycosylated (A1C)
83525 Insulin; total
83605 Lactate (lactic acid)
83655 Lead
83721 Lipoprotein, direct measurement; LDL cholesterol
84146 Prolactin
84439 Thyroxine; free
84443 Thyroid stimulating hormone (TSH)
84520 Urea nitrogen; quantitative
84702 Gonadotropin, chorionic (hCG); quantitative
84703 Gonadotropin, chorionic (hCG); qualitative
85007 Blood count; blood smear, microscopic examination with manual differential WBC count
85014 Blood count; other than spun hematocrit
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)
86038 Antinuclear antibodies (ANA)
86140 C-reactive protein
86592 Syphilis test; qualitative (e.g., VDRL, RPR, ART)
86703 Antibody; HIV-1 and HIV-2, single assay
87070 Culture, bacterial, definitive; any other source
87205 Smear, primary source, with interpretation; routine stain for bacteria, fungi, or cell types

Services and Costs Data Dictionary

| Page 21

Code Description
88262 Chromosome analysis; count 15-20 cells, 2 karyotypes, with banding
89051 Cell count, miscellaneous body fluids (e.g., CSF, joint fluid), except blood; with differential count.
92014 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program;
comprehensive, established patient, one or more visits.
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
92567 Tympanometry (impedance testing)
92579 Visual reinforcement audiometry (VRA)
92587 Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)
92588 Evoked otoacoustic emissions; comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic
emissions at multiple levels and frequencies)
92700 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 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for
echocardiographic imaging); complete
94664 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

Services and Costs Data Dictionary

| Page 22

Code Description
98967 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
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. (2008). 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.

Services and Costs Data Dictionary

| Page 23

Code

Description

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)

A0429

Ambulance service, basic life support, emergency transport (Bls-emergency)

G0176

Activity therapy, such as music, dance, art, or play therapies not for recreation, related to the care and treatment of patient’s
disabling mental health problems, per session (45 minutes or more)

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

H0023

Behavioral health outreach service (planned approach to reach a targeted population)

H0024

Behavioral health prevention information dissemination service (one-way direct or non-direct contact with service audiences to affect
knowledge and attitude)

Services and Costs Data Dictionary

| Page 24

Code

Description

H0025

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

H0036

Community psychiatric supportive treatment, face to face, per 15 minutes

H0037

Community psychiatric supportive treatment program, per diem

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 ½ day

H2010

Comprehensive medication services, per 15 minutes

H2011

Crisis intervention service, per 15 minutes

H2012

Behavioral health day treatment, per hour

H2013

Psychiatric health facility service, per diem

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

H2018

Psychosocial rehabilitation services, per diem

Services and Costs Data Dictionary

| Page 25

Code

Description

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

H2023

Supported employment, per 15 minutes

H2024

Supported employment, 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

H2028

Sex offender treatment service, per 15 minutes

H2029

Sex offender treatment service, per diem

H2030

Mental health clubhouse services, per 15 minutes

H2031

Mental health clubhouse service, per diem

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

Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and
personality disorders

Q3014

Telehealth originating site facility fee

S0163

Injection, risperidone, Long Acting, 12.5 mg

S0201

Partial hospitalization services, less than 24 hours, per diem

Services and Costs Data Dictionary

| Page 26

Code

Description

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

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

T1007

Alcohol and/or substance abuse services, treatment plan development and/or modification

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

T1018

School-based individualized education program (IEP) services, bundled

T1023

Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or
treatment protocol, per encounter

T1024

Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped
children, per encounter

T2001

Non-emergency transportation; patient attendant/escort

T2002

Non-emergency transportation; per diem

T2003

Non-emergency transportation; encounter/trip
Services and Costs Data Dictionary

| Page 27

Code

Description

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 (½) hour increments

T2022

Case management, per month

T2023

Targeted case management, per month

T2034

Crisis intervention, waiver; per diem

T2036

Therapeutic camping overnight, waiver each session

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

T2049

Non-emergency transportation; stretcher van, mileage, per mile

Services and Costs Data Dictionary

| Page 28

Code

Description

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)—Procedure Codes
94.01

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 (StanfordBinet, Wechsler Adult Intelligence Scale, Wechsler Intelligence Scale for Children)

