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COMMUNITY MENTAL HEALTH CENTER SCREENING FORM

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					                                             MENTAL HEALTH SCREENING FORM
I. IDENTIFYING DATA                    Screen Urgency _____________________________            Tracking #______________________

QMHP/LMHP                                                        Screen Date                   Start Time              AM/PM

Name of CMHC/LMHP                                                          Location of Interview

                                                                       Referred by __________________________________
______________________________________________________                 Consumer Status
 Name:   Last                 First            MI                       Current CMHC Consumer  Former CMHC Consumer
______________________________________________________                  Other CMHC Consumer  Never a CMHC Consumer
         Pre-Marital Name          Also Known As (AKA)                  Private Treater Consumer ________________________
                                                                       Screening Informant(s)
Street Address__________________________________________
                                                                        Family _______________________________________
City, State, Zip_________________________________________               CMHC/Private Treaters __________________________
                                                                        Hospital Staff __________________________________
Phone_______________________ Unique ID# ________________                JJA/Contractor _________________________________
SSN___________________________________           Veteran               LEO/Other agency ______________________________
                                                                        Other _______________________________________
DOB___________________ Age________            Gender__________         Child Custody Status
                                                                        Parental  SRS ______________________________
County/ Residence________________________________________               JJA         Contractor _________________________
                                                                       Type of Screening Completed
County/ Responsibility____________________________________
                                                                        Mental Health Reform
Courtesy Screen Authorized by _____________________________             Medicaid Inpatient Psychiatric
                                                                        Psychiatric Residential Treatment Facility (PRTF)
Current outpatient treatment order:  Yes    No  Unknown                                  Initial     Extension


II. SUPPORT SYSTEMS              Guardian:  Yes  No            Name/phone# :___________________________________________
This individual has others involved in a helpful way (circle) : Parent, Family, Friends, Case Worker, Neighbor, Landlord, Other
Name/address/phone#: ______________________________________________________________________________________
Name/address/phone#: ______________________________________________________________________________________
This individual :  has adequate support systems        has limited support systems       has no support systems
                      has a stable living environment  receiving MR/DD services          homeless         currently incarcerated
Explain:__________________________________________________________________________________________________
FINANCIAL RESOURCES:               Employed           Unemployed              Other ____________________________________
Third Party Payer(s)     Medicaid ID#___________________________________________ Pending Medicaid
Medicare ID# _________________________________ Other/ ID# (Specify)___________________________________________

III. PRESENTING PROBLEM(S)
 Current Danger    Potential Danger    to SELF            Self Care Failure          Substance Abuse
 Current Danger    Potential Danger    to OTHERS          Psychotic Symptoms         Other
 Current Danger    Potential Danger    to PROPERTY        Mood Disorder
____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

__________________________________________________________________________________________________________
                                                             PAGE 1

Revised March 2007
                                                                                                 Name ______________________________________
IV. RISK FACTORS
Current Danger to Self:  None  Ideation  Plan  Threat  Intent with means  Intent w/o means  Self-care Failure
                          Gesture/attempt  Risk aggravated by substance use     Able to contract no self-harm
Explain (Include dates, means, rescue) ____________________________________________________________________________
___________________________________________________________________________________________________________


