Co-Occurring Assessment Date: ___________________________ *Mental Health Screening Used: Nothing Mental Health Screen Form III Modified Mini Declined Medically or Clinically Inappropriate *Substance Abuse Screening Used: SSI Alcohol and Drugs CAGE- Adapted to Include Drugs Declined Medically or Clinically Inappropriate * Employment Status: Employed full time (in competitive employment) Paid but non-competitive work (work inside the Not in Labor Force: retired Employed part time (in competitive employment) clubhouse or treatment agency, mobile work crews Not in Labor Force: SSI SSDI Unemployed (looking for work in the past 30 days, or and consumer-run businesses) Not in Labor Force: Inmate of institution. on a layoff) Not in Labor Force: student enrolled in a school or Not in Labor Force: other reason Paid but non-competitive work (transitional job-training program Other employment programs) Not in Labor Force: homemaker Unknown *Highest Grade Completed: 1 9 16 2 10 17 3 11 18 4 12 19 5 13 20 6 14 21 7 15 Unknown 8 Persons Dependent on Income: 1 6 11 2 7 12 3 8 13 4 9 14 5 10 15 Minors Dependent on Income: 1 3 5 2 4
Co-Occurring Assessment Date: ___________________________ *Mental Health Screening Used: Nothing Mental Health Screen Form III Modified Mini Declined Medically or Clinically Inappropriate *Substance Abuse Screening Used: SSI Alcohol and Drugs CAGE- Adapted to Include Drugs Declined Medically or Clinically Inappropriate * Employment Status: Employed full time (in competitive employment) Employed part time (in competitive employment) Unemployed (looking for work in the past 30 days, or on a layoff) Paid but non-competitive work (transitional employment programs) Paid but non-competitive work (work inside the clubhouse or treatment agency, mobile work crews and consumer-run businesses) Not in Labor Force: student enrolled in a school or job-training program Not in Labor Force: homemaker Not in Labor Force: retired Not in Labor Force: SSI SSDI Not in Labor Force: Inmate of institution. Not in Labor Force: other reason Other Unknown *Highest Grade Completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Unknown Persons Dependent on Income: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Minors Dependent on Income: 1 2 3 4 5
CT_HMIS_Statewide_PATH_Family_Intake_Form_with_DDaP_-_7.2_1.docx