Form MO650-8427 "Cps Status Report" - Missouri

What Is Form MO650-8427?

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 July 1, 2018;
  • 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 fillable version of Form MO650-8427 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 MO650-8427 "Cps Status Report" - Missouri

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STATE OF MISSOURI
DEPARTMENT OF MENTAL HEALTH
CPS STATUS REPORT
Save
Print
Reset
PLEASE PRINT CLEARLY
CLIENT NAME
REPORTING DATE
CLIENT STATE ID
SSN NUMBER
MODIFIED GAF SCORE
AGENCY SITE (OPTIONAL)
ASSESSMENT TYPE
1. Admission
2. Annual/Review
3. Discharge
RESIDENTIAL STATUS (CHECK ONLY ONE)
EMPLOYMENT STATUS (CHECK ONLY ONE)
COMPETITIVE EMPLOYMENT
1. Homeless
1. Full-Time
2. Foster Home
2. Part-Time: Average Hours Worked per Week (Estimate) ____
3. Residential Care
3. Supported Employment
4. Crisis Residence
4. Unemployed - actively looking for work or laid off in past 30
5. Nursing Home
days
6. Hospital Inpatient
NOT IN LABOR FORCE
7.
Jail/Correctional Facility
5. Homemaker
8. Private Residence - Independent Living
6. Student (<16 years old must be check box “6” or “14”)
9. Private Residence - Dependent Living (Adults Only)
7. Retired
10. Private Residence - Youth Living with Family or Non-relative
8. Medical Disability
11. Other Residential Status
9. Behavioral Disability
12. Residential Status Unknown
10. Other Disability
SCHOOL ATTENDANCE STATUS (CHECK ONLY ONE)
11. Hospital patient or resident at any institution that keeps a
person from the labor force.
1. YES - Client has attended school at any time in past 3 mo.
12. Volunteer
2. NO - Client has not attended school at any time in past 3
13. Sheltered/Non-Competitive Employment
mo.
14. Not in Labor Force, but other than above
3. Pre-school age children (< 3 years old)
15. Unknown
4. Adults (>18 yrs. old, except young adults 18-21 who receive
LEGAL INVOLVEMENT
services from the State’s Children Mental Health System)
5. UNKNOWN
1. Number of Arrests in prior 30 days _____
2. Unknown
SCHOOL GRADE LEVEL (CHECK ONLY ONE)
SUBSTANCE USE/ABUSE
1. No years of schooling
1. Have you used any Tobacco products in the past 3 months?
2. Nursery School, Pre-School (including Head Start)
Yes
No
Unknown
3. Kindergarten
2. Females (and Males over 65): When was the last time you
4. Grade (Write in 1st-12th) _____
had 4 standard drinks in a day or night? _____
5. Self-Contained Special Ed. Class (No equivalent grade level
)
Was that within the last 3 months?
6. V
ocational School (see guidelines for definition)
Males under 65: When has the last time you had 5 standard
7. College Undergraduate Freshman (1st Year)
drinks in a day or night? _____
8. College Undergraduate Sophomore (2nd Year)
Was that within the last 3 months?
9. College Undergraduate Junior (3rd Year)
Yes
No
Unknown
10. College Undergraduate Senior (4th Year)
3. In the last 12 months, did you ever find yourself drinking
11. Graduate or Professional School (e.g., Master’s, Doctoral,
more than you meant to?
Medical or Law School)
Yes
No
Unknown
12. Unknown
4. In the last 12 months, did you ever think that maybe you
should cut down on your drinking?
Yes
No
Unknown
5. In the last 12 months, did you smoke pot, use another street
drug or use a prescription painkiller, stimulant or sedative for
a non-medical reason?
Yes
No
Unknown
MO 650-8427 (7-18)
PAGE 1
STATE OF MISSOURI
DEPARTMENT OF MENTAL HEALTH
CPS STATUS REPORT
Save
Print
Reset
PLEASE PRINT CLEARLY
CLIENT NAME
REPORTING DATE
CLIENT STATE ID
SSN NUMBER
MODIFIED GAF SCORE
AGENCY SITE (OPTIONAL)
ASSESSMENT TYPE
1. Admission
2. Annual/Review
3. Discharge
RESIDENTIAL STATUS (CHECK ONLY ONE)
EMPLOYMENT STATUS (CHECK ONLY ONE)
COMPETITIVE EMPLOYMENT
1. Homeless
1. Full-Time
2. Foster Home
2. Part-Time: Average Hours Worked per Week (Estimate) ____
3. Residential Care
3. Supported Employment
4. Crisis Residence
4. Unemployed - actively looking for work or laid off in past 30
5. Nursing Home
days
6. Hospital Inpatient
NOT IN LABOR FORCE
7.
Jail/Correctional Facility
5. Homemaker
8. Private Residence - Independent Living
6. Student (<16 years old must be check box “6” or “14”)
9. Private Residence - Dependent Living (Adults Only)
7. Retired
10. Private Residence - Youth Living with Family or Non-relative
8. Medical Disability
11. Other Residential Status
9. Behavioral Disability
12. Residential Status Unknown
10. Other Disability
SCHOOL ATTENDANCE STATUS (CHECK ONLY ONE)
11. Hospital patient or resident at any institution that keeps a
person from the labor force.
1. YES - Client has attended school at any time in past 3 mo.
12. Volunteer
2. NO - Client has not attended school at any time in past 3
13. Sheltered/Non-Competitive Employment
mo.
14. Not in Labor Force, but other than above
3. Pre-school age children (< 3 years old)
15. Unknown
4. Adults (>18 yrs. old, except young adults 18-21 who receive
LEGAL INVOLVEMENT
services from the State’s Children Mental Health System)
5. UNKNOWN
1. Number of Arrests in prior 30 days _____
2. Unknown
SCHOOL GRADE LEVEL (CHECK ONLY ONE)
SUBSTANCE USE/ABUSE
1. No years of schooling
1. Have you used any Tobacco products in the past 3 months?
2. Nursery School, Pre-School (including Head Start)
Yes
No
Unknown
