Maine DHHS - Questionnaire - Section 17


Status: Incomplete
   

Section 17


1. Date of referral:

Date:



2. Date Case Worker assigned:

Date:



3. Date seen face to face:

Date:



4. Has the member received treatment in a state psychiatric hospital, within the past 24 months, for a non-excluded DSM 5 diagnosis?

(Please select one.)


5. Has the member been discharged from a mental health residential facility, within the past 24 months, for a non-excluded DSM 5 diagnosis?

(Please select one.)


6. Has the member had two or more episodes of inpatient treatment for mental illness, greater than 72 hours per episode, within the past 24 months, for a non-excluded DSM 5 diagnosis?

(Please select one.)


7. Has the member been committed by a civil court for psychiatric treatment as an adult?

(Please select one.)


8. Is there an uploaded clinical letter from a clinician dated within the past year stating member is likely to have future episodes, related to mental illness, with a non-excluded DSM 5 diagnosis, that would result in or have significant risk factors of homlessness, criminal justice invlovelment or require a mental health inpatient treatment greater than 72 hours, or residential treatment unless community support program services are provided?

(Please select one.)


9. LOCUS Composite Score:



10. Date LOCUS Completed:

Date:



11. Name and credentials of who completed the LOCUS assessment:



12. LOCUS Rater ID#:



13. Date ANSA Completed:

Date:



14. Name and credentials of who completed the ANSA assessment:



15. ANSA Rater ID#:



16. Does the member receive Vocational Rehabilitation Services?

(Please select one.)


17. Does the member currently have a rent subsidy or live in subsidized housing?

(Please select one.)


18. Has a clinical opinion letter been uploaded?

(Please select one.)


19. Select the Section 17 service type:

(Please select one.)



Disclaimers (please check to confirm acceptance):