SAMHSA's National Mental Health Information Center

This Web site is a component of the SAMHSA Health Information Network

About the Toolkits

Illness Management and Recovery

Assertive Community Treatment

Family Psychoeducation

Supported Employment

Co-occuring Disorders: Integrated Dual Diagnosis Treatment

Feedback Form

Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Family Psychoeducation

Definitions for Quarterly Report Form

Each person completing the form should become familiar with the definitions of the data elements in order to provide consistency among reporters.

Heading information

Client ID
The client ID that is used at your agency. This is usually a name or an identifying number. This information will only be accessible to the agency providing the service.

Reported by
The name of the person who completed the form—the case manager or other staff member from the mental health agency who have access to the desired information.

Date
The date the report was completed.

Quarter
The time frame for the reporting period. For example, January–March, April–June, July–September, October–December.

Evidence-based practice

Eligible
Does the client meet the participation criteria for a specific EBP? For example, all persons who have a severe mental illness and a drug/alcohol diagnosis are eligible for participation in integrated dual disorders treatment. Each EBP has criteria for program participation that should be used to determine eligibility.

Enrolled
Is the client participating in a particular EBP service? Note: aggregate data about eligibility and enrollment can be used to determine the penetration of services to eligible persons served by a mental health agency.

For the following incidents, the quarterly report should record the number of weeks the client spent in the specific incident category during the 3 months of the reporting period.

Incidents reporting

In the past 3 months, how many weeks has the client held a competitive job?
Competitive employment is viewed as working in a paid position (almost always outside the mental health center) that would be open to all community members to apply. This would exclude persons working in sheltered workshops, transitional employment positions, or volunteering. It may include persons who are self-employed but the person must work regularly and be paid for the work.

Been homeless?
Record the number of weeks the client spent homeless during the reporting period. This refers to individuals who lack a fixed, regular, and adequate nighttime residence.

Been incarcerated?
Record the number of weeks the client spent incarcerated in jails or other criminal justice lock-ups during the reporting period.

Been hospitalized for psychiatric reasons?
Record the number of weeks the client spent hospitalized primarily for treatment of psychiatric disorder(s) during the reporting period. This includes both public and private hospitals whose primary function is the treatment of mental disorders.

Been hospitalized for substance use reasons?
Record the number of weeks the client spent hospitalized primarily for treatment of substance use disorder(s) during the reporting period. This includes those both public and private hospitals whose primary function is the treatment of substance use disorders.

Stage of substance abuse treatment

What has been the client’s stage of substance abuse treatment during the past 3 months?
For those persons participating in integrated dual disorders treatment, please indicate the appropriate stage of substance abuse treatment. N/A is used for persons who do not have a substance use problem or diagnosis.

Engagement: This category includes Pre-engagement and Engagement.

The person does not have any regular contacts with an assigned case manager, mental health counselor, or substance abuse counselor. The lack of regular contact implies lack of a working alliance.

Persuasion: This category includes Early Persuasion and Late Persuasion.

The client has regular contacts with a counselor but has not yet reduced substance use for more than a month (early persuasion), or has reduced substance use for at least one month while discussing substance use issues or attending groups (late persuasion). Regular contacts imply a working alliance and a relationship in which substance abuse can be discussed.

Active Treatment: This category includes Early Active Treatment and Late Active Treatment.

The client is engaged in treatment, is discussing substance use or attending a group, has reduced use for at least one month and is working toward abstinence as a goal, even though he or she may still be abusing (early active treatment). This category also includes persons engaged in treatment, who have acknowledged that substance abuse is a problem, and have achieved abstinence but for less than 6 months (late active treatment)

Relapse Prevention: This category includes Relapse Prevention, and In Remission or Recovery.

The client is engaged in treatment, has acknowledged that substance abuse is a problem, and has achieved abstinence for at least 6 months. Occasional lapses, not days of problematic use, are allowed (relapse prevention). This category also includes clients who have had no problems related to substance use for over one year and are no longer in any type of substance abuse treatment (in remission or recovery).

Residential and educational status

These data provide your agency with an ongoing record of the client’s residential and educational status. Record the status that applies to the client on the last day of the reporting period.

What is the client’s current living arrangement?
1. Psychiatric hospital. This includes those hospitals, both public and private, whose primary function is the treatment of mental disorders. This includes state hospitals and other freestanding psychiatric hospitals.

2. Substance use hospitalization. This includes those hospitals, both public and private, whose primary function is the treatment of substance use disorders.

3. General hospital psychiatric ward. This category includes psychiatric wards located in general medical centers that provide short-term, acute crisis care.

4. Nursing home or IC-MH. This category includes facilities that are responsible for the medical and physical care of a client and have been licensed as such by the state.