3. Kindergarten
2. Females (and Males over 65): When was the last time you
4. Grade (Write in 1st-12th) _____
had 4 standard drinks in a day or night? _____
5. Self-Contained Special Ed. Class (No equivalent grade level
)
Was that within the last 3 months?
6. V
ocational School (see guidelines for definition)
Males under 65: When has the last time you had 5 standard
7. College Undergraduate Freshman (1st Year)
drinks in a day or night? _____
8. College Undergraduate Sophomore (2nd Year)
Was that within the last 3 months?
9. College Undergraduate Junior (3rd Year)
Yes
No
Unknown
10. College Undergraduate Senior (4th Year)
3. In the last 12 months, did you ever find yourself drinking
11. Graduate or Professional School (e.g., Master’s, Doctoral,
more than you meant to?
Medical or Law School)
Yes
No
Unknown
12. Unknown
4. In the last 12 months, did you ever think that maybe you
should cut down on your drinking?
Yes
No
Unknown
5. In the last 12 months, did you smoke pot, use another street
drug or use a prescription painkiller, stimulant or sedative for
a non-medical reason?
Yes
No
Unknown
MO 650-8427 (7-18)
PAGE 1
CPS Status Report - Instructions
General Instructions:
Starting 04/01/2012, all clients, Adults and Youth, enrolled in CPS programs in CIMOR with the intention of regularly billing
services to CPS should have the "CPS Status Report" completed at admission to CPS services, at annual anniversary of that
admission and at discharge from CPS services. The status report information should be entered into the CPS Status Report
screen in CIMOR.
The above reporting requirement definition includes all CPR, ACT, TCM, DM 3700 and Healthcare Home clients. The ambiguous
cases are clients enrolled in "CPS [Adult/Youth] Community Services" in CIMOR but without any service claims paid by CPS.
Such clients are not required to have the CPS Status Report completed unless they also have claims submitted for payment to
CPS and are active (billed to) CPS clients for at least 30 days. CPS will run retrospective reports each month notifying agencies
of clients meeting reporting criteria and thus needing assessments completed. The agency can elect to complete a Status
Report for each client entered as a CPS client in CIMOR regardless of program if that is easier to track -- this will certainly meet
the reporting requirements.
Local agencies will sometimes have cycles of annual assessment dates that are different from the anniversary month inferred
from CIMOR data. This is acceptable so long as each client in CPS services has a status report at admission to CPS services and
an annual status report within no more than 12 months from the initial status report. For example, you could have a client
admitted to CIMOR and with an admission status report in April 2012, but due to pre-CPS enrollment services the local
anniversary date is December 2012. In that case, you would enter the subsequent "annual" 8 months later in December 2012,
and thereafter in each December if still in services (or in the month of subsequent discharge). You would not wait 20 months
(until December 2013) to complete the first annual. In effect, every CPS client should have a status report in CIMOR that is
current within no more than 12 months.
Existing clients without a past status report should have their first status report entered in their first annual anniversary month
after 04/01/2012. Clients discharged in CIMOR should have an updated status report entered within 30 days of discharge
unless the prior status report was less than 30 days old at the time of discharge. In such cases, it will be assumed that the same
status values apply to the discharge, unless the agency elects to enter updated values.
Brief Reference to categories on the CPS Status Report:
Residential Status - should be coded as the client's place of residence on the reporting date.
School Attendance Status - refers to school attendance in last 3 months or client age at time of status report.
School Grade Level - if school attendance above is "YES", this should be the current grade level. If not or if adult, this should be
the highest grade level completed.
Employment Status - should be coded as the client's employment on the reporting date. Even when youth < 16 years old have
a part time job, they are not in the federal definition of the labor force. Therefore youth must be coded as either "#6. Student”
or "#14. Not in labor force”. If a youth has "No" in "School Attendance Level” checked then their employment status should be
"#14. Not in labor force”. If "YES" in "School Attendance Level" then their employment status must be "#6. Student”.
Legal Involvement - number of arrests is the number of times the client was arrested for any cause during the past 30 days.
Any formal arrest should be counted regardless of whether incarceration or conviction resulted.
Substance Use / Abuse - question 2 is a compounded question, asking if the client has had that many standard drinks within
the last 3 months. If the last time they drank that number of standard drinks was more than three months ago (or never), then
the answer is "no". Refer to Standard Drink Legend below..
MO 650-8427 (7-18)
PAgE 2
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