Version 08/01/2014 1. Please select all services the consumer is receiving. (See Attachment I) NC-TOPPS Mental Health and Substance Abuse Child (Ages 6-11) Update Interview QP First Initial & Last Name LME-MCO Assigned Consumer Record Number Consumer Date of Birth: / / Consumer Gender: Male Female Child Mental Health, age 6-11 Pa g e 1 Please p rovide the followin g consumer information: Please select the a pp ro p riate a g e/disabilit y cate g or y( ies ) for which the individual is receiving services and supports. Type of Interview (mark only one) Confidentiality of SA and MH consumer-identifying information is protected under Federal regulations 42 CFR Part 2 and the Health Insurance Portability and Accountability Act of 1996, P.L. 104-91 (HIPAA) or implementing regulations, 45 CFR Parts 160 and 164. Consumer-identifying information may be disclosed without the individual's consent to the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS) and to its authorized evaluation contractors under the audit or evaluation exception. Redisclosure of consumer-identifying information without the individual's consent is explicitly prohibited. Your questions may be directed to (919) 515-1310. Sponsored by the NC MH/DD/SAS. 2. Please indicate the DSM-5 diagnostic classification(s) for this individual. (See Attachment II) Consumer Count y of Residence: 3. Since the last interview, the consumer has attended scheduled treatment sessions... All or most of the time Sometimes Rarely or never 4. Since the individual started services for this episode of treatment, which of the following areas has the individual received help? (mark all that apply) Educational improvement Housing (basic shelter or rent subsidy) Transportation Child Care Medical Care Dental care Screening/Treatment referral for HIV/TB/HEP Legal issues Volunteer opportunities None of the above 5. In the past 3 months, has the individual's family or guardian been involved in any contact with staff concerning any of the following? (mark all that apply) Treatment services Person-centered planning None of the above Section II: Com p lete items 6-22 usin g information from the individual's interview (p referred ) or consumer record 6. How are the next section's items being gathered? (mark all that apply) In-person interview (preferred) Telephone interview Clinical record/notes 7. Does your child and/or family ever have difficulty participating in treatment because of problems with... (mark all that apply) No difficulties prevented your child from entering treatment Active mental health symptoms (anxiety or fear, agoraphobia, p aranoia, hallucinations ) Active substance abuse symptoms (addiction, relapse) Physical health problems (severe illness, hospitalization) Family or guardian issues (controlling spouse, family illness, child or elder care, domestic violence, p arent/ g uardian coo p eration ) Treatment offered did not meet needs (availability of appropriate services, t yp e of treatment wanted b y consumer not available, favorite thera p ist q uit, etc. ) Engagement issues (AWOL, doesn't think s/he has a problem, denial, runawa y , overslee p s ) Cost or financial reasons (no money for cab, treatment cost) Stigma/Discrimination (race, gender, sexual orientation) Treatment/Authorization access issues (insurance problems, waiting list, p a p erwork p roblems, red ta p e, lost Medicaid card, IPRS tar g et p o p ulations, Value O p tions, referral issues, citizenshi p , etc. ) Language or communication issues (foreign language issues, lack of inter p reter, etc. ) Legal reasons (incarceration, arrest) Transportation/Distance to provider Scheduling issues (work or school conflicts, appointment times not workable, no p hone ) First three letters of consumer's last name: First letter of consumer's first name: 3 month update 6 month update 12 month update Other bi-annual update (18-month, 24-month, 30-month, etc. ) Deaf/Hard of hearing Begin Interview Provider Internal Consumer Record Number (optional) Medicaid ID Number (optional) Medicaid Count y of Residence: Local Area Code ( Re p ortin g Unit Number ) ( o p tional ) Please have the res p ondent si g n and date and p lace in consumer's file. Respondent Signature: Date: Date: I certif y that I am the Q P who has conducted and com p leted this interview. Q P Si g nature: Lack of stable housing Personal safety (domestic violence, intimidation or punishment) CNDS ID Number Use this form for backup only. Do not mail. Enter data into web-based system. (http://www.ncdhs. gov/mhddsas/nc-topps)
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NC-TOPPSChild6-11Update14 (1193 · Since the individual started services for this episode of ... Institutional setting (hospital or detention center/jail)Homeless(skip to 17)(answer
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Version 08/01/2014
1. Please select all services the consumer is receiving. (See Attachment I)
NC-TOPPS Mental Health and Substance AbuseChild (Ages 6-11) Update Interview
QP First Initial & Last Name
LME-MCO Assigned Consumer Record Number
Consumer Date of Birth:
/ /Consumer Gender:
Male Female
Child Mental Health, age 6-11
Page 1
Please provide the following consumer information:
Please select the appropriate age/disability category(ies)for which the individual is receiving services and supports.