History of Danger to Self:  None  Ideation  Plan  Threat  Intent with means  Intent w/o means  Self-care Failure
                            Gestures/attempts  Risk aggravated by substance use  Able to contract no self-harm
Explain (Include dates, means, rescue) ____________________________________________________________________________
___________________________________________________________________________________________________________
----------------------------------------------------------------------------------------------------------------------------- -------------------------------------
Current Danger to Others:  None  Ideation  Plan  Threat  Intent with means  Intent w/o means
                                    Gesture/attempt           Risk aggravated by substance use                   Able to contract no harm
Explain (Include dates, means, rescue)_____________________________________________________________________________
____________________________________________________________________________________________________________
History of Danger to Others:  None  Ideation  Plan  Threat  Intent with means  Intent w/o means
                              Gestures/attempts  Risk aggravated by substance use  Able to contract no harm
Explain (Include dates, means, rescue)____________________________________________________________________________
___________________________________________________________________________________________________________
----------------------------------------------------------------------------------------------------------------------------- ------------------------------------
Current Destruction of Property:  YES  NO  UNK                              History of Destruction of Property:  YES  NO  UNK
Explain ____________________________________________________________________________________________________
___________________________________________________________________________________________________________
----------------------------------------------------------------------------------------------------------------------------- -------------------------------------
Current Abuse:  YES  NO  UNK                            TYPES:  Physical  Sexual  Emotional  Neglect  History reported
If yes, individual is:        Victim  Perpetrator  Both  Neither, but abuse reported in environment
Explain ___________________________________________________________________________________________________
__________________________________________________________________________________________________________
------------------------------------------------------------------------------------------------------------------------------------------------------------------
Substance Use: Indication of substance related issues  Yes  No  Unknown                                   Positive lab screen for _______________
Drugs of Choice:
           Primary _________________________ Secondary ________________________ Tertiary __________________________
           _________ Currently using                          __________ Currently using                          ___________ Currently using
           _________ Past use                                 __________ Past use                                 ___________ Past use
           _________ Date of last use                         __________ Date of last use                         ___________ Date of last use
Frequency & amount of use: ___________________________________________________________________________________
Complications related to detoxification/withdrawal: ________________________________________________________________
Substance Abuse Treatment:  None                      Detox              Outpatient             Inpatient            Halfway House
Explain (Include current/ history, legal history)_____________________________________________________________________
___________________________________________________________________________________________________________
----------------------------------------------------------------------------------------------------------------------------- -------------------------------------
Medical Concerns:  None reported  Self/family report                             Primary Care Physician report               Medical records
  NKDA            Drug allergies ________________________________________________________________________________
Explain (Include current/ history) ________________________________________________________________________________
List Current Medications: Specify Name &Dosage Taking as directed: (Y) Yes (N) No (U) Unknown
                                                   Y N U                                                 Y N U
__________________________________________    ____________________________________________   
__________________________________________    ____________________________________________                                                     
__________________________________________    ____________________________________________                                                     
__________________________________________    ____________________________________________                                                     
Psychiatrist/Location _________________________________________________________________________________________
Primary Care Physician/Location_______________________________________________________________________________
Revised March 2007
                                                                           PAGE 2
                                                                   Name_________________________________
V. CLINICAL IMPRESSIONS (where two choices are offered, circle appropriate choice)

