Form F-11090 "Mental Health Day Treatment Functional Assessment" - Wisconsin

What Is Form F-11090?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2015;
  • The latest edition provided by the Wisconsin Department of Health Services;
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Download a fillable version of Form F-11090 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-11090 "Mental Health Day Treatment Functional Assessment" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
Wis. Admin. Code § DHS 107.13(4)
F-11090 (08/15)
FORWARDHEALTH
MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT
Instructions: Type or print clearly. Before completing this form, refer to the Mental Health Day Treatment Functional Assessment
Completion Instructions, F-11090A.
SECTION I — DEMOGRAPHIC AND MEMBER INFORMATION
1. Name — Member (Last, First, Middle Initial)
2. Member Identification Number
3. Date of Initial Assessment
4. Date of Reassessment
_________
5. Member has received
hours of day treatment since the initial assessment.
6. Referral Source
 Hospital
 Friend
 Self
Physician
 Family
 Agency
 Nursing Home
Other _________________________________
7. Name / Agency — Referral Source
8. Address — Referral Source (Street, City, State, ZIP Code)
 Yes
 No
9. Member presently hospitalized?
 Yes
 No
Member presently living in nursing home?
10. Name / Address — Facility (Street, City, State, ZIP Code)
11. Resident of Facility Since
Discharge Date
12. Usual Living Arrangement
Alone.
Household with spouse only.
Household with spouse and other relatives
Household with nonrelatives.
or with other relatives only.
Community-Based Residential Facility (CBRF).
Group quarters, other than a health-related facility.
Other (Specify) ___________________________________
13. Reason for Referral
14. Eligibility Decision Criteria
15. Current Services Being Received (Medical and
 Yes  No
a.
Substance Abuse Currently
Nonmedical)
Intellectual Disability Primary Diagnosis  Yes  No
b.
c.
Primary Diagnosis Code
Secondary and Other Code
d.
Scores, Level of Functioning (LOF)
(Sections II-IV) Total
e.
Likelihood of Benefit (Section V)
%
f.
Course of Functioning (Section V)
g.
Risk of Hospitalization (Section V)
%
16. SIGNATURE — Assessor
17. Discipline
18. Date Signed
19. SIGNATURE — Day Treatment Program Director
20. Date Signed
Continued
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
Wis. Admin. Code § DHS 107.13(4)
F-11090 (08/15)
FORWARDHEALTH
MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT
Instructions: Type or print clearly. Before completing this form, refer to the Mental Health Day Treatment Functional Assessment
Completion Instructions, F-11090A.
SECTION I — DEMOGRAPHIC AND MEMBER INFORMATION
1. Name — Member (Last, First, Middle Initial)
2. Member Identification Number
3. Date of Initial Assessment
4. Date of Reassessment
_________
5. Member has received
hours of day treatment since the initial assessment.
6. Referral Source
 Hospital
 Friend
 Self
Physician
 Family
 Agency
 Nursing Home
Other _________________________________
7. Name / Agency — Referral Source
8. Address — Referral Source (Street, City, State, ZIP Code)
 Yes
 No
9. Member presently hospitalized?
 Yes
 No
Member presently living in nursing home?
10. Name / Address — Facility (Street, City, State, ZIP Code)
11. Resident of Facility Since
Discharge Date
12. Usual Living Arrangement
Alone.
Household with spouse only.
Household with spouse and other relatives
Household with nonrelatives.
or with other relatives only.
Community-Based Residential Facility (CBRF).
Group quarters, other than a health-related facility.
Other (Specify) ___________________________________
13. Reason for Referral
14. Eligibility Decision Criteria
15. Current Services Being Received (Medical and
 Yes  No
a.
Substance Abuse Currently
Nonmedical)
Intellectual Disability Primary Diagnosis  Yes  No
b.
c.
Primary Diagnosis Code
Secondary and Other Code
d.
Scores, Level of Functioning (LOF)
(Sections II-IV) Total
e.
Likelihood of Benefit (Section V)
%
f.
Course of Functioning (Section V)
g.