Type of Interview (mark only one)
Confidentiality of SA and MH consumer-identifying information is protected under Federal regulations 42 CFR Part 2 and the Health Insurance Portability and Accountability Act of 1996, P.L. 104-91 (HIPAA) or implementing regulations, 45 CFR Parts 160 and 164. Consumer-identifying information may be disclosed without the individual's consent to the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS) and to its authorized evaluation contractors under the audit or evaluation exception. Redisclosure of consumer-identifying information without the individual's consent is explicitly prohibited. Your questions may be directed to (919) 515-1310. Sponsored by the NC MH/DD/SAS.
2. Please indicate the DSM-5 diagnostic classification(s) for this individual. (See Attachment II)
Consumer County of Residence:
3. Since the last interview, the consumer has attended scheduled treatment sessions...
All or most of the time Sometimes Rarely or never4. Since the individual started services for this episode of treatment, which of the following areas has the individual received help? (mark all that apply)
Educational improvementHousing (basic shelter or rent subsidy)TransportationChild CareMedical CareDental careScreening/Treatment referral for HIV/TB/HEPLegal issuesVolunteer opportunitiesNone of the above
5. In the past 3 months, has the individual's family or guardian been involved in any contact with staff concerning any of the following? (mark all that apply)
Treatment servicesPerson-centered planningNone of the aboveSection II: Complete items 6-22 using information from theindividual's interview (preferred) or consumer record
6. How are the next section's items being gathered? (mark all that apply)
Physical health problems (severe illness, hospitalization)
Family or guardian issues (controlling spouse, family illness, child orelder care, domestic violence, parent/guardian cooperation)
Treatment offered did not meet needs (availability of appropriateservices, type of treatment wanted by consumer not available, favoritetherapist quit, etc.)
Engagement issues (AWOL, doesn't think s/he has a problem, denial,runaway, oversleeps)
Cost or financial reasons (no money for cab, treatment cost)
Stigma/Discrimination (race, gender, sexual orientation)
Treatment/Authorization access issues (insurance problems, waitinglist, paperwork problems, red tape, lost Medicaid card, IPRS targetpopulations, Value Options, referral issues, citizenship, etc.)
Language or communication issues (foreign language issues, lack ofinterpreter, etc.)
Legal reasons (incarceration, arrest)
Transportation/Distance to provider
Scheduling issues (work or school conflicts, appointment times notworkable, no phone)
Provider Internal Consumer Record Number (optional)
Medicaid ID Number (optional)
Medicaid County of Residence:
Local Area Code (Reporting Unit Number) (optional)
Please have the respondent sign and date and place in consumer'sfile. Respondent Signature: Date:
Date:I certify that I am the QP who has conducted and completed thisinterview. QP Signature:
Lack of stable housingPersonal safety (domestic violence, intimidation or punishment)
CNDS ID Number
Use this form for backup only. Do not mail. Enter data into web-based system. (http://www.ncdhs. gov/mhddsas/nc-topps)
Version 08/01/2014
c-1. If school does not use traditional grading system, for yourchild's most recent reporting period, did s/he pass or fail most ofthe time?
