Resident/Client Intake Data Entry Form

Resident/Client Intake Data Entry Form

Important Confidentiality Information:

All persons filling out and (or) entering this information into CMHC must sign and adhere to

the YCS Confidentiality agreement. If you have not done so, contact the HR dept. for a confidentiality agreement. Sign and return the agreement as soon as possible to HR.

CMHC – Client Registration

Signature of Site Administrator:

Sign off indicates agreement of completion.______

(All applicable fields filled in & entered into CMHC.)

Identification TAB

Client Identifying Information

Last Name: ______Status: ____ (MUST BE FILLED)

(A = Active, T = Terminated)

First Name: ______

Date of birth: ____/____/____Social Security Number: _____/_____/_____

Street Address: ______

Do not enter the address of your program – if there is no parent or guardian use the address of the DYFS case manager. Treatment home should

Always use the Treatment Home address where the child is place.

City: ______State: ______Zip: ______

Phone: (H) (_____) ______

Email address: ______

Application Date: ____/____/____ Enter the date client first requested service from YCS

First Admit: ____/____/____ Enter the date client was admitted to program

Sex: M / F

Ethnicity: (circle one)

A = American Indian / Alaskan Native

B = Asian / Pacific Islander

C = Black, Not Hispanic

D = Hispanic

E = White, Not Hispanic

F = Other

Hispanic: Y / N

Marital Status: (circle one)

A = Married / Living as married

B = Widowed

C = Divorced

D = Separated

E = Never Married

F = Unknown

(Identification Tab Continued)

Department: (Program site Code, circle one)* MUST BE FILLED

320 = Adolescent Development Program
330 = Helen May Strauss Clinic – East Orange
350 = Helen May Strauss Clinic – Union City
351 = Helen May Strauss Clinic – Camden
380 = Family Preservation Service FPS
382 = Family Preservation Serve Step Down
383 = Nurse Family Partnership – Morris
384 = Nurse Family Partnership
390 = Behavioral Assistance/Intensive In-Community Services
397 = Parent as Teachers
575 = Therapeutic Nursery – Essex
576 = Therapeutic Nursery – Hudson
600 = New Brunswick Specialty Beds
610 = HolleyCenter
611 = Muller Hall IRTS
631 = Kid Connection Treatment Home Program DYFS
634A = In Home Behavioral Support
637 = Kid Connection Graduate Program
640 = Davis House
641 = Laurie Haven
650 = Fisher Hall
660 = Grace Hall I
661 = EmergencyDiagnosticReceptionCenterNewark
662 = Muller I – Newark
680 = Bridge
700 = Kid Connection
750 = Treatment Homes Central
751 = Treatment Homes Northern
752 = Treatment Homes Southern
760 = Infant Foster Care
761 = Early Childhood Foster Home
765 = Transitional Residence at (Star) Paul Moore Haven (Boys)
766 = Transitional Residence at (Star) Paul Moore Haven (Girls)
770 = Malcolm House
785 = Kid Connection FIS Foster Homes
789 = Sawtelle Burning Bush
790 = Kilbarchan
791 = Kilbarchan Paterson Assessment Unit
792 = Kilbarchan IRTS
793 = Sawtelle West Orange House
794 = SawtelleResidenceForest
795 = Sawtelle Residence Buffalo
796 = Sawtelle Residence – Thomas
797 = Sawtelle Hall
798= Sawtelle Home – Lawn Ridge
799 = Sawtelle Adult Emergency Capacity System
815 = Pre-Placement Assessments
831 = Options
835 = Sawtelle Home Care
837 = Evening and Weekend Reporting Center
840 = Sawtelle Home Camden
841 = Sawtelle HomeNew Brunswick
842 = Sawtelle Home Sewelle
844 = Sawtelle Home Blackwood
850 = Estell Manor
860 = Cedarbrook Residence
880 = Sayre House

(Identification Tab Continued)

881 = Sicklerville PCH
882 = Haddon Heights PCH
883 = Vineland Home Boys PCH
885 = Voorhees Group Home

Location: (Circle one code – for corrector address with the program name) * MUST BE FILLED

