- 3.1 Introduction
- Basic Information
- 3.2 Screening Agency
- 3.3 Referral Date
- 3.4 Screen Type
- 3.5 Applicant Age for MH/AODA Screen
- 3.6 Name
- 3.7 Social Security Number
- 3.8 Date of Birth
- 3.9 County of Residence and County/Tribe of Responsibility
- 3.10 Transfer Information
- 3.11 Applicant's Street Address/City/State/Zip/Phone Number
- 3.12 Directions
- 3.13 Referral Source
- 3.14 Primary Source for Screen Information
- 3.15 Where Screen Interview Was Conducted
- Contact Information
- Living Situation
- Vocational Information
Demographic information collected for the functional screen does not determine eligibility for mental health services. After the initial screen testing, some demographic info may be used for resource and budget planning for state and county budgets.
"Other" boxes are available as answer choices to allow screeners to fill in answers that may not be provided in the initial functional screen. These will be used in screen revisions.
This is a read-only field that the application will fill in automatically. To transfer a screen to another agency because of enrollment, referral, or applicant's move to another county, the Transfer utility should be used.
Enter the date someone requested that a functional screen be done. If no one requested the functional screen or the original referral was made years ago, enter the date you start it.
Select one option from the drop down box. There are three screen type options:
- Screen type 01, Initial Screen - The first Mental Health/AODA Functional Screen completed for the applicant. If the consumer has been enrolled in CSP for years but this is their first MH/AODA FS, check Initial Screen for the Screen Type.
- Screen type 02, Annual Screen - After full implementation, annual recertification screens may be required to continue in MH/AODA programs, such as CCS.
- Screen type 03, Change of Condition - At any time when a applicant's physical, emotional or living condition changes significantly they may request and/or receive additional screenings. For the MH/AODA FS, a change in condition screen should be completed if a significant change occurs that is likely to last 6 months or more. For example, a 19 year old applicant with a current diagnosis of depression who begins to have hallucinations and the psychiatrist changes the diagnosis.
"Applicant" is the consumer you are screening.
The minimum age for programs connected to the MH/AODA FS is 18 years of age. However, to allow for advance planning for youth entering adult mental health services, the MH/AODA FS can be completed for individuals as young as 16. Otherwise, teens and children's eligibility for Comprehensive Community Supports (CCS) will be determined through the Children's Long-Term Support Functional Screen.
- Middle name is optional; middle initial is sufficient.
- Last Name: If the applicant has a title such as "Jr." or "IV," list this in the Last Name box, following the last name.
Key in the 9 numbers with dashes (###-##-####). This is a required field.
Enter the applicant's date of birth in MM/DD/YYYY, as in 01/01/2002. The "/" must be entered between the field elements. Functional screen programming will not allow dates to be entered that make the applicant more than 150 or less than 16 years old. The date of birth must be earlier than the screen begin date.
In most cases these will be the same. In a few instances, persons may live in one county but another county/tribe is responsible for services, costs, and/or protective services. For the purposes of screening, residency is physical presence or the intent to reside. The functional screen program will automatically enter ("default") county of responsibility to be the same as county of residence. This can be overridden if different counties are involved.
The functional screen is a secure database, and only a few individuals have access to screen information. This section is a "transfer utility" that transfers access to an individual's MH/AODA FS content from the original screening agency to another agency of the applicant's choice (for example, a provider agency, or a new county if the applicant moves).
Include street number, street name, apartment number, city, and zip. Include telephone number if available. If there is a street address and a PO Box, enter street address and apartment information on line 1, PO Box on line 2, and use the PO Box ZIP Code.
For transient persons, enter the address they lived at the most in the last six months. If the person is homeless, write "homeless."
If the person is now in a hospital or other facility (nursing home, CBRF), that may or may not be their "permanent residence." If a person is now in a facility, but maintains their apartment in the community with the intention of returning to home in the next few weeks, the apartment (not the facility) would be the permanent residence.
