Form MO650-8478 "Compulsive Gambling Treatment Status and Outcomes Review" - Missouri

What Is Form MO650-8478?

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

Form Details:

  • Released on March 1, 2007;
  • The latest edition provided by the Missouri Department of Mental Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MO650-8478 by clicking the link below or browse more documents and templates provided by the Missouri Department of Mental Health.

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Download Form MO650-8478 "Compulsive Gambling Treatment Status and Outcomes Review" - Missouri

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STATE OF MISSOURI
DEPARTMENT OF MENTAL HEALTH
DIVISION OF ALCOHOL AND DRUG ABUSE
COMPULSIVE GAMBLING TREATMENT STATUS AND OUTCOMES REVIEW
NAME OF CONSUMER
DMH ID
DATE
PROVIDER AGENCY
COUNSELOR
TELEPHONE
Instructions: This review form should be completed during a consumer-counselor interview. If completed by the consumer as a
questionnaire, it should also be reviewed jointly by the counselor.
CONSUMER STATUS
Gambler (Primary)
Family/Significant Other (Collateral Dependent)*
*If consumer is a family member/significant other (collateral dependent), please complete Sections E and H.
SECTION A - GAMBLING
Types of Gambling Activities of Choice (please check all that apply)
Lottery (scratchers, pull tabs, numbers)
Roulette, Keno, Craps, other Casino Skill Games
Internet Slots
Games of Skill (pool, golf, bowling, etc.)
Casino Slots
Internet VLTs
Raffles (including 50/50)
Casino VLTs
Internet Poker
Bingo
Cards - Non-Internet (poker, blackjack)
Internet Other Games
Sports Betting - Non-Internet (horses, dogs,
Internet Sports (parimutuel,
football, other)
football, baseball)
Which do you consider to be your primary gambling activity? ______________________________________________________________
Preferred Gambling Locations (please check all that apply)
Casino/Riverboat
Internet
Grocery/Convenience Store
Home
Work
Church/Community Site
Race Track
Bookie
Bar/Restaurant
School
Off-Track Betting (OTB)
Other
In the past 30 days, how many days have you done any gambling at all?
_________ days
In the past 30 days, how many days have you gambled more than you could afford?
_________ days
How much money would you say you typically spend per week on gambling?
$ ________ per week
How much time would you say you typically spend per week gambling?
_________ hours/week
What was the date on which you last gambled?
_________ (mm/dd/yyyy)
How concerned have you been in the past 30 days about gambling problems?
0 = Not at all
1 = Slightly
2 = Moderately
3 = Considerably
4 = Extremely
SECTION B - EMPLOYMENT/FINANCIAL
What is the status of your current employment outside the home?
Full Time (30 or more hours per week)
Part-Time (less than 30 hours per week)
Sporadic (Seasonal)
Not employed outside home
If not employed outside the home, please check one of the following:
Homemaker
Student
Disabled
Otherwise Unemployed
Retired
How much is your current gambling debt? (include money borrowed from family and friends, loans, credit cards,
$ _____________
bookie, etc.)
How concerned have you been by financial problems in the past 30 days?
0 = Not at all
1 = Slightly
2 = Moderately
3 = Considerably
4 = Extremely
MO 650-8478 (3-07)
CONTINUED
STATE OF MISSOURI
DEPARTMENT OF MENTAL HEALTH
DIVISION OF ALCOHOL AND DRUG ABUSE
COMPULSIVE GAMBLING TREATMENT STATUS AND OUTCOMES REVIEW
NAME OF CONSUMER
DMH ID
DATE
PROVIDER AGENCY
COUNSELOR
TELEPHONE
Instructions: This review form should be completed during a consumer-counselor interview. If completed by the consumer as a
questionnaire, it should also be reviewed jointly by the counselor.
CONSUMER STATUS
Gambler (Primary)
Family/Significant Other (Collateral Dependent)*
*If consumer is a family member/significant other (collateral dependent), please complete Sections E and H.
SECTION A - GAMBLING
Types of Gambling Activities of Choice (please check all that apply)
Lottery (scratchers, pull tabs, numbers)
Roulette, Keno, Craps, other Casino Skill Games
Internet Slots
Games of Skill (pool, golf, bowling, etc.)
Casino Slots
Internet VLTs
Raffles (including 50/50)
Casino VLTs
Internet Poker