ADP = 260 B’Way Newark – Adolescent Development Program
AGE1 = 764 McLaughlin PlaceOrange – Malcolm House
AGE2 = 2345 Vine RoadVineland–Vineland Boys Home PCH
AGEFH = 2033 Sicklerville Rd. Sicklerville - Sicklerville PCH
AGEHH = 101 E. Atlantic Ave. Haddon Heights - Haddon Heights PCH
BASICS = 284 Broadway Newark - Behavioral Assistance/Intensive In-Community Services
BERGTH = 60 Evergreen Pl.East Orange - Northern Treatment Homes
BHDDD = 126 Buffalo Ave.Paterson- Sawtelle Residence –Buffalo
BRIDGE = 60 Evergreen Pl.East Orange–Bridge
CEDBRK = 34 South Cedar Brook Road Sicklerville - Cedarbrook PCH
CENTH = 60 Evergreen Pl. EastOrange, - Central Treatment Homes
CLINIC = 60 Evergreen Pl.East Orange - Mental Health Outpatient Clinic
DH = 284 B'Way Newark - Davis House
CRCNWK = 284 B'Way Newark–EmergencyDiagnosticReceptionCenter–Newark
EARLY = 60 Evergreen Pl.East Orange - Early Childhood Foster Home
ESTEL = 105 Cumberland Rod Estell Manor - Estell Manor PCH
EWRC = 433 Market St.Camden - Evening and Weekend Reporting Center
FIS = 1260 Bloomfield Ave.Fairfield - Kid Connection FIS Foster Homes
FISHER = 260 Union St.Hackensack - Fisher Hall
FPSSD = 533 32nd St.Union City - FPS Family Preservation Service Step Down
FPSTC = 533 32nd St.Union City - FPS Family Preservation Service
GRAD = 1260 Bloomfield Ave.Fairfield - Kid Connection Graduate Program
HMSC = 711 32nd St. 1st Fl, Suite #3Union City - Helen May Strauss Clinic - Union City
HMSCC = 517 Cooper St.Camden - Helen May Strauss Clinic –Camden
HOLLEY = 260 Union St.Hackensack - HolleyCenter
INFANT = 60 Evergreen East Orange - Infant Foster Care
INHOME = 241 Main St.Hackensack - In-Home Behavioral Support
KC = 1260 Bloomfield Ave.Fairfield - Kid Connection
KILB = 81 East 39th StreetPaterson–Kilbarchan
KBIRTS = 81 East 39th StreetPaterson - Kilbarchan IRTS
LH = 720 Amboy Ave Edison - Laurie Haven
LRTR = 45 Clifton PlaceJersey City - Transitional Residence (STAR) Girls at Paul Moore Haven
MULLER = 260 Union St.Hackensack - Muller Hall IRTS
MULI = 284 B'Way Newark - Muller 1 –Newark
NBSB = 18 Abeel St. New Brunswick - New Brunswick Specialty Beds
NFP = 260 Broadway Newark – Nurse Family Partnership Newark
NFP = 260 Broadway Newark - Nurse Family Partnership Morris
OPT = 20 E. Evergreen Ave. Somerdale –Options
PATKLB = 81 East 39th StreetPaterson - Kilbarchan Paterson
PAT = 760 Post Place, Secaucus, NJ - Parent as Teachers
PMHTR = 45 Clifton PlJersey City - Transitional Residence (STAR) Boys at Paul Moore Haven
PPA =20 E. Evergreen Ave Somerdale - PrePlacement Assessments
SAMWELL - 2005 Amwell Road, Somerset, NJ - Sawtelle Amwell Adult Emergency Capacity System
SAYRE =16 Hollywood Ave. Farmingdale - Sayer House
SBB = 694 Burning Bush Road, Bridgewater - Sawtelle Burning Bush
SH =517 Cooper St.Camden - Sawtelle Home –Camden
SHBLWD = 1600 Peter Chesseman RoadBlackwood, NJ - Sawtelle Home Blackwood
SHII = 189 George St. New Brunswick - Sawtelle Home - New Brunswick
SHALL = 260 Union St.Hackensack - Sawtelle Hall
SHS = 560 Hurffville Cross Keys Rd Sewell - Sawtelle Home Sewell
SHC = 20 E. Evergreen Ave Somerdale - Sawtelle Home Care
SHELES = 284 B'Way Newark - Grace Hall I

(Identification Tab Continued)