General Appearance                        Orientation                             Conduct Disturbance
 Appropriate hygiene/dress                Unable to assess  Impaired time       Unable to assess
 Poor personal hygiene                    Oriented x 4       Impaired person    Conduct appropriate
 Overweight  Underweight                 Impaired place                         Stealing                Lying
 Eccentric     Seductive                 Impaired situation                     Projects blame          Fire setting
                                                                                   Short-tempered
Sensory/Physical Limitations              Cognition/Attention                      Defiant/Uncooperative
 No limitations noted                     Unable to assess                       Violent behavior
 Hearing      Visual                     No impairment noted                    Cruelty to animals/people
 Physical     Speech                     Distractibility/Poor concentration     Running away            Truancy
                                           Impaired abstract thinking             Criminal activity       Vindictive
Mood                                       Impaired judgment                      Argumentative
 Cooperative              Calm           Indecisiveness                         Antisocial behavior
 Cheerful                 Anxious                                                Destructive to others or property
 Depressed                Fearful       Behavior/Motor Activity
 Suspicious               Labile         Unable to assess                      Occupational & School Impairment
 Tearful                  Pessimistic    Normal/Alert  Poor eye contact        Unable to assess
 Euphoric                 Irritable      Self-Destructive  Uncoordinated       No impairment noted
 Guilty                   Hostile        Lethargic          Catatonic          Impairment grossly in excess than
 Dramatized               Apathetic      Repetitious        Tense               expected in physical finding
 Elevated mood                            Agitated           Withdrawn          Impairment in occupational
 Marked mood shifts                       Tremors/Tics                            functioning
                                           Aggression/Rage                        Impairment in academic functioning
Affect                                     Restless/Overactive                    Not attending school/work
 Primarily appropriate                    Peculiar mannerisms
 Primarily inappropriate                  Bizarre behavior                      Interpersonal/Social Characteristics
 Restricted            Blunted           Impulsiveness                          Unable to assess
 Flat                  Detached          Compulsive                             No significant trait noted
                                           Indiscriminate socializing             Chooses relationships that lead to
Speech                                     Disorganized behavior                    disappointment
 Unable to assess                         Feigning of symptoms                   Expects to be exploited or harmed
 Logical/Coherent      Loud              Avoidance behavior                       by others
 Delayed responses  Tangential           Increase in social, occupational,      Indifferent to feelings of others
 Rambling              Slurred            sexual activity                        Interpersonal exploitiveness
 Rapid/Pressured                          Decrease in energy, fatigue            No close friends or confidants
 Incoherent/loose associations            Loss of interest in activities         Unstable and intense relationships
 Soft/Mumbled/Inaudible                                                           Excessive devotion to work
                                          Eating/Sleep Disturbance                 Inability to sustain consistent work
Thought Content/Perceptions                Unable to assess
 Unable to assess  Delusions                                                       behavior
                                           No disturbance noted                   Perfectionistic          Grandiose
 No disorder noted  Grandiose            Decreased/Increased appetite
 Paranoid            Racing                                                      Procrastinates           Entitlement
                                           Binge eating                           Persistent emptiness & boredom
 Circumstantial      Obsessive           Self-induced vomiting
 Disorganized        Flight of ideas                                             Constantly seeking praise or
                                           Weight gain/loss (lbs/time________)      admiration
 Bizarre             Blocking            Hypersomnia/Insomnia
 Auditory Hallucinations                                                          Excessively self-centered
                                           Bed-wetting                            Avoids significant interpersonal
 Visual Hallucinations                    Nightmares/Night Terrors
 Other hallucinatory activity                                                       contacts
 Ideas of reference                      Anxiety Symptoms                         Manipulative/Charming/Cunning
 Illusions/Perceptual distortions         Unable to assess
 Depersonalization or derealization       Within normal limits                  NOTES:__________________________
                                           Generalized anxiety
Memory                                     Fear of social situations             _________________________________
 Unable to assess-                        Panic attacks
 No impairment noted                      Obsessions/Compulsions                _________________________________
 Impaired remote                          Hyper-vigilance
 Impaired recent                          Reliving traumatic events             _________________________________
Insight (Age Appropriate)
 Unable to assess-                                                               _________________________________
 Good                Fair
 Poor                Lacking                                                    ________________________________
Revised March 2007
                                                       PAGE 3
                                                                          Name __________________________________
VI. TREATMENT/ PLACEMENT INFORMATION
Currently in treatment:  Yes  No  Unknown            Therapist/Case Manager ____________________________________
Agency/Provider/Service(s) ____________________________________________________________________________________
___________________________________________________________________________________________________________
Service Progress/Failure(s) _____________________________________________________________________________________
___________________________________________________________________________________________________________
Previously Hospitalized:  Yes  No  Unknown        Multiple Hospitalizations:  Yes x_____  No     Unknown
Last psychiatric hospitalization
Facility _______________________________________Date Admitted ______________Date Dismissed _____________ AMA
History in Corrections system and/or as juvenile offender:  Yes  No  Unknown Charges Pending:  Yes  No  Unknown
Determined by court to be:  CINC     JO  N/A        Explain ___________________________________________________
___________________________________________________________________________________________________________
Placement History: ___________________________________________________________________________________________
___________________________________________________________________________________________________________
 Detention x____  Foster Care x____  Level IV x____  Level V x____  Level VI x ____  PRTF x____  YRC x____
Name of School _______________________________________________Highest Grade Completed __________________________
 Regular ED          BD    LD    EMH      Current IEP   Alternative School    Pursuing GED    Not Attending
VII. CLINICAL SUMMARY AND DIAGNOSTIC IMPRESSIONS
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
            DIAGNOSTIC CODE                             DIAGNOSIS                                          PRIMARY
AXIS I :    __________________      ________________________________________________________________________ ____
            __________________      ________________________________________________________________________ ____
            __________________      ________________________________________________________________________ ____
            __________________      ________________________________________________________________________ ____
            __________________      ________________________________________________________________________ ____
AXIS II : __________________        ________________________________________________________________________ ____
            __________________      ________________________________________________________________________ ____
AXIS III : __________________________________________________________________________________________________
AXIS IV: __________________________________________________________________________________________________
AXIS V: CURRENT GAF: _________________________________ HIGHEST GAF PAST YEAR:________________________