NC-TOPPS Mental Health and Substance AbuseChild (Ages 6-11) Update Interview
Use this form for backup only. Do not mail. Enter data into web-based system. (http://www.ncdhs.gov/mhddsas/nc-topps)
11. In the past 3 months, how often did your child participatein extracurricular activities?
17. Was this living arrangement in your child's homecommunity?
Confidentiality of SA and MH consumer-identifying information is protected under Federal regulations 42 CFR Part 2 and the Health Insurance Portability and Accountability Act of 1996, P.L. 104-91 (HIPAA) or implementing regulations, 45 CFR Parts 160 and 164. Consumer-identifying information may be disclosed without the individual's consent to the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS) and to its authorized evaluation contractors under the audit or evaluation exception. Redisclosure of consumer-identifying information without the individual's consent is explicitly prohibited. Your questions may be directed to (919) 515-1310. Sponsored by the NC MH/DD/SAS.
9. For K-12 only:a. What grade is your child currently in?
c. For your child's most recent reporting period, what grades did s/heget most of the time? (mark only one)
A's B's C's D's F's School does not usetraditional grading system
Pass Fail10. For K-12 only: In the past 3 months, has your child been...
15. In the past 3 months, how many times has your child moved residences?
16. In the past 3 months, where did your child live most of thetime?
b. If homeless, please specify your child's living situation most ofthe time in the past 3 months.
Sheltered (homeless shelter or domestic violence shelter)
Unsheltered (on the street, in a car, camp)c. If residential program, please specify the type of residentialprogram your child lived in most of the time in the past 3 months.
Therapeutic foster homeLevel III group homeLevel IV group homeState-operated residential treatment centerOther
Page 2
(enter zero, if none)
b. Since beginning treatment, your child's school attendance has...improved stayed the same gotten worse
NeverA few timesMore than a few times
12. In the past 3 months, how often have your child'sproblems interfered with play, school, or other daily activities?
NeverA few timesMore than a few times
13. In the past month, how would you describe your child'smental health symptoms?
Extremely Severe
Severe
Moderate
Mild
Not present
14. In the past month, if your child has a current prescriptionfor psychotropic medications, how often has your child takenthis medication as prescribed?
No prescription
All or most of the time
Sometimes
Rarely or never
Yes No
18. In the past 3 months, has your child received anyresidential services outside of his/her home community?
Yes No
19. In the past 3 months, has your child used tobacco oralcohol?
Yes No Don't know20. In the past 3 months, has your child used illicit drugs orother substances?
Yes No Don't know
a. suspended from school? Yes No
b. expelled from school? Yes No
21. In the past month, how many times has your child had a petition filed for any offense? (enter zero, if none)
22. Does your child have a Court Counselor or is your childcurrently under the supervision of the juvenile justice system?
Yes No
Section III: This next section includes questions which areimportant in determining consumer outcomes. Thesequestions require that they be asked directly to therespondent either in-person or by telephone.
23. Is the respondent present for an in-person or telephoneinterview or have you directly gathered information from therespondent within the past two weeks?
Yes - Complete items 24-34
No - Stop here
24. Since the last interview, has your child visited a physicalhealth care provider for a routine check up?
Yes No
8. Is your child currently enrolled in school or courses thatsatisfy requirements for a certification, diploma or degree?(Enrolled includes school breaks, suspensions, and expulsions)
Yes No −> (skip to 9)b. If yes, what programs are your child currently enrolled in forcredit? (mark all that apply)
Alternative Learning Program (ALP)Academic schools (K-12)Other
- at-risk students outside standard classroom
In a family setting (private or foster home)
Residential program (supportive housing, group home, PRTF)
Institutional setting (hospital or detention center/jail)
Homeless
−> (skip to 17)
−> (answer c)
−> (skip to 17)−> (answer b)
−> (skip to 17)Temporary housing
25. Since the last interview, has your child visited a dentist fora routine check up?
Yes No
Version 08/01/2014
b. had visits to a hospital emergency room?