SHLR = 332 Lawn Ridge RdOrangeNJ - Sawtelle Home - Lawn Ridge
SRF = 2A Forest AveWest Orange, NJ - SawtelleResidenceForest
SWOH = 2A Forest AveWest Orange, NJ - Sawtelle West Orange House
THCAM = 20 E. Evergreen Ave.Somerdale, NJ - Treatment Homes Southern
THDDD = 33-35 Thomas Street, Paterson, NJ = Sawtelle Residence – Thomas
THNE = 60 Evergreen Place EastOrange - Therapeutic Nursery –Essex
THNH = 760 Post Place Secaucus – Therapeutic Nursery – Hudson
TRHOME = 1260 Bloomfield Ave.Fairfield - Kid Connection Treatment Home – DYFS
VGH = 301 American Way - Voorhees Group Home

Adopted: Is this an adopted Child?

Y= Yes N = No

RP Info TAB

Responsible Party If you have this information available, please fill in the following for the child's parent or guardian. Responsible party in this case is the person who takes care of the child.

Rel: [Relationship: In the box that says Rel above the First Name enter the code for one of the following]

(circle one)

Parent Guardian Foster Parent Great/Grandparent Aunt/Uncle Sister Brother

Self Spouse

**For all Medicaid clients - The RP info. must always be filled in, including Social Security Number.

Use SE in the Relationship field (Rel) for Self. This will automatically bring over the client information

with their address and SS#, which is required here for Medicaid.

Last Name: ______First Name: ______

Street Address: ______

City:______State: ______Zip:______

Phone: (__)______Sex:M / F DOB: ____/____/____SS#: ____/____/____

Single Caretaker: Yes No Unknown (circle one)

[Did client come from a single parent or single primary caretaker home?

If DYFS is only know guardian enter U or Unknown]

Clinical TAB

Please provide diagnosis:Code Description:

*Both the code and description must be filled in on this form. [AXIS III - for Medical diagnosis only]

AxisI. a. ______.______

AxisI. b. ______.______

AxisI. c. ______.______

Axis II.a ______.______

Axis II.b ______.______

[Medical Diagnosis should be entered in Axis III]

Axis III.a_____.______

Axis III.b _____.______

Axis IV: List Psychosocial and Environment Problems/Stressors:

______

GAF1 score: ______(range 1-100 1 = minimal functioning 100 = highest level of functioning)

Gaf1 used at admission. If your program does not do client testing enter a 1 here.

Sub Use TAB

Child of Abuser: (circle one)

1 = No

2 = Child of Alcoholic (COA)

3 = Child of Substance Abuser (COSA)

4 = Child of both - COA & COSA

5 = Unknown

MISC. I TAB

Geo1: (write here the Zip Code where clients lives) ______

(Do not type anything in the Geo1 field: Instead, put the cursor in the Geo 1 Field then hit the f2 key,

along the top of your keyboard. A popup box will come up. Click on the word zip in the popup box. This

will put the list in zip code order. Now type your zip code. Look for the city and zip code that applies,

click to highlight the choice and hit enter and this will fill in the correct Geo code.)

Yrs. Ed:(Number of years of Education completed, numeric input only): ______

Ed Type: (circle one)

A = Regular Education

B = Special Education

C = Adult Education

D = Not in School

Language: (Primary language spoken, circle one)

A = English

B = Spanish

C = Other Foreign

D = American Sign

Living Circ: (living circumstance prior to being admitted to YCS, circle one)

A = Alone / Independent

B = With relatives / Family / Friend

Q = Newly Adopted Family

C = Foster Care

D = RTC [Residential TreatmentCenter]

F = Shelter

G = Group Home

H = Hospital

K = Incarcerated

L = IRTS (Intensive Residential Treatment Service]

M = PCH / PCR [Psychiatric Children's Home / Residence]

N = Specialty Beds [SPEC]

P = Treatment Home

J = Unknown

E = Other

(Misc. I Tab Continued)

Ref Src: (referral source to YCS, circle one)

Emergency/Screening/InpatientCommunity Programs/Residential Sources

A = Designated screening centerH = Community mental health agency

B = EmergencyJ = Alcohol treatment program

C = CCIS inpatientK = Drug treatment program

D = County psychiatric hospitalL = School District/Child study team

E = State psychiatric hospitalM = Other social service agency

F = Other psychiatric inpatientN = Nursing home

G = GeneralHospitalO = Boarding home

P = Homeless shelter

Q = Child care/pre-school provider

R = Other residential program

Legal/Justice SystemIndividualsDept. of Human Services

S = Police / Court / JailX = Self6 = DYFS

T = State correctional program1 = Family or friend7 = Div. of Dev. Disab.