94.02

Administration of standardized psychologic test designed to measure abilities, aptitude, and achievement, or to evaluate personality
traits (Bender Visual-Motor Gestalt Test, Benton Visual Retention Test, Minnesota Multiphasic Personality Inventory, Wechsler Memory
Scale)

94.03

Character analysis

94.08

Other psychologic evaluation and testing

94.09

Psychologic mental status determination, not otherwise specified

94.11

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

94.12

Routine psychiatric visit, not otherwise specified

94.13

Psychiatric commitment evaluation; pre-commitment interview

94.19

Other psychiatric interview and evaluation; follow-up psychiatric interview NOS

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

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

Services and Costs Data Dictionary

| Page 29

Code

Description

94.35

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.

94.36

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

Psychodrama; primarily a technique of group psychotherapy which involves a structure, directed, and dramatized acting out of the
patient's personal and emotional problems

94.44

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

Services and Costs Data Dictionary

| Page 30

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

The official date of the child or youth’s first enrollment into system of care services.

Discharge Date 1

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.

Enrollment Date 2

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.

Discharge Date 2

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.

Enrollment Date 3

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.

Discharge Date 3

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.

Services and Costs Data Dictionary

| Page 31

SERVICE TYPE—General Community-Based/Episodic Services
Intake/Screening/Diagnosis/Assessment The process of gathering and documenting information about a child or youth’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 96110 96111 96116 96118
96119 96120 96150 96151.
Includes HCPCS codes: H0001 H0002 H0003 H0031 T1023.
Evaluation

The process of collecting and interpreting information about a child or youth. An evaluation may
include a variety of tests, observations, and background information and is typically conducted by a
multidisciplinary team of clinical or educational professionals. The purpose of an evaluation is to
determine whether the child or youth 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/youth.
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 T1024.
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.

Consultation/Meeting

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 99361 99362 99371 99372 99373.

Case Management/Clinical Coordination The procedures that a trained service provider uses to access and coordinate services for a child or
youth and the child’s/youth’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 T2022 T2023.
Service Planning

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 codes: H0032 T1007.

Services and Costs Data Dictionary

| Page 32

Crisis Intervention/Crisis
Stabilization/Crisis Hotline

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.

Emergency Room Psychiatric Service

Includes triage, psychiatric evaluation, and extended observation within an emergency room setting.
Includes CPT-4 codes: 99281 99282 99283 99284 99285.

Early Intervention/Prevention

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 and youth 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.

Caregiver Support/Family Support

Non-therapeutic and support services provided to caregivers or siblings. These may include family
activities, behavior management training, parent classes, and support groups, but do not include
respite care, recreational activities, or transportation services.
Includes HCPCS codes: H2015 H2016 S5110.

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 care giving for a brief time to
provide a break for the parent or caregiver. The service may be provided in the child’s or youth’s
home or in other community locations.
Includes HCPCS codes: H0045 S5150 S5151 T1005.

Advocacy

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.

Legal Service

Services provided to ensure the protection and maintenance of a child’s, youth’s, 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.

Recreational Activity/Recreational
Therapy

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 H2031 H2032 G0176 T2037.

Afterschool Program or Childcare

Afterschool 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.

Services and Costs Data Dictionary

| Page 33

Training/Tutoring/Education/Mentoring

A range of child- and youth-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.

Behavioral/Therapeutic Aide Service

Supervision of a child or youth 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.

Medication Treatment/
Administration/Monitoring

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
prescription, administration, assessment of drug effectiveness, and periodic assessment and
monitoring of the child’s/youth’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.

Medical Care/Physical Health Care/
Laboratory Related to Mental Health

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 71020 80048 80050 80053 80061 80076 80100 80101 80102 80164
80178 80196 81000 81001 81002 81003 81025 82003 82043 82055 82487 82550 82565 82570
82803 82947 82977 83036 83525 83605 83655 83721 84146 84439 84443 84520 84702 84703
85007 85014 85025 85027 86038 86140 86592 86703 87070 87205 88262 89051 90899 92014
92567 92579 92587 93000 93005 93010 93303 93320 94664 94760 96372 99354 99383 99393
99394.
Includes HCPCS code: Q3014.