Risk of Hospitalization (Section V)
%
16. SIGNATURE — Assessor
17. Discipline
18. Date Signed
19. SIGNATURE — Day Treatment Program Director
20. Date Signed
Continued
MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT
2 of 5
F-11090 (08/15)
Name — Member
Date of Initial Assessment
Date of Reassessment
SECTION II — LOF TASK ORIENTATION SCALE
Note: You must know firsthand or have it reliably documented that the member has actually done the tasks.
Indicators:
a. Degree of self-application (concentration, follow through, assuming responsibility) and, if necessary, the amount of
guidance (instruction in performance) and support (reinforcement, reassurance) needed to maintain functioning.
COMMENTS
b. Relationship of level of stress to task functioning and the amount of support needed to engage or re-engage in tasks.
1. a. Cannot apply self to any task for any period of time. Demonstrates no goal directed behavior. May wander aimlessly.
Guidance and support have no effect on task functioning.
b. Cannot cope with any stress.
2. a. Rarely concentrates. When alone, rarely follows through with tasks. In a highly structured situation with others, very
limited task follow-through even with constant guidance and support.
b. Functioning breaks down with slightest stress. Needs much support to re-engage.
3. a. Concentrates intermittently. When alone, limited follow-through. Some follow-through with continuous support; no
guidance necessary.
b. With low stress, task functioning breaks down. Support needed to re-engage.
4. a. Concentrates fairly consistently. At times able to follow through. Occasionally assumes responsibility for tasks, when
requested to do so, if support is provided.
b. With low stress, task functioning is usually diminished. Support needed to re-engage.
5. a. Follows through frequently and voluntarily assumes responsibility for tasks. Occasionally needs support.
b. With low stress, functioning will occasionally be impaired. With moderate stress, functioning will almost always be
impaired. Usually needs support to re-engage.
6. a. Concentration is consistent and purposeful. Follows through well and often assumes responsibility for tasks, only
requiring support when under stress.
b. With moderate stress, functioning is usually impaired. Can re-engage by self.
7. a. Concentration is almost always consistent and purposeful. Follows through very well and is actively responsible in
relation to tasks. Usually follows through even with frustrating tasks. Task mastery is experienced as valuable and
satisfying. Very seldom needs support.
b. With moderate stress, can maintain functioning. With high stress, functioning is impaired but can re-engage by self.
8. a. Excellent concentration and achievement orientation. Very seldom subject to distraction. Follows through even with the
most frustrating tasks. Almost never needs support.
b. With high stress, functioning only slightly impaired. Can re-engage by self.
SCORE THIS
PAGE
John Williams, M.A., Framingham Day Hospital, Framingham, Massachusetts, with consultation from Iris Carroll, O.T.R., M.P.H., Framingham
Day Hospital and Fred Altaffer, Ph.D., Massachusetts Department of Mental Health, August, 1979. Reproduced by ForwardHealth with
permission from Programs for People, Inc., 2/14/05. Copyright applied for; reproduction by a process without permission violates copyright
laws.
Continued
MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT
3 of 5
F-11090 (08/15)
Name — Member
Date of Initial Assessment
Date of Reassessment
SECTION III — LOF SOCIAL FUNCTIONING SCALE
Note: Social interaction can be in or out of the program. You must know of its occurrence first hand or it must be reliably
documented. Social interaction with staff is not to be taken into consideration when rating.
Indicators:
a. Ability to initiate interpersonal contact.
b. Degree of conversational interaction.
c. Degree of comfort in interpersonal situations.
d. Relationship between level of stress and social functioning. Amount of support needed to engage or re-engage.
COMMENTS
1. a. Does not initiate contact. When approached, no response.
b. Shows no ability to listen or respond in conversation.
c. Extreme discomfort being with others.
d. Unable to cope with any stress.
2. a. Very rarely initiates contact. When approached, sometimes responds.
b. Rarely listens. Responses not appropriate to conversation flow (lack of continuity, coherence).
c. General discomfort with others most of the time.
d. With the slightest stress functioning breaks down. Needs support to re-engage.