V = Community corrections2 = Private mental8 = Other (DHS Service)

programs health practitioner9 = DCBHS

W = Family crisis intervention3 = Private psychiatrist

Unit4 = Medical doctor

5 = ClergyZ = Other

Misc. II TAB

Pri Prob: (Primary Problem – circle one)

A = Alcohol abuseT = No social support resources

B = AnxietyV = Organic mental disorder

C = Assaultive Behavior/ThreatW = Physical abuse/assault victim

D = Bizarre behaviorX = Physical neglect

E = Compulsive gamblingY = Delinquent behavior

F = Daily living problemsZ = Substance abuse exposure

G = Depression/mood disorder1 = Runaway behavior

H = Destructive to property2 = School Problems

J = Developmental disability3 = Sexual abuse/rape victim

K = Drug abuse4 = Sexual abuser

L = Eating disorder5 = Social/interpersonal (other than family)

M = Economic stress6 = Suicide attempt

N = Fire setting/ideation7 = Suicide threat

O = Homicidal behavior/threat8 = Thought disorder

P = Legal/justice involvement9 = Other

R = Marital/family problem10 = Hyperactivity

S = Medical/somatic complaints11 = Short attention span

12 = Aggression (without assaultive behaviors/threats)

Prob 1 (Presenting Problem: Circle up to 4 and number them to 1 to 4 in order of priority)

[2nd - 4th choices enter under Prob 2, Prob 3, Prob 4)

**Note – Prob1 should be a repeat of primary problem.

A = Alcohol AbuseT = No social support resources

B = AnxietyV = Organic mental disorder

C = Assaultive behavior/threatW = Physical abuse/assault victim

D = Bizarre behaviorX = Physical neglect

E = Compulsive gamblingY = Delinquent behavior

F = Daily living problemsZ = Substance abuse exposure

G = Depression/mood disorder1 = Runaway behavior

H = Destructive to property2 = School Problems

J = Developmental disability3 = Sexual abuse/rape victim

K = Drug abuse4 = Sexual abuser

(Misc. II Continued)

L = Eating disorder5 = Social/interpersonal (other than family)

M = Economic stress6 = Suicide attempt

N = Fire setting/ideation7 = Suicide threat

O = Homicidal behavior/threat8 = Thought disorder

P = Legal/justice involvement9 = Other

R = Marital/family problem10 = Hyperactivity

S = Medical/somatic complaints11 = Short attention span

12 = Aggression (without assaultive behaviors/threats)

IS #1(Family Income source: Main source, circle up to 2. Enter 2nd choice under IS #2)

A = Disability insurance/workman’s comp.

B = Family or relative

C = Pension

D = Public assistance

E = Social security

F = Unemployment insurance

G = Wage/salary income

H = Other

J = Unknown

SR #1(Source of reimbursement: Circle up to 2) [Enter 2nd choice under SR #2]

A = None – Organization to absorb total costI = Div. of Health & Mental Srvcs. Dept of Ed.

B = Self/legally responsible relativeJ = Supplemental social security Income (S.S.I)

C = MedicaidK = DYFS

D = MedicareL = Division of mental health

E = Other public sourcesM = Local school district

F = Service contract (e.g., HMO)N = Office of education – Dept. of Human Srvcs.

G = Other third party insurance

H = Unknown

User 1 TAB

Case Manager: (select one for this client)

CMO – Care Management Organization

DDD – Division of Developmental Disabilities

UCM – Unified Case Management

YCM – Youth Case Management

NONE – None of these case managers are involved with this client

DYFS or Spirit #: (enter number here) ______

Name:(Name of the clinical person completing this form) ______

(Required Field) (Print Name)

(Press F2 for a list of Names)

______

(Signature)

(User 1 Tab Continued)

ED. CL (Education Classification: For students, circle one)

A = Auditory impaired

B = Autistic

C = Mild cognitive impairment

D = Moderate cognitive impairment

E = Severe cognitive impairment

F = Communication impaired

G = Emotionally disturbed

H = Multiply disabled

I = Orthopedically impaired

J = Other health impaired

K = Preschool disabled

L = Social maladjustment

M = Specific learning disability

N = Traumatic brain injury

O = Visually impaired

Prior Hosp: (Did client have any psychiatric hospitalizations during the year prior to intake)

This question must be answered or record will not be saved.