Day Treatment/Partial-Day Treatment

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 other community locations.
Includes CPT-4 codes: 99217 99238 99239.
Includes HCPCS codes: H0037 H2012.

Services and Costs Data Dictionary

| Page 34

Individual Therapy/Counseling/
Psychosocial Therapy/Play Therapy

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 96152.
Includes HCPCS codes:G0176 H0004 H0036 H0039 H0040 H2019 H2020 H2027 H2028 H2029
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.

Group Therapy/Group Counseling

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.

Family Therapy/Family Counseling

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.

Psychosocial Rehabilitation/Cognitive
Rehabilitation

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 including grooming,
bodily care, and 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.

Tribal Healing Service

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.

Services and Costs Data Dictionary

| Page 35

Social Work Service

Social work services include diagnostic or active clinical treatments provided with the intent to
reasonably improve the child’s or youth’s physical or mental condition or functioning. Includes global
evaluation to determine a child’s or youth’s developmental status and need for early intervention
services; making home visits to assess a child’s/youth’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/youth within the family context to determine the
need for social work or other counseling services; working with issues in the child’s/youth’s and
family’s living situation (e.g., home, community, etc.); and identifying, mobilizing, and coordinating
community resources and services to enable the child/youth and family to receive maximum benefit
from early intervention services.
No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.

Vocational/Life Skills
Training/Independent Living
Services/Youth Transition

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, and
counseling. Designed for older adolescents to facilitate the move from the child system to the adult
mental health system.
Includes CPT-4 code: 97537.
Includes HCPCS codes: G0177 H2014 H2023 H2024 H2025 H2026 T2038.

Transportation

Transportation to appointments and other scheduled services and activities.
Includes HCPCS codes: A0080 A0090 A0100 A0110 A0120 A0130 A0140 A0160 A0170 A0425
A0426 A0427 A0428 A0429 S0215 T2001 T2002 T2003 T2004 T2005 T2007 T2049.

SERVICE TYPE—Services Specific to Child Welfare
Child Protective Service

Includes investigation of maltreatment allegations and validation of the child maltreatment report;
assessment of child/youth safety, early intervention and prevention, and alleged risk (alternative
response). Develops a safety plan, if needed, to assure the child's or youth’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.

Case Evaluation and Monitoring

Assessing the need for child welfare services, providing or arranging for services, and coordinating
and evaluating child welfare services provided to a child/youth and family. Includes referring a
child/youth 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.

Services and Costs Data Dictionary

| Page 36

Family Preservation

An intensive combination of therapeutic and support services provided to the child, youth, or family
within the home to prevent out-of-home placement. These services may include 24-hour access to
support services, and intensive in-home support during crisis when a child or youth is at risk of out-ofhome placement or when the child or youth 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.

Adoption Service

Finding the adoptive family, supporting the child/youth through the process, etc. Service to postplacement, 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.

Therapeutic Foster Care/Therapeutic
Group Home

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 include supportive counseling, crisis back-up, behavior
management, and social development.
No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.

Family Foster Care With NonRelative/Non-Therapeutic Foster Care

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.

Group Foster Care

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.

Relative Care

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-9-CM 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
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.

Services and Costs Data Dictionary

| Page 37

Court Services

Includes preparing statutory required legal documents, court orders, and court docket entries;
reviewng 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.

Juvenile Detention

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.

Jail/Prison

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.

Parole/Aftercare Service

Discretionary release of a convicted or adjudicated delinquent juvenile from detention or custody prior
to the expiration of his or her 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.

Probation/Monitoring

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 Support
Services

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.

Services and Costs Data Dictionary

| Page 38

Early Intervention (Part C) Support
Services

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, aged 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; 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.

Head Start Program Support Services

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.

Preschool Special Education Program
(Part B)

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 preschoolaged 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.

