Care Management Scale--Youth Rev. 10/26/07

Care Management Scale--Youth Rev. 10/26/07 Client Name: ID: Date: _ Person Completing: Chronicity: Client has a qualifying diagnosis (see attached list) Mental Health condition was first documented to be present: Within the last year 1-3 years ago More than 3 years ago Clinically significant symptoms of the mental health condition have been present without a period of interruption lasting more than 30 days for: Less than six months For six months to 3 years For more than 3 years. Debilitation: Self Care: Youth has not had a period of six consecutive months living in the same living arrangement within the community within the last 2 years. Youth evidences notable deficits in personal hygiene requires substantial cueing to engage in personal hygiene Youth typically fails to complete chores (such as cleaning room) without direct supervision Youth is not able to be left alone unsupervised for developmentally appropriate periods of time (30 minute for youth 9-11, 1 hour for youth 11-12, 3-4 hours for youth 13 and older) Client has been psychiatrically hospitalized at least once in the last year or 2 or more times in the last 5 years Social Interaction Youth does not utilize 2 or more close friends/family members for emotional support on a weekly basis. Youth engaged in interpersonal conflict resulting in outside intervention (police being called, friends/neighbors intervening) one or more times in the last year Youth does not have a best friend Youth has been involved in a close relationship within the last year with someone who engages in destructive behavior including physical violence, substance abuse, or criminal behavior. Youth lives in a home environment that includes violence/substance abuse

Vocational/Economic Functioning: Youth has missed more than 25% of school days in the last school year Youth has been placed in an alternate school placement (behavioral management classroom, special education do not check for vocational school or Occupational Work Experience) Youth has been suspended from school in the last year Youth has been terminated from a job in the last year Self-Directed Behavior Youth has engaged in criminal activity at the felony level in the last 5 years Youth has engaged in criminal activity in the last year at the misdemeanor level Youth has been charged with criminal activity within the last year Youth regularly engages in socially inappropriate behavior including verbal outbursts, making threats, fighting, etc. Youth has engaged in self-damaging behavior in the last year (self mutilation, suicide gestures, intentional failure to meet own basic needs do not check for passive failure to meet own needs/neglect). Current Mediating Factors (typically within the last 3 months): Positive Factors (enter 1-3 from the attached key) Has and utilizes social support system outside of the treatment relationship Has and utilizes family or surrogate family support system Engages in treatment Has insight into mental health condition System involvement (Court, Children Services, etc.) Lives in a structured living arrangement (ie. Group Home, Foster Care, etc.) Takes medication as prescribed with good outcome Negative Factors (enter 1-3 from the attached key) _ Uses alcohol/illicit substances _ Engages in regular social interaction with persons who affiliate with the criminal subculture (not including contact through the court and/or treatment programs). _ Acute objective stressor onset within the last 3 months (rejection, loss of significant support, etc.)

Qualifying Diagnosis Code Diagnosis Grouping 296.00 Bipolar I Disorder, Single Manic Episode Unspecified 296.01 Bipolar I Disorder, Single Manic Episode Mild 296.02 Bipolar I Disorder, Single Manic Episode Moderate 296.03 Bipolar I Disorder, Single Manic Episode Severe without Psychotic Features 296.04 Bipolar I Disorder, Single Manic Episode Severe with Psychotic Features 296.05 Bipolar I Disorder, Single Manic Episode In Partial Remission 296.06 Bipolar I Disorder, Single Manic Episode In Full Remission 296.20 Major Depressive Disorder, Single Episode Unspecified 296.21 Major Depressive Disorder, Single Episode Mild 296.22 Major Depressive Disorder, Single Episode Moderate 296.23 Major Depressive Disorder, Single Episode Severe Without 296.25 Major Depressive Disorder, Single Episode In Partial Remission 296.26 Major Depressive Disorder, Single Episode In Full Remission 296.30 Major Depressive Disorder, Recurrent Unspecified 296.31 Major Depressive Disorder, Recurrent Mild 296.32 Major Depressive Disorder, Recurrent Moderate 296.33 Major Depressive Disorder, Recurrent Severe Without Psychotic Features 296.34 Major Depressive Disorder, Recurrent Severe With Psychotic Features 296.35 Major Depressive Disorder, Recurrent In Partial Remission 296.36 Major Depressive Disorder, Recurrent In Full Remission 296.40 Bipolar I Disorder, Most Recent Episode Manic Unspecified 296.401 Bipolar I Disorder, Most Recent Episode Hypomanic 296.41 Bipolar I Disorder, Most Recent Episode Manic Mild 296.42 Bipolar I Disorder, Most Recent Episode Manic Moderate 296.43 Bipolar I Disorder, Most Recent Episode Manic Severe without 296.44 Bipolar I Disorder, Most Recent Episode Manic Severe with 296.45 Bipolar I Disorder, Most Recent Episode Manic In Partial Remission 296.46 Bipolar I Disorder, Most Recent Episode Manic In Full Remission 296.50 Bipolar I Disorder, Most Recent Episode Depressed Unspecified 296.51 Bipolar I Disorder, Most Recent Episode Depressed Mild 296.52 Bipolar I Disorder, Most Recent Episode Depressed Moderate 296.53 Bipolar I Disorder, Most Recent Episode Depressed Severe Without 296.54 Bipolar I Disorder, Most Recent Episode Depressed Severe With 296.55 Bipolar I Disorder, Most Recent Episode Depressed In Partial Remission 296.56 Bipolar I Disorder, Most Recent Episode Depressed In Full