3. a. Rarely initiates contact. If approached, almost always responds.
b. Sometimes listens. Responses occasionally appropriate to conversation flow.
c. Discomfort with others but can tolerate limited supported interaction.
d. With low stress, functioning almost always breaks down. Needs support to re-engage.
4. a. Sometimes initiates contact. Always responds.
b. Usually listens. Responses often appropriate with some sharing in the conversation flow.
c. Some discomfort but with support can tolerate most interactions.
d. With low stress, functioning at this level usually diminishes. Needs support to re-engage.
5. a. Often initiates contact.
b. Can listen well. Usually responds in shared way to the conversation flow.
c. Usually comfortable with others in interactions that are not stressful.
d. Under low stress, functioning occasionally breaks down. With moderate stress functioning will almost always be
impaired. Usually needs support to re-engage.
6. a. In most cases can initiate contact.
b. Listens very well. Responds in shared way to conversation flow. At times actively shapes conversation.
c. Usually comfortable in most interactions.
d. With moderate stress, functioning is occasionally impaired. Can re-engage by self.
7. a. Almost always able to initiate contact as desired.
b. Listens with empathy. Not only responds, but actively shapes conversation appropriately.
c. Not only feels comfortable, but experiences interactions as satisfying.
d. With moderate stress, can maintain functioning. With high stress, functioning diminishes. Can re-engage by self.
8. a. Initiates contacts as desired.
b. Listens intuitively. Responds and shapes conversations appropriately, as desired.
c. Not only feels comfortable, but experiences being with others as self-enhancing.
d. With high stress, involvement may be diminished, but member is not immobilized.
SCORE THIS
PAGE
Framingham Functional Assessment Scale, J. Williams, I. Carroll and F. Altaffer, August 1979. Copyright applied for, Framingham Day Hospital.
Reproduction by any process without permission violates copyright laws. Reproduced by ForwardHealth with permission from Programs for People,
Inc., 2/14/05.
Continued
MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT
4 of 5
F-11090 (08/15)
Name — Member
Date of Initial Assessment
Date of Reassessment
SECTION IV — LEVEL OF FUNCTIONING EMOTIONAL FUNCTIONING SCALE
Indicators:
a. Member’s ability to be aware of and understand his emotional states.
b. Member’s relationship to his emotional states (overwhelmed? sufficiently controlled? a sense of objectivity?).
c. Amount of support needed to function emotionally, with varying levels of stress.
COMMENTS
1. a. Emotional states appear to be either extremely controlled and rigid (flat) or extremely uncontrolled (labile). Cannot
objectively acknowledge his emotions.
b. Appears severely overwhelmed by emotional experience.
c. Intervention or support has no effect. Emotional states prevent almost all everyday functioning.
2. a. Although may refer to emotional states, reveals no experienced awareness or objective understanding of emotions at
the time they occur.
b. Excessively overwhelmed by emotions.
c. Even with constant support, becomes overwhelmed with slightest stress. Needs support to regain functioning.
3. a. Indicates beginning awareness of emotional states, but anxious about this awareness.
b. Emerging objectivity in relation to emotions, though frequently overwhelmed by his emotions.
c. Even with constant support, in low stress situations, functioning breaks down.
4. a. Usually aware of emotional states. Indicates an acceptance of emotions as a necessary part of life. May begin to take
new actions based on awareness of his emotions.
b. Some objectivity in relation to his emotions but often feels overwhelmed by them.
c. Even with frequent support, in low stress situations, functioning is diminished. Needs support to regain functioning.
5. a. Indicates that he is almost always aware of his emotions and is developing an understanding of them.
b. Somewhat uncomfortable and overwhelmed by his emotions, but still objective enough to begin to understand them.
c. Even with support, emotional functioning is impaired with moderate stress. Needs support to regain functioning.
6. a. Understands his emotions and how they relate to everyday functioning. Begins to feel comfortable with various
emotional states.
b. Behavior indicates sufficient emotional objectivity to function with flexibility.
c. Emotional functioning somewhat impaired with moderate stress. At times needs some support to regain functioning.