Other Early Care and Education
Programs

Special education and related services provided to children under the age of 5 years.
No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.

Special Education Class, SelfContained

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 codes, or ICD-9-CM Procedure Codes.

Special Education, Resource Service

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.
Includes HCPCS code: T1018.

Special Education, Inclusion

Practice of educating children and youth with special needs in regular education classrooms.
No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.

Physical Therapy, Occupational,
Speech, Hearing, or Language Service

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.

Teacher Aide Service/Other
Paraprofessional Service

Services provided by individuals who work either with individual students or a program to meet the
requirements of individualized education programs (IEP). Teacher aides are often assigned to
inclusion students.
No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.

Services and Costs Data Dictionary

| Page 39

SERVICE TYPE—Informal/Natural Support Services
Self-Help Group/Peer
Counseling/Support Group

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-of-charge, and nonprofit
basis; provide support and education; and are voluntary, anonymous, and confidential.
Includes HCPCS code: H0038.

Counseling from Clergy

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.

Informal Transportation

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

The process of collecting and interpreting information about a child or youth in an inpatient or
residential setting. An evaluation consists of a variety of tests, observations, and background
information and is conducted by a multidisciplinary committee or team of educational professionals.
Examination or evaluation of a child or youth for the purpose of determining whether the child/youth
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/youth.
Includes CPT-4 codes: 99218 99219 99220 99221 99222 99223 99231 99232 99233 99234.
Includes CPT codes: 99324 99325 99326 99327 99328 99334 99335 99336 99337.

Inpatient Consultation

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.

Inpatient Behavioral Health Service

Mental health treatment provided in a hospital setting 24 hours a day. Inpatient hospitalization
provides (1) short-term treatment in cases where a child or youth is in crisis and possibly a danger to
himself/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 CPT-4 code: 99235.
Includes HCPCS codes: H0017 H0035 H2013 S0201.

Services and Costs Data Dictionary

| Page 40

Residential Therapeutic
Camp/Wilderness Program

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/youth resides. Treatment focuses on group
process and social skills development.
Includes HCPCS code: T2036.

Residential Treatment Service, NonHospital

Treatment provided in secure non-hospital residential facilities that typically serve 10 or more children
or youth; provide 24-hour 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.

Residential Care/Custodial Care

Supervision of a child or youth with serious emotional or behavioral challenges by trained adults outof-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.

Shelter Placement

This placement, also known as an emergency shelter placement, is used for children or youth when
an unanticipated placement need arises for a child/youth and no regular contracted placement exists.
Shelter placements generally do not exceed 30 days. During the placement a caseworker attempts to
return the child/youth to the home, to foster care, or to other appropriate substitute care resource.
No applicable CPT-4 codes, HCPCS codes, or ICD-9-CM Procedure Codes.

PROVIDER AGENCY/SERVICE SECTOR
Mental Health

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/Social 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, childcare, family
services, family assistance, and food assistance.

Juvenile Justice (Juvenile Court,
Corrections, Probation)

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 children and youth at risk.

Education/School/Early Childhood
Program/Childcare Organization

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.

Pediatrician/Physical Health Care
Provider

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.

Services and Costs Data Dictionary

| Page 41

Family Organization

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 Organization

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, afterschool programs, independent living skills, literacy, mentoring, tutoring, workforce
partnerships, health and fitness activities.

PROVIDER TYPE
Case Manager/Care Coordinator

Organizes and coordinates services and supports for children and youth with mental health problems
and their families. (Alternate terms: service coordinator, advocate, and facilitator.)

Psychologist (Ph.D. or similar
credential)

A professional with a doctoral degree in psychology who specializes in assessment and therapy.
Includes Ph.D., or similar credential.

Mental Health Professional/Licensed
Professional Counselor

A professional with an advanced degree in mental health or other social services trained in
assessment and treatment.

Social Worker

Health professionals trained in client-centered advocacy who assist clients with information, referral,
and direct help in dealing with local, state, or Federal Government agencies. Helps individuals deal
with a variety of mental health and daily living problems to improve overall functioning. 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.

Recreational Therapist/Behavioral
Aide/Respite Worker/Other Mental
Health Staff

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 associate’s 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.