MEETS CRITERIA FOR:  SED              SPMI     UNKNOWN          N/A



                                                        PAGE 4

Revised March 2007
COMPLETE FOR MEDICAID INPATIENT PSYCHIATRIC                                             Name __________________________________
VIII. INPATIENT CRITERIA
Level 1, Independent: Criteria which, in and of themselves, MAY constitute justification for admission.
 1. Suicide attempt, threats, gestures indicating potential danger to self.
 2. Homicidal threats or other assaultive behavior indicating potential danger to others.
 3. Extreme acting out behavior indicating danger or potential danger to property.
 4. Self-care failure indicating an inability to manage daily basic needs that may cause self-injury.

Level 2, Dependent: Clinical characteristics of psychiatric disorders, any of which in combination with at least ONE
         Level 3 criterion, MAY constitute justification for admission.
 5. Clinical depression.
 6. Intense anxiety or panic that may cause injury to self or others.
 7. Loss of reality testing with bizarre thought processes such as paranoia, ideas of reference, etc.
 8. Impaired memory, orientation, judgment, incoherence or confusion.
 9. Impaired thinking and/or affect accompanied by auditory or visual hallucinations.
 10. Mania or Hypomania.
 11. Mutism or catatonia.
 12. Somatoform disorders.
 13. Severe eating disorders such as bulimia or anorexia.
 14. Severely impaired social, familial, academic, or occupational functioning, which may include excessive use of substances.
 15. Severe maladaptive or destructive behaviors in school, home or placement, which may include excessive use of substances.
 16. Extremely impulsive and demonstrates limited ability to delay gratification.

Level 3, Contingent: Acute-care program needs which MAY justify psychiatric hospital admission.
 17. Need for medication evaluation or adjustment under close medical observation.
 18. Need for 24-hour structured environment due to inability to maintain treatment goals or stabilize in less
         intensive levels of care.
 19. Need for continuous secure setting with skilled observation and supervision.
 20. Need for 24-hour structured therapeutic milieu to implement treatment plan.

DISPOSITION/REIMBURSEMENT AUTHORIZATION
   (A.) Meets inpatient criteria; Hospitalization recommended.
         Admitted/transferred/referred to hospital ______________________________________________Admission Date ________________
Treatment Expectations/Preliminary Discharge Plan _________________________________________________________________
____________________________________________________________________________________________________________
   (B.) Alternative community services plan recommended in lieu of hospitalization, copy given to legally responsible individual.
   (C.) Does not meet inpatient criteria. Alternative community services plan recommended, copy given to legally responsible individual.
Comments: _____________________________________________________________________________________________
__________________________________________________________________________________________________________
IX. TIME DOCUMENTATION SUMMARY (Do not include travel time)
Contact /Activity            Amount of Time
 Chart Review:                        __________________                    I certify that local community resources have been
                                                                             investigated and/or consulted to determine whether or not
 Paperwork:                           __________________                    any of them can furnish appropriate and necessary care. I
 Face-to-Face Interview:              __________________                    have seen this individual and have evaluated him/her and
                                                                             his/her situation. I have also considered alternate modes of
 Coordination of Admission:           __________________                    treatment. All community resources have been
 Collateral Contacts:                 __________________                    investigated, and are not available if hospitalization is
                                                                             recommended.
 Consultation/Team Meetings:          __________________

Total Time:                            _____ Hours _____ Minutes


_____________________________________________________________________                            _______________________________
Signature of Qualified Mental Health Professional designated as a member of MHC Screening Team    Date          Copies:   CMHC       (white)
                                                                                                                          Hospital   (yellow)
                                                               PAGE 5A                                                    Other      (blue)