Bingo
Cards - Non-Internet (poker, blackjack)
Internet Other Games
Sports Betting - Non-Internet (horses, dogs,
Internet Sports (parimutuel,
football, other)
football, baseball)
Which do you consider to be your primary gambling activity? ______________________________________________________________
Preferred Gambling Locations (please check all that apply)
Casino/Riverboat
Internet
Grocery/Convenience Store
Home
Work
Church/Community Site
Race Track
Bookie
Bar/Restaurant
School
Off-Track Betting (OTB)
Other
In the past 30 days, how many days have you done any gambling at all?
_________ days
In the past 30 days, how many days have you gambled more than you could afford?
_________ days
How much money would you say you typically spend per week on gambling?
$ ________ per week
How much time would you say you typically spend per week gambling?
_________ hours/week
What was the date on which you last gambled?
_________ (mm/dd/yyyy)
How concerned have you been in the past 30 days about gambling problems?
0 = Not at all
1 = Slightly
2 = Moderately
3 = Considerably
4 = Extremely
SECTION B - EMPLOYMENT/FINANCIAL
What is the status of your current employment outside the home?
Full Time (30 or more hours per week)
Part-Time (less than 30 hours per week)
Sporadic (Seasonal)
Not employed outside home
If not employed outside the home, please check one of the following:
Homemaker
Student
Disabled
Otherwise Unemployed
Retired
How much is your current gambling debt? (include money borrowed from family and friends, loans, credit cards,
$ _____________
bookie, etc.)
How concerned have you been by financial problems in the past 30 days?
0 = Not at all
1 = Slightly
2 = Moderately
3 = Considerably
4 = Extremely
MO 650-8478 (3-07)
CONTINUED
CONSUMER NAME
DMH ID
SECTION C - FAMILY/SOCIAL
In the past 30 days, have you experienced serious problems getting along with (check all that apply)
Yes
No
Yes
No
Spouse/Partner/Significant Other?
Parent?
Child/Children?
Other family members?
Friends/co-workers?
Employer?
__________ days
In the past 30 days, how many days have you had serious conflicts with your FAMILY/SIGNIFICANT OTHER?
How concerned have you been in the past 30 days by problems with FAMILY/SIGNIFICANT OTHER?
0 = Not at all
1 = Slightly
2 = Moderately
3 = Considerably
4 = Extremely
In the past 30 days, how many days have you had serious problems with FRIENDS, CO-WORKERS or other
__________ days
SOCIAL RELATIONSHIPS?
How concerned have you been in the past 30 days by problems with FRIENDS/OTHERS?
0 = Not at all
1 = Slightly
2 = Moderately
3 = Considerably
4 = Extremely
SECTION D - LEGAL
Are you on probation or parole?
Yes
No
Are you presently awaiting legal charges, trial or sentencing?
Yes
No
_________________________________________________________
If yes, what for? (If multiple charges, indicate the most severe)
Are your legal issues related to your gambling behavior?
Yes
No
How serious do you feel your present legal problems are? (Exclude civil problems such as divorce)
0 = Not at all
1 = Slightly
2 = Moderately
3 = Considerably
4 = Extremely
SECTION E - EMOTIONAL
BEFORE you (or your loved one) experienced gambling problems, were you ever diagnosed with or treated for:
Depression
Anxiety
Bipolar Disorder/Manic Depression
Other Mental Health Diagnosis: __________________________________________________________
No Prior Diagnoses
If yes, year of first diagnosis: __________
Were you prescribed medication?
Yes
No
If yes, what medications? _______________________________________________
Do you currently take the medication(s) as prescribed?
Yes
No
Not Applicable
SINCE experiencing problems with (or associated with a loved one’s) gambling, have you:
experienced depression?
Yes
No
experienced anxiety?
Yes
No
experienced other psychological or emotional problems?
Yes
No
If yes, please describe: __________________________________________________________________________________________
During the past 6 months, have you experienced any thoughts of suicide?
Yes
No
If yes, the Lethality Scale must be administered by counselor.
Rating _____________
If the rating is three (3) or higher, a referral must be made for assessment and/or treatment by a physician or ER, as appropriate. Referral