Tribal Healer

Uses culturally traditional healing practices such as plant medicines and foods, prayer, ceremony and
song, healing hands, cleansing, and culturally sensitive counseling.

Faith-Based Professional

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.

Services and Costs Data Dictionary

| Page 42

Psychiatrist (M.D. or similar credential)

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.

Physical Health Care
Physician/Pediatrician

A medical doctor who diagnoses, treats, and helps prevent diseases and injuries. Includes M.D., D.O.,
or similar credential.

Nurse Practitioner/Physician Assistant

A nurse practitioner is an advanced practice nurse who works in an expanded role and manages
patients' medical conditions. A nurse practitioner focuses on health promotion, disease prevention,
health education, and diagnosis and treatment of a wide range of health conditions; order, perform,
and interpret diagnostic tests; prescribe medications; and manage patients’ overall care. A physician
assistant is a certified and licensed health professional who practices medicine as a member of a
team with supervising physicians, delivers a broad range of medical and surgical services to diverse
populations in rural and urban settings, conducts physical exams, diagnoses and treats illnesses,
orders and interprets tests, counsels on preventive health care, assists in surgery, and prescribes
medications.

Nurse/Psychiatric Nurse

A nurse can be either a licensed practical nurse (L.P.N.), a registered nurse (R.N.), or an advanced
practice nurse. Nurses develop and implement nursing care plans, 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 diagnoses and treats individuals or families with psychiatric problems or disorders, or
potential for such disorders.

Alternative Health Care Practitioner

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.

Medical Technician/Laboratory

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 Worker/Child
Protective Investigator/Foster Care
Case Worker

Child protective services workers and investigators investigate reports of child abuse or neglect in
order to determine whether any child or youth in a referred family has been abused or neglected or is
at risk of abuse or neglect, and initiate protective services for children and youth who need protection.
Foster care case workers provide many services, including intake, assessment, behavioral
management services, crisis intervention, referral, report writing, family reunification, emancipation,
and discharge planning. They maintain case files, and recruit, certify, train, and provide ongoing
support to foster parents.

Foster Family/Foster Parent

Foster families and parents provide daily care and nurturing of children and youth in foster care; help
children and youth learn daily life skills; are advocates for children and youth in their schools and
communities; inform caseworkers about adjustments in the home, school, and community; provide
positive role models for birth families; and participate with caseworkers’ efforts to reunify the child or
youth with the birth family.

Services and Costs Data Dictionary

| Page 43

Teacher/Special Education Teacher/
Resource Teacher

A teacher is an individual who teaches basic academic, social, and other formative skills to students in
a preschool, daycare 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.

School Counselor/School Psychologist

An individual with an advanced degree in psychology who assesses children and youth for the
presence of learning and emotional problems, diagnoses, and treats children and youth in the school
system. Roles of school psychologists will vary by location.

Speech, Language Therapist/
Audiologist/Occupational or Physical
Therapist

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; and 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.

Teacher Aide/Educational
Paraprofessional

Performs duties that are instructional in nature or delivers direct services to students, under direct
supervision of a teacher. Serves in a position for which a teacher or another professional has ultimate
responsibility for designing and implementing educational programs and services.

Tutor

Provides professional academic or educational instruction in a given subject or field. Instruction may
be given one-on-one or in a group setting.

Childcare Provider

Attends to children at schools, businesses, private households, and childcare facilities. Perform a
variety of tasks, such as play supervision and custodial care.

Court Services Worker

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.

Detention/Corrections Staff

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.

Probation/Parole Officer

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.

Youth Coordinator

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.

Services and Costs Data Dictionary

| Page 44

Youth

Child or youth aged 21 years or younger participating in system of care programs.

Family Member/Relative/Friend/
Neighbor/Volunteer

A family member, relative, friend, or neighbor of a child or youth participating in system of care
programs; a volunteer providing services to a child, youth, or family who are participating in system of
care programs.

Advocate/Family Advocate/Education
Advocate/Court Advocate

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.

Mentor

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.