5. Family care home. This category is for situations in which a client is living in a single family dwelling with a non-relative who provides substantial care. Here (as with #8), substantial care is determined by the degree that the non-relative(s) is responsible for the daily care of the individual. Such things as medication management, transportation, cooking, cleaning, restrictions on leaving the home, and money management are considered. The non-relative may have guardianship responsibilities. If the client is not able to do a majority of the daily living tasks without the aid of the caretaker, the caretaker(s) is providing substantial care.

6. Lives with relatives (heavily dependent for personal care). Here the individual client and relatives should be consulted to the degree that family members are responsible for the daily care of the individual client. An important distinction between this status and #9 is to ask, “If the family was not involved, would the person be living in a more restrictive setting?” In assessing the extent to which the members provide substantial care, such things as taking medication, transportation, cooking, cleaning, control of leaving the home, and money management can be considered. If the client is unable to independently perform a majority of the daily living functions, the family member(s) is providing substantial care.

7. Group home. A group home is defined here as a residence that is run by staff who provide many functions (shopping, meal preparation, laundry, etc.) that are essential to independent living.

8. Boarding house. A boarding home is a facility that provides for a place to sleep and meals, but it is not seen as an extension of a mental health agency, nor is it staffed with mental health personnel. These facilities are largely privately run, and clients have a high degree of autonomy.

9. Lives with relatives (but is largely independent). As with status #8, an assignment to this category requires information provided by the client and family. The key consideration relates to the degree that the individual is able to perform the majority of tasks essential to daily living without the supervision of a family member.

10. Supervised apartment program. Here, the client is living (fairly independently) in an apartment sponsored by a mental health agency. In determining whether someone fits in this category, look at the extent to which mental health staff have control over key aspects of the living arrangements. Example characteristics of control include:

the mental health agency signs the lease,
the mental health agency has keys to the house or apartment,
the mental health agency provides on-site day or evening staff coverage, or
the mental health agency mandates client participation in certain mental health services—medication clinic, day program, etc.—in order to reside in the house or apartment. Clients only receiving case management support or financial aid are NOT included in this category; they are considered to be living independently (#11).

11. Independent living. This category describes clients who are living independently and are capable of self-care. It includes clients who live independently with case management support. This category also includes clients who are largely independent and choose to live with others for reasons not related to mental illness. They may live with friends, a spouse, or other family members.

The reasons for shared housing could include personal choice related to culture and/or financial considerations.

12. Other. This status should be clearly defined in the space provided by those completing the form.

13. Emergency shelter. This category includes temporary arrangements due to a crisis or misfortune that are not specifically related to a recurrence of the client’s illness. While many emergency shelters provide emotional support, the need for emergency shelter is due to an immediate crisis not related to the client’s mental illness.

14. Homeless. This category includes individuals who lack a fixed, regular, and adequate nighttime residence.

What is the client’s current educational status?
1. No educational participation.

2. Avocational/educational involvement. These are organized classes in which the client enrolls consistently and expects to take part for the purpose of life enrichment, hobbies, recreation, etc. These classes must be community based, not run by the mental health center. Classes are those that any citizen could participate in, not just persons with severe mental illness. If any of these activities involve college enrollment, use status #8 or #9.

3. Pre-educational explorations. Individuals in this status are engaged in educational activities with the specific purpose of working towards an educational goal. This includes individuals who attend a college orientation class with the goal of enrollment, meet with the financial aid office to apply for scholarships, or apply for admission for enrollment. This status also includes those persons who attend a mental health center sponsored activity focusing upon an educational goal, e.g., campus visits with a case manager to survey the location of classrooms; meetings with the case manager and college staff to secure entitlements.

4. Working on GED. This status includes people who are taking classes to obtain their GED.

5. Working on English as second language. This includes those who are taking classes in English as a second language in a community setting.

6. Basic educational skills. This includes those who are taking adult educational classes focused on basic skills such as math and reading.

7. Attending vocational school or apprenticeship, vocational program (CAN training), or attending high school. This status includes those participating in community based vocational schools; learning skills through an apprenticeship, internship, or in a practicum setting; involved in on–the-job training to acquire more advanced skills; participating in correspondence courses which lead to job certification; and young adults attending high school.

8. Attending college: 1–6 hours. This individual attends college for 6 hours or less per term. This status continues over breaks, etc., if the individual plans to continue his/her enrollment. This status suggests regular attendance by the individual. Includes correspondence, TV, or video courses for college credit.

9. Attending college: 7 or more hours. This individual attends college for more than 7 hours per term. This status continues over breaks, etc., if the individual plans to continue his/her enrollment. Regular attendance with expectations of completion of course work is essential for assignment to this status.

10. Other. This status should be clearly defined in the space provided by those completing the form.

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