MH/AODA FS Instructions Module 6 - Risk Factors


6.1 Self-Injurious Behaviors
6.2 Substance Use
6.3 Trauma/Abuse Question
6.4 Housing Instability
6.5 Intensity of Treatment or Functional Severity
6.6 Interdivisional Agreement 1.67
6.7 Current COP Level 3 Funding

Check all that apply or have applied.

6.1 Self-Injurious Behaviors

Includes cutting, burning, pica, polydipsia, head-banging. Does not include suicide attempts.

  • "Pica" is eating inedible objects such as metal or coins.
  •  "Polydipsia" is drinking excessive amounts of water, large amounts of which can be fatal.

Check this for applicant who:

  • Cuts him or herself.
  • Has mental illness and developmental disability and has to be monitored almost constantly to prevent them from drinking huge amounts of water (from which they have almost died in the past).

Do NOT check this for applicant who:

  • Engages in prostitution and/or other high-risk activities.
  • Has unhealthy habits such as smoking, drinking, or misusing over-the-counter meds.
  • Gets many body piercings and/or tattoos.

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6.2 Substance Use

NOTE: On the MH/AODA FS, substance use does NOT include tobacco or caffeine.

Outcomes of Substance Use (Part 1):

  • No use or low risk use in 12 months
  • In past 12 months, substance use has involved risks but it is not clear that negative consequences have occurred.
  • In past 12 months, person has experienced negative consequences in legal (including OWI), vocational, financial, relational, or health domains that are linked to substance use.

Most of the FS uses expected frequency of help needed from others. This substance use question instead asks about the outcomes-the consequences-of substance use. With just a few questions it's quite easy to categorize alcohol use in one of these four categories:

  •  "No use or Low Risk" Drinking
  •  "At-risk" or "Hazardous" Drinking
  •  "Harmful" or "Problem" Drinking
  • Dependency

(Most AODA professionals consider any illegal drug use to be inherently risky or harmful because of legal risks. Some argue that occasional use of some illegal drugs can be low risk.)

Hazardous or harmful drinking can consider the amount consumed, by these federal guidelines:

Recommended Alcohol Limits
(from US Dept. of Health & Human Services)
Number of Standard Drinks

Under Age 65

Under Age 65

Over Age 65
Over Age 65
While Pregnant
Per Occasion 4 3 2 1 0

Per Week

14 9 9 6 0


Many people do not recognize that their AOD use creates any risks or problems. That's okay. The question asks for "problems linked to substance use"; some links are objectively evident even if the applicant doesn't see the link. To recognize such links is not to blame, judge, or label people; it is to help people. (The first stage of treatment is forming an empathic relationship and helping the person see the links.) In the meantime, for purposes of this FS, consumer advocacy is better served by screeners indicating apparent AOD problems or risks, regardless of whether the consumer recognizes them. This is not just screener opinion, but is based on evidence and expertise. Evidence can include scientifically proven links, for example, between alcohol and depression, insomnia, accidents, falls, stomachaches (gastritis, esophagitis), liver disease, or problems managing diabetes or seizures or other health conditions. Some problems--in relationships, jobs, or finances-may be less clearly linked to AOD use; see examples below.


Check this box for person who:

  • Does not drink alcohol or use recreational drugs, and uses prescription drugs only as prescribed.
  • Drinks less than recommended limits and has no health conditions or medications creating risks or problems even with low to moderate alcohol intake.
  • Has been abstinent for the past 12 months (If any use occurred, check a box below).


Check this box for person who:

  • Drinks more than recommended limits but has not had negative consequences, (yet)
  • Drinks less than recommended limits but has health conditions or medications indicating that person should not drink at all or as much.
  • Has driven drunk but hasn't been caught doing so.

IN PAST 12 MONTHS, PERSON HAS EXPERIENCED NEGATIVE CONSEQUENCES in legal (including OWI), financial, family, relational, or health domains that are linked to substance use.

Check this box for person who:

  • Has diagnosis of AOD dependence and continues to use.
  • Has sign(s) of dependence--cannot control use, cannot go long without using, has withdrawal symptoms if doesn't use, and/or continues to use despite negative consequences.
  • Experienced negative outcomes 11 months ago and has been abstinent since.
  • Has had health problems worsened by alcohol or drug use (or has been advised to quit or reduce use and hasn't).
  • Has been charged with OUI.
  • Was arrested, ED'd, or taken to detox or ER after AOD use.
  • Has had any of the following after AOD use: Violence (victim or perpetrator), abuse (victim or perpetrator), child neglect or abuse, injuries, car accident, fall.
  • Does not recognize (or denies) link between problems and AOD use, but evidence indicates link is probable.

    •  "My wife said she left me because of my drinking, but she's crazy, I don't' drink too much."
    • "My doctor told me to quit because of my liver, but I can handle it."
    • Screener asks, "What did they say about why they fired you?" Reply: "They said I was late to work too many mornings." Screener: "Could that be from all that partying you do during the week?" Absent other reason for tardiness, a link is likely even if person doesn't see it.

