Continuing Stay Request Acentra Health Questionnaire

Clients Name *

First Name

Last Name

Date *

MM

DD

YYYY

What has been the progress toward goals? *

None

Minimal

Moderate

Significant

Are there any medication changes since last request? *

Yes

No

What are the symptoms since last review? (Select all that apply) *

Activities of Daily Living (ADL)

Aggression

Agitation

Appetite Impairments

Auditory Hallucinations

Capacity for Independent Living

Delusions

Has Met Pharmacological Criteria of Substance Abuse

Homicidal Ideation

Learning

Impaired Control Regarding Substance Use

Memory Impairments

Mobility

Mood Swings

Paranoia

Physical Aggression

Problem Sexualized Behaviors

Racing Thoughts

Risk/Danger to Others

Risk/Danger to Self

Risky Use of Substances

Self-Care

Self-Direction

Sensory Hallucinations

Sleep Impairments

Social Impairment Regarding Substance Use

Suicidal Ideation

Understanding and Use of Language

Verbal Aggression

Visual Hallucinations

Select the member's current living situation: *

Assisted Living Facility

Community Residential Facility

Dorothea Dix

Foster Care

Homeless Shelter or on the Streets

Hospitalized for Medical Reasons

Incarcerated in a State Prison or County Jail

Nursing Home

Other Psychiatric Inpatient Unit or Facility

Own Apartment or Home

Residential Treatment Facility

Group Home Arrangement

Riverview Psychiatric Center

Supported Apartment

Temporarily Staying with Others

Select the member's current vocational/employment status: *

Clubhouse Transitional Employment

Competitively employed full-time (32 or more hours per week)

Competitively employed part-time (Less than 32 hours per week)

Not employed - looking for work

Not employed - not looking for work

Self-employed

Student

Volunteer

Working with supports full-time (32 or more hours per week)

Working with supports part-time (Less than 32 hours per week)

Is this member of transition age (16-20 years)? *

Yes

No

If member is age 16-20, What is the member's current grade level?

*Only select an option here if client is between ages of 16-20*

9

10

11

12

College

Technical College

Stopped school BEFORE grade 9

Stopped school after grade 9

Stopped school after grade 10

Stopped school after grade 11

Stopped school after grade 12

In the past three (3) months has attendance at school been an issue for this member? *

Yes

No

Was this member involved with the Department of Corrections within the past six (6) months? *

Yes

No

If the member has a guardian, is the guardian engaged in treatment? *

Yes

No

N/A

Does the member require an Interpreter? *

Yes

No

Has this member received all authorized units of service during last review period? *

Yes

No

*If no, why did member not receive all authorized units of services?

Staff Availability

Family Availability

Illness

Would the guardian be interested in the member participating in a Section-28 group that included other Section-28 members? *

Yes

No

Would the guardian be interested in participating in a Section-28 group with other Section-28 members and guardians? *

Yes

No

Program Manager Name *

First Name

Last Name