(Circle one)

Y = Yes N = No U = Unknown

Prior # Hosp (Only if prior Hosp is Yes. Enter Number of psychiatric hospitalizations for the year prior to intake)

______

Money in Pocket:(Enter the amount of money the client has on them. Required for all Residential programs as per the U.S. Dept. of Agriculture policy.)

$ ______._____

In CMHC enter the dollar amount, i.e.: 12.25

Do not put in the symbol $ If the client has no money on them enter 0.

Care Management Organizations: (Select the county for the Care Management Organization involved through

the Partnership for Children.)

ATCM = Atlantic/Cape May CountiesHUD = HudsonCounty

BER = Bergen CountyMER = MercerCounty

BUR = BurlingtonCountyMID = MiddlesexCounty

CAM = CamdenCountyMON = MonmouthCounty

CGS = Cumberland/Gloucester/SalemMSC = Morris/Sussex Counties

ESX = Essex CountyPAS = PassaicCounty

HSW = Hunterdon/Somerset/WarrenUNI = UnionCounty

Admit Restrictiveness of Living Environment: *[Only Required for Kid Connection]

(The restrictiveness of living Environment prior to KC admission – circle one)

1 = Hospitalized or incarcerated

2 = Residential treatment

3 = Group home / Aging in

4 = Shelter

5 = Treatment home / Foster home

6 = Family / friend / independent living

(User 1 Tab Continued)

DDD Serial Number: [DDD residences only enter 6 digit serial number here] ______

CCW Eligible: [For DDD residents, circle one] - Y = Yes, N= No

(CCW = community care waiver)

After completing all the above information, click on the SAVE Icon. A box will popup that says;Client’s admit to Initial Program.

The Admit Date defaults to today’s date. Be sure to change that to the accurate admit date. Fill in your location code, department code, program code and staff ID code for the staff member working with this client. (You can also use F2 to bring up a list for each of these codes.)

[When the record is not being created new, but you are updating an existing record, you will do those steps using the following procedure.

Select the PROGRAMS button along the button of Client Registration. Click on the New button at the top of the screen. With your cursor in the new, empty Prog. Field hit F2 for a list of programs and select the program the child is being admitted to or just type in the 3 digit code in that spot. The admit date defaults to today’s date, be sure to correct that if the intake date is not today. Tab over to the Staff field, do the same here, selecting the appropriate staff member for that program.]

PROGRAMS button

Program Code: ______(same as Department Code)

Fill in the Social Worker’s name:

Social Worker’s Name:
Select the STAFF button along the bottom of Client Registration.

Click on the New button at the top, then F2 for a list & select

Social Worker’s name for this child. Then tab to the TYPE field

and choose Social Worker .

** In addition for Medicaid clientsalways click in the box to indicate Primary Provider.

STAFF button

Social Worker’s Name: ______

(That will be working with this client)

Next click on the Payors button along the bottom of Client Registration. Click on the new button at the top. Tab over to Pol# and enter the 12 Digit Medicaid number, no dash. * Please note this number should always be verified before entering it here. A copy of the Medicaid card must be sent to Anita Taylor in accounting.

PAYORS button – (enter Medicaid number written in the boxes below into the field that says Pol#/Pat ID)

Medicaid #: (12 Digit Medicaid #)

[*Enter one number in each box to complete the 12 digit Medicaid #]

Now click on the RELATED button. Click on the new button at the top. Fill in the DYFS case manager’s first and last name. Then in the TYPE field use the F2 key to bring up the list and select DYFS or DYGD. **If DYFS has legal responsibility then select DYGD to indicate this is the DYFS Worker & they have legal responsibility. Enter the address of the DYFS worker’s office and then tab down to phone # and enter the DYFS district office phone number.

RELATED button

DYFS Case Manager: (First and Last Name) ______

Type: (Circle one): DYFS – DYFS Case Manager only. DYGD – DYFS has legal responsibility.

DYFS District Office address: ______

______

DYFS District Office Phone Number: (___) ______

In accordance with federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights. Room 326-W, WhittenBuilding, 1400 Independence Avenue SW, Washington,, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

January 2013

Research/CMHC Reporting/CMHC Forms & Procedures/CMHC_Intake.doc