information must be documented below. Consumer referred to the following physician or emergency room:
NAME
DATE
TIME
If suicidal issues have occurred in the past 6 months, but are not imminent at this time, please describe the prior situation(s), how the
suicidal behavior was addressed, and report who the consumer is seeing for ongoing treatment for such issues.
MO 650-8478 (3-07)
CONTINUED
CONSUMER NAME
DMH ID
SECTION F - SUBSTANCE ABUSE
In the past 30 days, how many days have you consumed alcohol?
_________ days
On those days, how many standard drinks (one beer, one mixed drink, one glass wine) have you
consumed on average?
_________ drinks
In the past 30 days, how many days have you used the following:
Marijuana:
_________ days
Cocaine/Crack:
_________ days
Methamphetamine:
_________ days
LSD/Hallucinogens:
_________ days
Pain Killers (Vicodin, Oxycontin):
_________ days
Benzodiazepines (Valium, Xanax):
_________ days
Heroin:
_________ days
Have you ever felt you should cut down on your drinking or drug use?
Yes
No
Have people annoyed you by criticizing your drinking or drug use?
Yes
No
CAGE-AID
Have you ever felt bad or guilty about your drinking or drug use?
Yes
No
Have you ever had a drink or used drugs first thing in the morning to steady your
nerves or to get rid of a hangover (eye opener)?
Yes
No
Have you ever been treated for:
Alcohol abuse/dependence?
Yes
No
Drug abuse/dependence?
Yes
No
SECTION G - SERVICES
In the past 30 days, how many days have you:
attended Gamblers Anonymous meetings?
_________ days
attended AA/NA or other self-help group meetings?
_________ days
attended counseling sessions for gambling problems?
_________ days
received treatment services for mental health problems?
_________ days
received treatment services for substance abuse problems?
_________ days
SECTION H - COUNSELOR REPORT
The following section is to be completed by the counselor.
INDICATE TYPE OF REQUEST
Initial
30-Day Review
120-Day Review
210-Day Review
300-Day Review
__________-Day Review
Complete the following for an INITIAL request for a gambler (primary consumer)
DATE OF ADMISSION
AGE FIRST GAMBLED
SCREENING SCORES
DSM 2-Question (Lie-Bet) = _________
GA 20 Questions = _________
REFERRAL SOURCE
Phone Helpline (888-BETSOFF)
www.BETSOFF.org Website
Advertising (billboards, radio, television)
Dept. of Mental Health Website
Friend or Family Member
Gaming Merchandise (i.e., back of tickets, etc.)
Self-Help Group (GA/AA/NA)
Attorney/Legal Counsel
Clergy, School Counselor, Other Advisor
Physician/Medical Facility
Other: _________________________
Complete the following for a 30-DAY review for a gambler (primary consumer)
ASSESSMENT SCORES
IS THE GAMBLING BEHAVIOR BETTER ACCOUNTED FOR BY A MANIC EPISODE?
SOGS = _________
DSM-IV = _________
Yes
No
MO 650-8478 (3-07)
CONTINUED
CONSUMER NAME
DMH ID
Complete the following for ALL primary consumer reviews.
Is the consumer regularly attending treatment services?
Yes
No
If no, please describe attendance patterns: _____________________________________________________________________________
_______________________________________________________________________________________________________________
Does the consumer have a financial plan/budget to resolve any financial problems?
Yes
No
Describe progress on or obstacles to consumer’s financial plan/budget: _______________________________________________________
_______________________________________________________________________________________________________________
Identify the clinical reasons for service provision in the next treatment period. Include patterns of continued gambling, impact of issues on
family, financial, legal and/or emotional status. This section should be completed for both primary and collateral dependent consumers.
Identify treatment goals/objectives planned during the next service period. This section should be completed for both primary and
collateral dependent consumers. This section DOES NOT replace the need for a Master Treatment Plan to be developed and maintained
in the consumer record.
ANTICIPATED DISCHARGE DATE
COUNSELOR SIGNATURE AND DATE
MO 650-8478 (3-07)
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