Client Episode Summary

SANTA BARBARA COUNTY ALCOHOL, DRUG AND MENTAL HEALTH SERVICES

Client Episode Summary

Confidential Patient Information See Welfare & Institutions Code 5328

EPISODE OPENING EPISODE UPDATE EPISODE ANNUAL EPISODE CLOSING

Date: Date: Date:

(At Update)
Client Address:
Street, City, State, Zip
Client Phone: Home: Work: Cell:
(At Opening)
Referred From: 0001 - Self0002 - Family0003 - Friends0004 - Employer0005 - Other0006 - County Resident0010 - State Hospital (MH)0011 - State Hospital (DD)0012 - Other Psychiatric Hospital0013 - Psychiatric SNF0014 - Alternative to Hospitalization0015 - CRTS Program/Crisis0017 - Jail0020 - Acute Day Treatment0021 - Habilitative Day Treatment0030 - Emergency Psychiatric0031 - Suicide & Crisis0032 - Outpatient Clinic0033 - Private Mental Health Practice0037 - Case Management0038 - Homeless Program0052 PHF Police0090 Mental Health Administration 0040 - Medical Inpatient0041 - Medical Outpatient0042 - Convalescent Hospital0043 - Department Social Service0044 - Criminal Justice0045 - Drug Abuse Program0046 - Alcohol Abuse Program0047 - School/College0048 - Vocational Rehabilitation Program0049 - Veterans Administration0050 - Clergy or Religious Organization0051 - Other Human Services Code
Admission Hour Research Item Team
(At Opening, At Update, or At Closing)
Legal Status: W51500 - 72 Hour HoldW52500 - First 14 Day HoldW52600 - Second 14 Day HoldW52700 - Thirty Day Ext. for Grave DisabilityW53000 - 180 Day Post CertificationW53500 - Temporary ConservatorshipW53520 - Temporary Conservatorship (30 Days)W53521 - Temp. Conservatorship ExtensionW53550 - Permanent ConservatorshipW53551 - Permanent Conservatorship ExtensionW60000 - VoluntaryW65000 - Judicial Commitment DDW65500 Commitment of Minor DD EvaluationW99998 - Other Involuntary CivilW55850 - 72 Hour Hold for MinorP00470 - Charges/Conviction PendingP10260 - Not Guilty By Reason of InsanityP13680 - Incompetent to Stand TrialP13700 - Incompetent to Stand Trial (MH)P13720 - Cont of Tx to Maint Comp to Stand TrialP26840 - Transfer Correction FacilityP99997 - Sexual PsychopathyP99998 - Other Involuntary CriminalU99999 - Unknown Trauma: Y-YesN-NoU-Unknown
Legal Consent: A - Temporary ConservatorshipB - Lanterman-Petris-ShortC - MurphyD - ProbateE - PC 2974F - Representative Payee w/out ConservatorshipG - Juvenile Crt, Dependent of CrtH - Juvenile Crt, Ward Status OffI - Juvenile Crt, Ward Juv OffendJ - Not ApplicableU - Unknown
Diagnoses:
Axis I: Axis II: Axis III:
Primary Secondary Primary Secondary
Axis IV: A - Problems with primary support groupB - Problems related to social environmentC - Educational problemsD - Occupational problemsE - Housing problemsF - Economic problemsG - Problems with access to hlth care srvcsH - Problems related to interaction w/legal systemI - Other psychosocial & environmental problemsJ - Unknown / Not available
Axis V Current: Past Yr:
Alternate Diagnoses:
Axis I: Axis II: Axis III:
Secondary Secondary Axis III:
Substance Abuse/Dependence Diagnoses:
Issue: Y-YesN-NoU-Unknown Diagnosis:
Clinician(Case Worker) #
Physician: #
Assessor: #
Source of Income 0 - Not Collected1 - None2 - Earned Through Employment4 - Retirement5 - General or Public Assistance6 - Other(VA Benefits,Rent,Interest Div,Child Sup)7 - Unknown3 - Disability