Revised March 2007
COMPLETE FOR MENTAL HEALTH REFORM                                                       Name ____________________________________
X. SCREENING DISPOSITION
 Not in need of Inpatient psychiatric treatment.
 Alternative plan to State Hospital Admission and copy given to legally responsible individual.
 Recommended voluntary admission to __________________________________State Hospital.
 Recommended involuntary outpatient commitment to __________________________________.
 Recommended involuntary admission to ________________________________State Hospital in accordance with KSA Statutes.
  (Must meet criteria 1, 2, and 3, plus 4 and/or 5 below)
        1. Is suffering from a severe mental disorder to the extent that he/she needs involuntary care in a State Hospital.
        2. Lacks the capacity to make an informed decision concerning his/her need for treatment.
        3. Is not manifesting a primary diagnosis of antisocial personality disorder, chemical abuse/addiction, mental retardation,
                organic personality syndrome, or an organic mental disorder.

        4. Is likely, in the reasonably foreseeable future, to cause substantial physical injury or physical abuse to self or others or
                substantial damage to another’s property, as evidenced by behavior causing, attempting, or threatening such injury,
                abuse or damage; OR

        5. Is substantially unable, except for a reason of indigence, to provide for any of his/her basic needs, such as food,
                clothing, shelter, health, or safety, causing a substantial deterioration of the person’s ability to function with current
                level of support, care or structure.

         Please note For children under 18, admission to a state hospital must be by
                          1.)      Voluntary application for a child age 14 or over.
                          2.)      Voluntary application by a parent.
                          3.)      Involuntary civil commitment if the child has a legal guardian, or is in SRS/state custody.
                          4.)      Involuntary civil commitment.

Treatment Expectations/Preliminary Discharge Plan _________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Comments:________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
XI. TIME DOCUMENTATION SUMMARY (Do not include travel time)
Contact /Activity            Amount of Time
 Chart Review:                        __________________                    I certify that local community resources have been
                                                                             investigated and/or consulted to determine whether or not
 Paperwork:                           __________________                    any of them can furnish appropriate and necessary care. I
 Face-to-Face Interview:              __________________                    have seen this individual and have evaluated him/her and
                                                                             his/her situation. I have also considered alternate modes of
 Coordination of Admission:           __________________                    treatment. All community resources have been
 Collateral Contacts:                 __________________                    investigated, and are not available if hospitalization is
                                                                             recommended.
 Consultation/Team Meetings:          __________________

Total Time:                            _____ Hours _____ Minutes



_____________________________________________________________________                            _______________________________
Signature of Qualified Mental Health Professional designated as a member of MHC Screening Team    Date
                                                                                                                Copies:   CMHC       (white)
                                                                    PAGE 5B                                               Hospital   (yellow)
                                                                                                                          Other      (blue)

Revised March 2007
                                                                                             Name __________________________________

COMPLETE FOR PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF)
XII. ADMISSION CRITERIA
Level 1, Diagnostic Criteria (both required)
 1. Axis I diagnosis that is psychiatric in nature and not solely due to MR/DD and/or substance abuse.
      If sole diagnosis of Substance abuse, refer youth to Prepaid Inpatient Health Plan (PIHP)
 2. Less restrictive treatment is not considered to be adequate. Psychiatric Residential Treatment Services can reasonably be
      expected to improve the youth’s condition or prevent further regression so that those services will no longer be needed.

Level 2, Chronic Safety Concerns (at least one required)                 (if acute safety concerns, complete page 5A)
 3. Suicide attempt, threats, gestures indicating potential danger to self.
 4. Homicidal threats or other assaultive behavior indicating potential danger to others.
 5. Self-care failure indicating an inability to care for own physical health and safety which creates a danger to own life.

Level 3, Functional Impairment (at least one required)
 6. Severely impaired social, familial, academic, or occupational functioning, which may include excessive use of substances.
 7. Severe maladaptive or destructive behaviors in school, home or placement, which may include excessive use of substances.
 8. Extremely impulsive and demonstrates limited ability to delay gratification resulting in unsafe consequences.
 9. Sexual acting-out that is harmful to self or others, and /or age inappropriate.
 10. History of running away which renders youth/others at risk.

Level 4, Contingent: need for continual support (at least one required)
 11. Need for medication monitoring or adjustment under close medical observation.
 12. Need for 24-hour structured environment due to inability to maintain treatment goals or stabilize in less intensive levels of care.
 13. Need for a setting with continuous skilled observation and supervision.