Additional Outcomes of Substance Use Questions (Part 2)

The following questions have been added as screening items that will identify additional need for further substance use screening, assessment and treatment referral. The five questions have been adapted for the screen from the extensively researched Global Appraisal of Individual Needs (GAIN) Short Screener with permission from Chestnut Health Services.

Please ask the person the questions directly and record their answer. If one of their answers seems to be different from than the collateral information available, please ask additional clarifying questions.

The responses to the questions require that a time frame be chosen. The definitions are as follows:

Past Month: Any one single incident or more in the past 30 days
2-12 Months: Any one single incident or more that occurred 60 days to 12 months ago
1 year or more ago: Any one single incident or more that occurred 12 months or longer ago, even if that incident was 20 years ago.

If there is a response to any question where there is a choice between two or more time frames record the time frame that is the most recent.

These questions are only screening questions to identify a potential issue and do not represent the information needed in a Substance Use and Addiction assessment.

Used Alcohol and Drugs Weekly:
This question is designed to determine a frequency of substance use, not quantity of weekly use or the seriousness or dangerousness of use.

If the person asks," Does drinking a glass of wine count?" Explain that this is only a frequency question and if they are experiencing no other negative consequences from their usage the question will not by itself forward them to a referral or label them in any way.

Check for applicant who:

  • Uses marijuana daily or a shot of whiskey at night before bed (past or present).
  • Has a glass of wine with dinner (past or present)
  • Drinks or uses only on the weekends (past or present)

DO NOT check this for applicant who:

  • Has never or rarely consumes alcohol or drugs
  • Uses prescription medication as prescribed
  • Rarely consumes alcohol but smokes cigarettes daily

Spent a lot of time either getting alcohol or drugs, using alcohol or drugs or feeling the effects of alcohol or drugs (high or sick).
This question is designed to receive a response that demonstrates the level of preoccupation the person experiences regarding their use of alcohol and drugs.

Check this for applicant who:

  • Spends a lot of time thinking about getting alcohol or drugs.
  • Uses alcohol or drugs while knowing that using in combination with other health issues will make them sick.
  • States that their usage makes the other psychotropic medication work better.
  • Uses prescription drugs on a different frequency than prescribed.

DO NOT check this for applicant who:

  • Uses prescription medication as prescribed
  • Has one glass of wine with dinner

Kept using alcohol or drugs even though it was causing social problems, leading to fights, or getting into trouble with other people.
This question is designed to measure the negative social and physical aggressive consequences that some people experience when using drugs or alcohol.

  • Refer to section 4.9 for a definition of Social or Interpersonal skills
  • Refer to section 5.6 for definitions of Physical Aggression
  • Refer to section 5.7 for definitions of Physical aggression has resulted in the injured person being hospitalized
  • Refer to section 5.8 for definitions regarding Involvement with the Corrections systems

Check this for applicant who:

  • Continues to drink even when his wife says she is leaving if he does not stop drinking.
  • Has gotten a DWI or OWI or any drug related charges.
  • Has gotten into fights while using drugs or alcohol.

DO NOT check this for applicant who:

  • Drinks socially and it does not lead to arguments with others, loss of friendships, or legal repercussions.

Use of alcohol or drugs caused applicant to give up, reduce or have problems at important activities at work, school, home or social events.
This question is designed to measure the negative impacts of the person's major life responsibilities solely related to the use of substances.

  • Refer to section 4.9 for a definition of social and interpersonal skills
  • A comprehensive list of home issues can be found in the definitions from 4.7 to 4.16 under Specific Community living skills

Check this for applicant who:

  • Does not have enough money to pay the rent due to the high cost of alcohol and substances.
  • Has had negative consequences in the school system for possession or use of substances in school.
  • Has experienced decreased capacity to perform job responsibilities, loss of job, demotion or reduction of hours due to substance use.

DO NOT check this for applicant who:

  • Drinks on the weekends but always follows through with work or school responsibilities (showing up on time, completing tasks as assigned, etc.).
  • Has used marijuana but it has not lead to withdrawal from social situations or apathy at work.

Had withdrawal problems for alcohol or drugs like shaking hands, throwing up, having trouble sitting still or sleeping or used any alcohol or drugs to stop being sick or avoid withdrawal problems
This question is designed to measure the negative physical effects caused by using too much of a substance.

Check this for applicant who:

  • Experiences blackouts
  • Has been hospitalized due to the use of substances or has had detoxification treatment episodes.
  • Has trouble sitting still due to over use of amphetamines.
  • Has trouble sleeping due to either the use of alcohol or other sedatives.
  • Has to have a drink first thing in the morning (the morning eye opener) or other continued use to avoid withdrawal symptoms.

DO NOT check this for applicant who:

  • Uses alcohol or drugs and has never experienced a negative physical response.