Living Situation 05 - Foster Family Home06 - Single Room (Hotel, Motel, Rooming House)07 - Group Quarters(dorm,barracks,mig camp,etc)08 - Group Home09 - CRTS/Crisis Stabilzation - Long Term or Trans10 - Satelite Housing11 - Alternatives to Hospitalization (6 beds or <)12 - Alternatives to Hospitalization (7 beds or <)13 - House or Apartment14 - House or Apt w/support15 - House or Apt w/supervision16 - Supported Housing22 - Residential Treatment Center23 - Community Treatment Center24 - Adult Residential/Social Rehabilitation31 - State Hospital32 - VA Hospital33 - SNF/ICF/IMD, for Psychaitric Reasons34 - SNF/ICF/IMD, for Physical Health Reasons35 - General Hospital36 - Mental Health Rehabilitation Center37 - PHF/Inpatient Psych 40 - Drug Abuse Facility41 - Alcohol Abuse Facility42 - Justice Related50 - Temporary Arrangement51 - Homeless, No Identifiable County Residence52 - Homeless, In Transit98 - Other99 - Unknown
Employment Status 01 - Competitive Job Market, 35 Hrs or > Per Week02 - Competitive Job Market, < 20 Hrs Per Week03 Competitive Job Market, 20 - 30 Hrs Per Week04 - Full Time Homemaker Responsibilities05 - Rehabilitative Work, 35 Hrs or > Per Week06 Rehabilitative Work, < 20 Hrs Per Week07 - Rehabilitative Work, 20 - 30 Hrs Per Week08 - School, Full Time09 - Job Training, Full Time10 - Part Time School/Job Training11 - Volunteer Work12 - Unemployed, Actively Seeking Work13 - Unemployed, Not Actively Seeking Work14 - Retired15 - Not in the Labor Force16 - Unknown17 Resident/Inmate
(At Closing)
Referred To: (At Closing) 0001 - Self0002 - Family0003 - Friends0004 - Employer0005 - Other0006 - County Resident0010 - State Hospital (MH)0011 - State Hospital (DD)0012 - Other Psychiatric Hospital0013 - Psychiatric SNF0014 - Alternative to Hospitalization0015 - CRTS Program/Crisis0017 - Jail0020 - Acute Day Treatment0021 - Habilitative Day Treatment0030 - Emergency Psychiatric0031 - Suicide & Crisis0032 - Outpatient Clinic0033 - Private Mental Health Practice0037 - Case Management0038 - Homeless Program 0040 - Medical Inpatient0041 - Medical Outpatient0042 - Convalescent Hospital0043 - Department Social Service0044 - Criminal Justice0045 - Drug Abuse Program0046 - Alcohol Abuse Program0047 - School/College0048 - Vocational Rehabilitation Program0049 - Veterans Administration0050 - Clergy or Religious Organization0051 - Other Human Services Code
Referred To: (At Closing) 0001 - Self0002 - Family0003 - Friends0004 - Employer0005 - Other0006 - County Resident0010 - State Hospital (MH)0011 - State Hospital (DD)0012 - Other Psychiatric Hospital0013 - Psychiatric SNF0014 - Alternative to Hospitalization0015 - CRTS Program/Crisis0017 - Jail0020 - Acute Day Treatment0021 - Habilitative Day Treatment0030 - Emergency Psychiatric0031 - Suicide & Crisis0032 - Outpatient Clinic0033 - Private Mental Health Practice0037 - Case Management0038 - Homeless Program 0040 - Medical Inpatient0041 - Medical Outpatient0042 - Convalescent Hospital0043 - Department Social Service0044 - Criminal Justice0045 - Drug Abuse Program0046 - Alcohol Abuse Program0047 - School/College0048 - Vocational Rehabilitation Program0049 - Veterans Administration0050 - Clergy or Religious Organization0051 - Other Human Services Code
Reason for Discharge (At Closing) 1 - Mutual Greement/Treatment Goals Reached2 - Mutual Agreement/Tx Goals Partially Reached3 - Mutual Agreement/Tx Goals Not Reached5 - Client Withdrew:AWOL,AMA No Improvement6 - Client Died7 - Client Moved Out of Service Area8 - Client Discharged/Program Unilateral Decision9 - Client Incarcerated10 - Discharge/Administrative Reasons11 - Other
Completed By: Date:
Service Provider RU: CC: RU 62579 CSOC / CC: RU 62479 NON CSOC
/ Client ID#: / Client Name (Last, First, MI):

Patient Rep Init CES Support Staff Init File Init

Fields required for Annual update