The phone number fields are optional; you can leave them blank.
This is provided as an optional space for you to enter directions to the applicant's home.
- Check one box to indicate who referred the applicant to you for assistance.
- Leave blank if it does not apply, such as when you are testing the MH/AODA FS.
This question is meant as a quality assurance reminder that screeners must not take shortcuts and complete a screen by only talking with caregivers, staff, etc. If the applicant could participate in the screen, the applicant should participate in the screen interview. If the person is not the primary source of information, it is expected that in most cases other parts of the screen will indicate significant cognitive limitations. It will also be used in research to explore differences in MH/AODA FS depending on who provides the information.
"Primary" means the majority, over 50 percent. Please select the one source that most accurately reflect the primary source for screen info. In most cases, the primary source for screen information should be the consumer. Often, screeners will also need to have "collateral" (i.e., additional) contacts with family, residential staff, health care providers; but those are only additional, not "primary," contacts.
If an interpreter is used, the consumer (not the interpreter) is still the primary source of information.
- Check only one box. Select the place where the screen was conducted from the drop-down box.
- If you select "Other" please write a description, such as "school."
"Person's current residence" includes private homes, residential facilities, or nursing homes.
"Nursing home" includes ICFs-IID and FDDs. Select "nursing home" if the nursing home is not the applicant's primary residence (i.e. they have a permanent residence elsewhere).
"Temporary residence (non-institutional)" is intended for instances when a consumer is staying with family or friends temporarily, for instance to recuperate from an illness or surgery. It also includes temporary stays in residential facilities, such as respite in a CBRF. Do not select this if the person is in an institution such as hospital, IMD, or nursing home.
Check ALL that apply.
If Medicare is checked, enter the person's Medicare number, and check box to indicate Part A or B or Medicare Managed Care as applicable. (Note: Medicare Managed Care is a new form of voluntary HMO Medicare called "Medicare Plus Choice." You may see it written as "M + C.")
Private insurance includes employer-sponsored insurances (e.g., an HMO) available as a job benefit. BadgerCare and MAPP (Medical Assistance Purchase Plan, Wisconsin's Medicaid Buy-in) are forms of Medicaid. If the person is on BadgerCare or MAPP, enter this information under Medicaid with the number, and put a comment about this information in the Notes section.
Hispanic or Latino ethnicity is included in Wisconsin's functional screens to provide data for federal reporting, quality improvement and advocacy efforts. This is not a required field; however, we expect this field will be completed unless the individual objects. The content of this section follows federal standards.
Hispanic or Latino: A person of Mexican, Puerto Rican, Cuban, Central, South American, or other Spanish culture or origin, regardless of race.
Race is included in Wisconsin's functional screens to provide data for federal reporting, quality improvement and advocacy efforts. This is not a required field; however we expect this field to be completed unless the individual object. The content of this section follows federal standards.
For persons with mixed heritage please check all that apply.
Following are federal definitions:
- American Indian or Alaska Native: "American Indian and Alaska Native" refers to people having origins in any of the original people of North and South America (including Central America), and who maintain tribal affiliation or community attachment. It includes people who indicate their race or races as Rosebud Sioux, Chippewa, or Navajo.
- Asian or Pacific Islander: Refers to people having origins in any of the original peoples of the Far East, Southeast Asian, or the Indian subcontinent. It includes people who indicate their race or races as "Asian Indian," "Chinese," "Filipino," "Korean," "Japanese," "Vietnamese," or "Other Asian," or as Burmese, Hmong, Pakistani, or Thai.
- Black or African American: "Black or African American" refers to people having origins in any of the Black racial groups of Africa. It includes people who indicate their race as "Black," African American, Afro American, Nigerian, or Haitian.
- White: "White" refers to people having origins in any of the original peoples of Europe, the Middle East, or North Africa. It includes people who indicate their race as "White" or as Irish, German, Italian, Lebanese, Near Easterner, Arab, or Polish.