If the eligibility results indicate a "Yes" for the GAIN Assessment it is recommended that the applicant receive further AODA assessment by a qualified substance abuse professional.

Substance Use Treatment (not detox)
This means "formal" substance use treatment by professional "AODA" (alcohol or other drug abuse) counselor(s). It can include individual or group therapy.

Substance Use Peer Group Support (e.g., aftercare group, AA, NA)
Includes participation in any peer support groups, including on-line ones. This does not include groups run by professional AODA counselors.

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6.3 Trauma/Abuse Question

We know that many people have experienced physical, emotional, or sexual abuse or neglect as an adult or in childhood. Trauma and its aftermath are under-recognized realities in many people's lives. Wisconsin's State Trauma Workgroup (2000-2001) suggested more screening to raise awareness and support advocacy efforts.

This question is optional; it can be answered Unknown. It is obviously a sensitive topic, and many people will not want to answer it. Be very clear that they do not have to answer it. The question, "Would you say that you have?" is purposefully equivocal so that it can be answered, "No, I have not experienced abuse" or "No, I would not say," i.e., "No, I will not divulge that information for the functional screen."

Screeners should always preface this question with a statement that the consumer does not have to answer it. You could say something like this:

  • "The state and advocates are concerned that trauma and abuse are usually overlooked, so the functional screen includes a question on it. You do not have to answer it."

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6.4 Housing Instability

If "Yes," check all boxes that apply to indicate type of housing instability within the past 12 months:

  • Currently homeless (on the street or no permanent address).
    • Includes staying at homeless shelters, living in a car or tent, or "crashing" at friends' or relatives' houses for short periods (days or weeks).
  • Homeless less than half the time in the past year.
  • Homeless 50 percent of the time or more within the past year.
  • Has been evicted two or more times in the past year (by landlords, family, friends, etc.)

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6.5 Intensity of Treatment or Functional Severity

The current CSP regulations at DHS 63.08 (1) address criteria for admission to a CSP. The rule indicates that admission to a CSP shall be limited to an individual who has chronic mental illness which by history or prognosis requires repeated acute treatment or prolonged periods of institutional care and who exhibits persistent disability or impairment in major areas of community living as evidenced by either:

  1. Specific diagnoses (e.g., schizophrenia), a significant risk of either continuing in a pattern of institutionalization or living in a severely dysfunctional way if CSP services are not provided, and impairment in one or more of the listed functional areas; or
  2. Another diagnosis listed in the DSM-III-R other than a diagnosis listed in par. (a) that has required consistent and extensive efforts beyond basic outpatient clinical standards of practice to treat the client, such as use of special structured housing or home visiting when the client does not come in for appointments, for a person who exhibits persistent dangerousness to self or others, a significant risk of either continuing in a pattern of institutionalization or living in a severely dysfunctional way if CSP services are not provided, and impairment in one or more areas listed under sub. (2).

If the person has a history of dangerousness to self or others preceding the initiation of the consistent and extensive treatment efforts (within three months), then it may be reasonable to assume that without these treatment efforts that the person may have continued to exhibit behavior that posed a danger to self or others. If there is appropriate documentation, then this item is met.

Example 1. Person A has a diagnosis of schizotypal personality disorder. Twenty years ago, he believed that his parents were spying on him for the FBI and had a plan to kill his parents, but was arrested before he could carry out the plan. He spent five years in a correctional facility and then moved to Wisconsin. He has not seen his family since then. Three years ago, he began to receive consistent and extensive treatment following a referral from public housing officials who were preparing to evict him due to nonpayment of rent and general lack of cleanliness of his apartment. This history does not satisfy the CSP admission criteria, but he may be appropriate for enrollment in a CCS program.

Example 2. Five years prior to the completion of the functional screen, Person B received a diagnosis of borderline personality disorder. After going out on a date, he told his date that he would commit suicide if she did not see him again. When he did not hear from her for one week, he did attempt suicide and was held under an emergency detention. Following the hospitalization, he began to receive consistent and extensive treatment from the county. He continues to have significant problems with interpersonal relationships, although he has not attempted or threatened to commit suicide in the past five years. If he has impairments in one or more of the listed areas, then this history is sufficient to indicate that he meets the CSP admission criteria. He may also meet the enrollment criteria for CCS and, if so, then he should have a choice between CSP and CCS.

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6.6 Interdivisional Agreement 1.67

Applies to individuals for whom a DHS/Division of Quality Assurance nursing home surveyor has issued a 1.67 administrative order to refer the individual to the county for nursing home discharge and alternative living arrangement (or other needed services).

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6.7 Current COP Level 3 Funding

Applies to individuals that are currently receiving COP Level 3 funding for serious and persistent mental illness. This does not apply if the person is receiving COP waiver or regular state COP funding for Level 1 or 2 due to a medical or physical condition. That person should receive a LTC FS.

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Last Revised: December 29, 2016