DISPOSITION/REIMBURSEMENT AUTHORIZATION
 (A.) Meets psychiatric residential treatment criteria; admission recommended.
         Admitted/transferred/referred to facility _____________________________________________ Admission Date ________________
Risk factors associated with admission to PRFT: __________________________________________________________________
Recommended Treatment Goals/Preliminary Discharge Plan __________________________________________________________
____________________________________________________________________________________________________________
    (B.) Alternative community services plan recommended in lieu of admission, copy given to legally responsible individual.
    (C.) Does not meet admission criteria. Alternative community services plan recommended, copy given to legally responsible individual.
Comments: _______________________________________________________________________________________________


CMHC Contact Person (name/center/phone #): _________________________________________________________________
XIII. TIME DOCUMENTATION SUMMARY (Do not include travel time)
Contact /Activity        Amount of Time         I certify that:
 Chart Review:                       __________________
                                                                        I have seen this individual and have evaluated him/her and
 Paperwork:                          __________________               his/her situation including consulting with the legal guardian of the
 Face-to-Face Interview:             __________________               youth. I have reviewed the CBST plan which indicates that local
                                                                       community resources have been identified and determined
 Coordination of Admission:          __________________               inadequate to meet the immediate treatment needs of the youth at
 Collateral Contacts:                __________________               this time.
 Consultation/Team Meetings:         __________________                This is an Exception screen; therefore the CBST plan has not
                                                                       yet been completed. I have seen this individual and have evaluated
        Total Time:            _____ Hours _____ Minutes               him/her and his/her situation including consulting with the legal
                                                                       guardian of the youth A short length of stay is authorized pending
                                                                       complete certification of need indicated by the CBST plan.


___________________________________________________________                          __________________
Signature of QMHP/LMHP designated as a member of the Screening Team                   Date                     Copies: CMHC/LMHP       (white)
                                                                                                                       Facility        (yellow)
                                                                                                                       Other           (blue)
                                                             PAGE 5C
Revised March 2007
                                                                                Name __________________________________
ALTERNATIVE COMMUNITY SERVICES PLAN
Alternative plan will include the following existing community resources:

      Resource                        Date                 Time                  Provider/Facility
 Emergency services ______________________________________________________________________________________
       Crisis appointment _________________________________________________________________________________
       Crisis attendant care ________________________________________________________________________________
       Crisis case management ______________________________________________________________________________
       Telephone intervention _______________________________________________________________________________
 Crisis resolution ________________________________________________________________________________________
 Outpatient services ______________________________________________________________________________________
 Individual therapy _______________________________________________________________________________________
 Family therapy _________________________________________________________________________________________
 In home family therapy __________________________________________________________________________________
 Case management services ________________________________________________________________________________
 Attendant care __________________________________________________________________________________________
 Respite care ___________________________________________________________________________________________
 Day treatment services ___________________________________________________________________________________
 Supportive educational/vocational program ___________________________________________________________________
 Outpatient testing/evaluation _______________________________________________________________________________
 Residential group home __________________________________________________________________________________
 Therapeutic foster care ___________________________________________________________________________________
 Nursing facility/mental health bed __________________________________________________________________________
 Outpatient substance abuse services _________________________________________________________________________
 Social detox ___________________________________________________________________________________________
 Inpatient substance abuse unit ______________________________________________________________________________
 Local/area inpatient psychiatric unit _________________________________________________________________________
 Immediate medical evaluation _____________________________________________________________________________
 Other _________________________________________________________________________________________________
     Immediate medication evaluation _______________________________________________________________________
     Refer for co-occurring disorder evaluation     MH/DD        MH/Substance abuse
Community/Safety Plan: Specify plan for involving natural or other support systems. Include provider address/phone #s.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Signature below indicates that I have reviewed and received a copy of this plan.

 ____________________________________________________________________________________                   __________________
Consumer/Legally Responsible Individual                                                                 Date

__________________________________           ___________      ____________________________________     __________________
QMHP/LMHP                                    Date             Collateral                               Date

                                                                                            Copies:   CMHC/LMHP           (white)
                                                                                                      Hospital/Facility   (yellow)
                                                                                                      Other               (blue)
Revised March 2007

				
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