c. spent nights in a medical/surgical hospital?(excluding birth delivery)
NC-TOPPS Mental Health and Substance AbuseChild (Ages 6-11) Update Interview
Use this form for backup only. Do not mail. Enter data into web-based system. (http://www.ncdhs.gov/mhddsas/nc-topps)
Confidentiality of SA and MH consumer-identifying information is protected under Federal regulations 42 CFR Part 2 and the Health Insurance Portability and Accountability Act of 1996, P.L. 104-91 (HIPAA) or implementing regulations, 45 CFR Parts 160 and 164. Consumer-identifying information may be disclosed without the individual's consent to the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS) and to its authorized evaluation contractors under the audit or evaluation exception. Redisclosure of consumer-identifying information without the individual's consent is explicitly prohibited. Your questions may be directed to (919) 515-1310. Sponsored by the NC MH/DD/SAS.
26. Other than yourself, how many active, stable relationship(s) with adult(s) who serve as positive role models does your child have? (i.e., member of clergy, neighbor, family member, coach )
None 1 or 2 3 or more
27. In the past 3 months, how often has your child been hit,kicked, slapped, or otherwise physically hurt?
Never A few times More than a few times Deferred
28. In the past 3 months, how often has your child hit, kicked,slapped, or otherwise physically hurt someone?
Never A few times More than a few times Deferred
29. Since the last interview, how often has your child tried tohurt him/herself or cause him/herself pain on purpose (suchas cut, burned, or bruised self)?
Never A few times More than a few times
30. Since the last interview, how often has your child hadthoughts of suicide?
NeverA few timesMore than a few timesDon't know
32. In the past 3 months, how well has your child been doingin the following areas of his/her life?
a. Emotional well-being
b. Physical health
c. Relationships with family
Excellent Good Fair Poor
Page 3
31. Since the last interview, has your child attempted suicide?Yes No
33. In the past 3 months, has your child...a. had contacts with an emergency crisis provider?
Yes No
Yes No
Yes No
e. spent nights homeless? (sheltered or unsheltered)Yes No
f. spent nights in detention, jail, or prison?(adult or juvenile system)
Yes No
d. increasing your child's control over his/her life?Not helpful Somewhat helpful Very helpful NA
c. increasing your child's hope about the future?Not helpful Somewhat helpful Very helpful NA
b. decreasing your child's symptoms?Not helpful Somewhat helpful Very helpful NA
a. improving the quality of your child's life?Not helpful Somewhat helpful Very helpful NA
34. How helpful have the program services been in...
End of interview
Enter data into web-based system: http://www.ncdhhs.gov/mhddsas/nc-topps
Do not mail this form
e. improving your child's educational status?Not helpful Somewhat helpful Very helpful NA
For Data Entry User (DEU) only:This printable interview form must be signed by the QP whocompleted the interview for this consumer.
Does this printable interview form have the QP'ssignature (see page 1)? Yes No
NOTE: This entire signed printable interview form must beplaced in the consumer's record.
d. Living/Housing situation
d. spent nights in a psychiatric inpatient hospital?Yes No
Version 08/01/2014
Intensive In-Home Services (IIH) - H2022
Multisystemic Therapy Services (MST) - H2033
Attachment I:NC-TOPPS Services
Community Based Services
Facility Based Day ServicesMental Health - Partial Hospitalization - H0035
Child and Adolescent Day Treatment - H2012 HA
Residential Services
Behavioral Health - Level III - Long Term Residential - H0019Residential Treatment - Level II - Program Type (Therapeutic Behavioral Services) - H2020
Psychiatric Residential Treatment Facility - YA230Group Living - High - YP780
Therapeutic Foster Care ServicesResidential Treatment - Level II - Family Type (Foster Care Therapeutic Child) - S5145