Organization Name: Program Name: Date: Individual’s Name (First MI Last): Record #: DOB: Provider Number: Program Number: Sex: Male Female Date Last Treated: Education at Discharge (if education at admission was entered incorrectly, it must be updated in Management” online) “Client Highest Grade Completed No formal education 6th High School Diploma 1st 7th General Equivalency Diploma 2nd 8th Vocational Cert w/o Diploma/GED 3rd 9th Vocational Cert w/ Diploma/GED 4th 10th Some College No degree – 5th 11th Associates Degree Bachelors Degree Graduate Degree Employment Employment Status Not in Labor Force, Disabled Soc Srvcs Work Exp Program Employed FullTime-35+ hrs/wk Not in Labor Force, In Training Soc Srvcs Determined, Not Employed Part Time-<35 hrs/wk Not in Force, Inmate Employed/Able to Work Employed in Sheltered Workshop Not in Labor Force, Retired Soc Srvcs Determined, Unable to Work, Unemployed, In Treatment Not in Labor Force, Student Mandated Treatment Unemployed, Looking for Work Not in Labor Force, Other Not in Labor Force, Child Care Length of Employment at Discharge: 0-30 Days 31- 60 Days 61-90 Days 91-120 Days 121 + Days Individual’s of Residence Type of Residence CD Community Residence MH/OPWDD Community Residence Private Residence CD Supportive Living Other Group Residential Setting Homeless, Shelter Institution, Other (Jail/Hospital) Homeless, No Shelter Other Single Resident Occupancy Living Arrangements: Living Alone Living w/ Non-Related Persons Living with Spouse/Relatives Primary Payment Source (Select One) None Medicaid Pending Private Insurance Fee for – Self-Pay Medicare Service Medicaid DSS Congregate Care Private Insurance Managed – Medicaid Managed Care Department of Veterans Affairs Care Other: Mental Health Co-existing Psychiatric disorder Yes No Ever Treated for a mental illness problem Yes No Ever Hospitalized for mental illness Yes No Ever Hospitalized for 30 or more days for mental illness Yes No
Organization Name: Program Name: Date: Individual’s Name (First MI Last): Record #: DOB: Provider Number: Program Number: Sex: Male Female Date Last Treated: Education at Discharge (if education at admission was entered incorrectly, it must be updated in “Client Management” online) Highest Grade Completed No formal education 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th High School Diploma General Equivalency Diploma Vocational Cert w/o Diploma/GED Vocational Cert w/ Diploma/GED Some College – No degree Associates Degree Bachelors Degree Graduate Degree Employment Employment Status Employed FullTime-35+ hrs/wk Employed Part Time-<35 hrs/wk Employed in Sheltered Workshop Unemployed, In Treatment Unemployed, Looking for Work Not in Labor Force, Child Care Not in Labor Force, Disabled Not in Labor Force, In Training Not in Force, Inmate Not in Labor Force, Retired Not in Labor Force, Student Not in Labor Force, Other Soc Srvcs Work Exp Program Soc Srvcs Determined, Not Employed/Able to Work Soc Srvcs Determined, Unable to Work, Mandated Treatment Length of Employment at Discharge: 0-30 Days 31- 60 Days 61-90 Days 91-120 Days 121 + Days Individual’s of Residence Type of Residence Private Residence Homeless, Shelter Homeless, No Shelter Single Resident Occupancy CD Community Residence CD Supportive Living MH/OPWDD Community Residence Other Group Residential Setting Institution, Other (Jail/Hospital) Other Living Arrangements: Living Alone Living w/ Non-Related Persons Living with Spouse/Relatives Primary Payment Source (Select One) None Self-Pay Medicaid Medicaid Managed Care Medicaid Pending Medicare DSS Congregate Care Department of Veterans Affairs Private Insurance – Fee for Service Private Insurance – Managed Care Other: Mental Health Co-existing Psychiatric disorder Yes No Ever Treated for a mental illness problem Yes No Ever Hospitalized for mental illness Yes No Ever Hospitalized for 30 or more days for mental illness Yes No
NYSCRI-IAP%20Discharge-Part%20B.docx