Program Support Staff

Provides general administrative or program assistance to system of care programs.

Driver

Drives automobiles, vans, or buses to transport passengers.

SERVICE LOCATION
Office/Independent Clinic

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.

Public Health Clinic/Rural Health
Clinic/Federally Qualified Health Center

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 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.

Indian Health Service/Tribal 638 Facility

A facility or location, owned and operated by the Indian Health Service, that provides diagnostic,
therapeutic (surgical and non-surgical), 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 non-surgical), and rehabilitation services to tribal members admitted as
inpatients or outpatients.

Services and Costs Data Dictionary

| Page 45

Community Mental Health Center

A facility that provides the following services: outpatient services, including specialized outpatient
services for children,, youth, 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 psychosocial 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.

Social Service Center or Agency

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.

Ambulance

A land, air, or water vehicle specifically designed, equipped and staffed for lifesaving and transporting
the sick or injured.

Mobile Unit

A facility/unit that moves from place to place equipped to provide preventive, screening, diagnostic,
and/or treatment services.

Urgent Care Facility

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.

Inpatient Hospital

A facility, other than psychiatric, that primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under the supervision of, physicians to patients admitted
for a variety of medical conditions.

Outpatient Hospital

A portion of a hospital that provides diagnostic, therapeutic (both surgical and non-surgical), and
rehabilitation services to sick or injured persons who do not require hospitalization or
institutionalization.

Emergency Room–Hospital

A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

Inpatient Psychiatric Hospital/Facility

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.

Psychiatric Facility–Partial
Hospitalization

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.

Residential Psychiatric Treatment
Center

A facility or distinct part of a facility for psychiatric care that provides a total 24-hour therapeutically
planned and professionally staffed group living and learning environment.

Correctional Facility

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.

Homeless Shelter/Temporary Lodging

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 a
short-term accommodation such as a hotel, campground, hostel, ship, or resort where the patient
receives care.

Services and Costs Data Dictionary

| Page 46

School

A facility whose primary purpose is education.

Home

Location, other than a hospital or other facility, where the patient receives care in a private residence.

Group Home/Custodial Care Facility

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 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

A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a
physician’s office.

Other Community Location/Public Place

Other community location or public place not included in any other service location definitions,
including Boys/Girls Club, YMCA, library, place of worship, etc.

Phone

A conversation over the telephone between a child, youth, or family member and a service provider.

COSTS AND PAYMENT SOURCE
Amount Charged

Amount originally charged by provider prior to any adjustments that may be applied.

Amount Paid

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.

Medicaid

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.

SCHIP

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 and youth in families with incomes that are modest but too high to qualify for
Medicaid.

SAMHSA CMHI Cooperative Agreement 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.
Other Government Funds

Includes other Federal, state, local funds, Temporary Assistance for Needy Families (TANF), and title
funds, but does not include Medicaid, EPSDT, or SCHIP.

Mental Health Agency or Provider

The service sector that is responsible for the planning, monitoring, and managing of mental health
care to children or youth and their families, at the state or local level.

Services and Costs Data Dictionary

| Page 47

Child Welfare Agency

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 and youth’s
health and living conditions.

Juvenile Justice Agency

The service sector that is responsible for serving children and youth accused of or judged to have
committed unlawful or delinquent acts. Includes juvenile court, juvenile detention facilities, other
corrections facilities, and probation organizations.

Education

Includes education, early childhood, or childcare organizations.

Family Organization

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.

Youth Organization

Includes any funding from youth organizations (e.g., Youth M.O.V.E., YMCA, Big Brothers Big Sisters,
Girl Scouts, Boys and Girls Club).

Foundation Funds

Includes any funding from private foundations (e.g., Annie E. Casey Foundation).

Private Insurance

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, pointof-service, and fee-for-service arrangements.

Client Out-of-Pocket

The portion of the service expenses that are paid for by the recipient or recipient’s family.

Other Source of Payment

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.

Estimate For Informal, Natural Support,
In-Kind, or Volunteer Service

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

Services and Costs Data Dictionary

| Page 48

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

Services and Costs Data Dictionary

| Page 49