- Native Hawaiian or other Pacific Islander: "Native Hawaiian or other Pacific Islander" refers to people having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. It includes people who indicate their race or races as "Native Hawaiian," "Guamanian or Chamorro," "Samoan," or "Other Pacific Islander," or as Tahitian, Mariana Islander, or Chuukese.
Human service and health care providers are required by law to provide interpreters for individuals needing them. This information on the MH/AODA FS will help the state, counties, and stakeholders see the extent of such needs, and will also help programs better serve non-English speaking consumers and families.
- Leave this table blank if no interpreter is needed.
- Select the appropriate language if an interpreter is needed. If "Other," please write in the language needed.
Court orders are those issued by a judge. Police do an "emergency detention" and a 72-hour hold. This is followed by a "probable cause hearing" in which a judge can issue "court orders" for involuntary commitment to a psychiatric institution or for community-based treatment. The latter constitutes court-ordered treatment for the purposes of the MH/AODA FS.
"Negotiated settlements" are alternatives to court-ordered treatment that judges might use if the consumer voluntarily promises to accept treatment. The consumer may, for example, promise to take her psych meds as part of a negotiated settlement. If she refused to promise the judge this, the judge could impose court orders for her to take her meds.
Probation officers might impose conditions of probation, but they cannot issue court orders; only judges can.
For each individual, check the box to indicate if that person is the "Primary contact" for the applicant. In every case, the Middle Name is optional.
This table is optional. Leave it blank if the adult applicant does not have a "legal guardian of person."
If the person does have a legal guardian of person, provide the guardian's name, phone number, and address. This information may be needed to complete the screen, and/or to notify the guardian of the applicant's eligibility determination. This refers to guardian of person for the applicant (not whether the applicant is a guardian of someone else). This does not include guardians of estate or finances. (The need for help with money management is captured elsewhere on the functional screen.)
If the applicant is a minor, complete this field to indicate a parent's name and contact information. Enter a parent who has legal responsibilities for the child's medical decisions (a parent who would receive mail from Medicaid and the county). A second parent can be entered in the "Other relevant contact" field.
3.23 Activated Power of Attorney for Health Care Responsible for Making Decisions about Medical Care
This table is optional. Leave it blank if person does not have an activated Power of Attorney for Health Care (POAHC), also called a "durable power of attorney."
Some people may have a durable power of attorney for health care document drafted by their attorney that they think has been "active" from the time it was initially drawn up. However, such documents do not count as an "Activated POA for health care." Such a POAHC is "in force" when it is first filled out, but the consumer makes all her own decisions until she loses the ability to do so. The POAHC cannot make decisions for the person until after they are incapacitated. That is what is meant on the screen by "activated." A POAHC is "activated" only when the consumer has lost their capacity to make their own health care decisions. (Activation usually requires documentation by two physicians.)
This table is optional. Screeners do not have to complete it unless the individual is a "Primary Contact" or an important contact for the screener or future case manager to know. A spouse, family member, or case manager may be an important contact to indicate here, particularly if they participated in the screening interview with the applicant. However, this information is not necessary for others who are not important contacts. You do not have to record the name of every applicant's probation officer or ex-spouse, for example. You would only enter it here if they participated in the screen interview or only if the applicant agrees that they are important contacts. Complete this table only with the applicant's permission, and preserve confidentiality.
Check only one box. If you select "other," type an explanation in the "other" box. Most of the drop-down box menu options are self-explanatory. For further clarification:
- "Transitional housing" - Certified or licensed housing provided by human services agencies or corrections system (e.g., half-way house).
- CBRF = Community-based residential facility, also called "group homes."
- RCAC = Residential care apartment complex, also known as "assisted living."
- ICF-IID/FDD = Intermediate care facility for individuals with intellectual disabilities (formerly known as ICF-MR)/Facility serving people with developmental disabilities.
- IMD = Other institute for mental disease.
- Child caring institution = A specially licensed setting for minors with high needs.