7. a. Not only understands emotions and how they relate to everyday functioning, but experiences this as satisfying, and a
part of emotional growth.
b. In experiencing diverse emotional states, even extremes, person usually maintains a tempering objectivity.
c. With high stress, functioning will diminish. Occasionally needs support to regain functioning.
8. a. Indicates thorough understanding of his emotional life and experiences emotional growth as part of a lifelong process.
b. Wide variety of emotions are experienced in a larger context of emotional growth.
c. With high stress, functioning slightly impaired. No need for support to regain functioning.
SCORE THIS
PAGE
Framingham Functional Assessment Scale, J. Williams, I. Carroll and F. Altaffer, August 1979. Copyright applied for, Framingham Day Hospital.
Reproduction by any process without permission violates copyright laws. Reproduced by ForwardHealth with permission from Programs for People,
Inc., 2/14/05.
Continued
MENTAL HEALTH DAY TREATMENT FUNCTIONAL ASSESSMENT
5 of 5
F-11090 (08/15)
Name — Member
Date of Initial Assessment
Date of Reassessment
SECTION V — SCORING
Likelihood of Benefit from Mental Health Day Treatment. In comparison with other individuals’ day treatment pre-admission
functioning and subsequent success in achieving treatment goals, what is the probable benefit of mental health day treatment to this
individual? (Circle Level)
Score
0%
10
20
25
30
40
50
60
70
75
80
90
100%
No likelihood of achieving
Moderate likelihood in achieving
Complete likelihood in achieving
treatment goals
treatment goals
treatment goals
Course of Functioning During the Past Year (Circle Level)
1. Vulnerability to stress. What is the likelihood that the individual exhibited severe psychopathological symptoms in response to
mild to moderate levels of stress?
1
2
3
4
5
Score
100%
75%
50%
25%
0%
Complete likelihood of severe
Moderate likelihood of severe
No likelihood of severe
psychopathological symptoms
psychopathological symptoms
psychopathological symptoms
2. Activities of daily living skills. What has been the individual’s level of functioning with regard to activities of daily living (e.g.,
bathing, grooming, and dressing; basic housekeeping and shopping; use of public transportation; preparing or obtaining meals;
maintaining prescribed program of medication; taking initiative to seek assistance with problems)?
1
2
3
4
5
Score
Unable to perform three
Unable to perform two
Unable to perform one
Marginal performance of
Adequate performance
or more essential
essential activities of
essential activity of
activities of daily living
of activities of daily
activities of daily living
daily living without
daily living without
living
without assistance
assistance
assistance
Specify.
3. Dependence on institutional and other support systems. To what extent has the individual required mental hospitalizations or
other institutional support or been unable to achieve self-sufficient living?
1
2
3
4
5
Score
Has had mental hospital
Has been involved in mental
Has not required mental health day
admission
health day treatment
treatment or more restrictive care
4. Working in the competitive job market. To what extreme has the individual been unemployed, sporadically employed, or
experienced emotionally related job difficulties?
1
2
3
4
5
Score
Extensive periods of unemployment or
Moderate difficulty in obtaining or maintaining
No significant difficulty with regard
serious emotionally-related job difficulties
employment or moderate emotionally related job
to competitive employment
difficulty
5. Interpersonal relations. To what extent has the individual exhibited social withdrawal and/or inappropriate behavior that interfered
with interpersonal relationships necessary for community living?
1
2
3
4
5
Score
TOTAL (1-5)
Serious degree of withdrawal and/or
Moderate degree of withdrawal and/or
No evidence of social withdrawal or
inappropriate behavior
inappropriate behavior
inappropriate behavior
Risk of Hospitalization. If the individual does not receive mental health day treatment at this time, what is the likelihood of the
person requiring inpatient care within the next three months? Note: If feasible, this estimate should be made in comparison with
other members with similar diagnoses, levels of functioning, and course of functioning. Also averaging more than one clinical
judgment tends to increase the accuracy of this estimate. (Circle Level)
Score
0%
10
20
25
30
40
50
60
70
75
80
90
100%
No likelihood of inpatient care
Complete likelihood of
requiring inpatient care
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