- "No permanent residence" includes living on the street or in a shelter, living in a car, or "crashing" at friends' or relatives' houses for short periods (days or weeks).
If applicant lives with parents:
- For youth up to age 19 still living in their parent(s) home, check "Own home or apartment (alone or with someone)."
- For applicants age 19 or over still living in their parent's home, check "Someone else's home or apartment."
Check only one box. If you select "other," type an explanation in the "other" box.
This question asks precisely and only for the consumer's own stated preference. It will be used to see if MH consumers are living where they want to live and to track changes over time. This question is asking the person's informed preference. Record where the applicant would like to live - not where anyone else wants them to live, and not where you or others think is realistic. Screeners must take the time to explain the person's options. People cannot express a preference if the screener has not informed them of their options first.
It is well known that people often acquiesce to whatever they feel limited to or whatever they've been told. For example, people with developmental disabilities who live in institutions often think "group home" is the only option available to them. You must take the time to ask questions to help the person articulate her/his preferences. Some people like to live with others; others highly value having their own space. While the person's preference may be difficult to ascertain, screeners are to use their best interviewing skills to select the most accurate answer.
Screeners should select the answer that most accurately reflects what the person is saying. If a person is telling you that she wants "a place of my own," then you select the most accurate selection of "own home or apartment." Do NOT select "someone else's home or apartment" or an "RCAC" even if that is probably what the person will need. The purpose of this question is to record what the person says, not what the system will provide or what you think the person really needs.
If the applicant's preferred living situation is not listed, select "Other" and please type in what the "Other" is, for possible screen revisions in future.
Wisconsin is very committed to removing barriers to employment for people with disabilities or mental illness who want to work. This section gathers work-related information that will be helpful on county and statewide bases to help improve employment for people receiving MH services.
- Check only one box.
- "Full time" means 32 hours/week or more.
- "Competitive" means a paid job that the applicant had to apply for. Check this if the applicant went through customary job application processes and is paid minimum wage or more.
Sheltered Employment is non-competitive (i.e., the person does not have to apply for and compete for the job). Human service staff are present to assist participants not able to work at competitive paid jobs.
Retired: Do not check if person stopped work due to disabilities or mental illness, even if applicant prefers to use the term "retire."
Unemployed: Check this if person is not retired, is of working age, and is currently not working. Do NOT check if person is on medical leave from a job, as they are still "employed."
Unpaid work: homemaker, caregiver, volunteer, or student. Since only one box can be checked, you'll check this only if none of the above choices apply. This does no work in eligibility, but was added at stakeholders' requests to recognize unpaid labor.
INTEREST IN A JOB:
- Check only one box.
- Check "Interested in a job or a new job" for someone who is not working currently but wants a job or for a person who has a job but wants a different one.
- Check "Not interested in a job or a new job" for someone who is not interested in having a job or for a person who is employed and does not want to change jobs.
- Check "Wants to work, but is afraid of losing MA and SSA benefits" for someone who wants a paying job but does not have one because they are afraid of losing their benefits due to earning too much money.
NEEDS ASSISTANCE TO FIND WORK:
- Check "NA" if the person does not want a job or if the person is not interested in finding a new job.
- Check "Independent" if the person wants to find a job but does not need assistance to do so.
- Check "Needs Assistance" if the person needs help finding a job, such as looking through the Want Ads, completing an application, developing a resume, etc.
- Needs Assistance to Work:
Needs assistance to function at a job (includes showing up on time, dressing appropriately, performing expected tasks, and performing in cooperation with others), or for job related activities. (Does not include transportation, which is covered elsewhere.) "Assistance" includes monitoring supervision, reminding, coaching or direct service.
- Needs Assistance with Schooling
Check this for a person who needs help finding or applying for school or for someone who needs assistance to function at school. This includes registering for school, scheduling classes, showing up on time, performing in cooperation with others, etc. This does not include educational tutoring. For example, do not check this for an applicant who has a learning disability and needs educational support in reading comprehension.