Code Diagnosis Grouping Remission 296.60 Bipolar I Disorder, Most Recent Episode Mixed Unspecified 296.61 Bipolar I Disorder, Most Recent Episode Mixed Mild 296.62 Bipolar I Disorder, Most Recent Episode Mixed Moderate 296.63 Bipolar I Disorder, Most Recent Episode Mixed Severe without 296.64 Bipolar I Disorder, Most Recent Episode Mixed Severe with 296.65 Bipolar I Disorder, Most Recent Episode Mixed In Partial Remission 296.66 Bipolar I Disorder, Most Recent Episode Mixed In Full Remission 296.7 Bipolar I Disorder, Most Recent Episode Unspecified 296.80 Bipolar Disorder NOS 296.89 Bipolar II Disorder 296.90 Disorder NOS 300.4 Dysthymic Disorder 301.13 Cyclothymic Disorder 311 Depressive Disorder NOS 300.12 Dissociative Amnesia Dissociative 300.13 Dissociative Fugue Dissociative 300.14 Dissociative Identity Disorder Dissociative 300.15 Dissociative Disorder NOS Dissociative 300.6 Depersonalization Disorder Dissociative 302.6 Gender Identity Disorder NOS Sexual Dysfunction/Identity 302.61 Gender Identity Disorder in Children Sexual Dysfunction/Identity 302.85 Gender Identity Disorder in Adolescents or Adults Sexual Dysfunction/Identity 302.90 Sexual Disorder NOS Sexual Dysfunction/Identity 302.2 Pedophilia Paraphilias 302.20 Pedophilia Paraphilias 302.3 Transvestic Fetishism Paraphilias 302.4 Exhibitionism Paraphilias 302.81 Fetishism Paraphilias 302.82 Voyeurism Paraphilias 302.83 Sexual Masochism Paraphilias 302.84 Sexual Sadism Paraphilias 302.89 Frotteurism Paraphilias 302.9 Paraphilia NOS Paraphilias 302.91 Sexual Disorder NOS Paraphilias V61.12 Sexual Abuse of Adult Paraphilias V61.21 Sexual Abuse of Child Paraphilias 307.1 Anorexia Nervosa Eating Disorders 307.50 Eating Disorder NOS Eating Disorders 307.51 Bulimia Nervosa Eating Disorders 307.421 Insomnia Related to...(axis I/Axis II Disorder) Sleep Disorders

Code Diagnosis Grouping 307.44 Primary Hypersomnia Sleep Disorders 307.441 Hypersomnia Related to...(axis I/Axis II Disorder) Sleep Disorders 307.45 Circadian Rhythm Sleep Disorder Sleep Disorders 307.461 Sleep Terror Disorder Sleep Disorders 307.47 Dyssomnia NOS Sleep Disorders 307.471 Parasomnia NOS Sleep Disorders 347 Narcolepsy Sleep Disorders 313.82 Identity Problem Other V-Codes 995.51 Sexual Abuse of Child (attention focus on victim) Other V-Codes 995.52 Physical Abuse of Child(attention focus on victim) Other V-Codes 995.53 Neglect of Child(focus of attention is on victim) Other V-Codes 995.81 Sexual Abuse of Adult (attention focus on victim) Other V-Codes 995.811 Physical Abuse of Adult(attention focus on victim) Other V-Codes 293.89 Anxiety Disorder Due to a General Medical Condition Anxiety 300.00 Anxiety Disorder NOS Anxiety 300.01 Panic Disorder Without Agoraphobia Anxiety 300.02 Generalized Anxiety Disorder Anxiety 300.21 Panic Disorder With Agoraphobia Anxiety 300.22 Agoraphobia Without History of Panic Disorder Anxiety 300.23 Social Phobia Anxiety 300.29 Specific Phobia Anxiety 300.3 Obsessive-Compulsive Disorder Anxiety 309.81 Posttraumatic Stress Disorder Anxiety 290.0 Dementia of the Alzheimer's Type, with Late Onset Uncomplicated Cognitive/Organic 290.101 Dementia Due to Pick's Disease' Cognitive/Organic 290.102 Dementia Due to Creutzfeldt-Jakob Disease' Cognitive/Organic 290.103 Dementia of the Alzheimer's Type, with Early Onset Uncomplicated Cognitive/Organic 290.11 Dementia of the Alzheimer's Type, with Early Onset With Delirium Cognitive/Organic 290.12 Dementia of the Alzheimer's Type, with Early Onset With Delusions Cognitive/Organic 290.13 Dementia of the Alzheimer's Type, with Early Onset With Cognitive/Organic Depressed 290.20 Dementia of the Alzheimer's Type, with Late Onset With Delusions Cognitive/Organic 290.21 Dementia of the Alzheimer's Type, with Late Onset With Depressed Cognitive/Organic 290.3 Dementia of the Alzheimer's Type, with Late Onset With Delirium Cognitive/Organic 290.40 Vascular Dementia Uncomplicated Cognitive/Organic 290.41 Vascular Dementia With Delirium Cognitive/Organic 290.42 Vascular Dementia With Delusions Cognitive/Organic 290.43 Vascular Dementia With Depressed Cognitive/Organic 293.0 Delirium Due to a General Medical Condition Cognitive/Organic 293.81 Psychotic Disorder Due to... With Delusions Cognitive/Organic 293.82 Psychotic Disorder Due to... With Hallucinations Cognitive/Organic 293.83 Disorder Due to a General Medical Condition Cognitive/Organic 293.891 Catatonic Disorder Due to... Cognitive/Organic 294.1 Dementia Due to Other General Medical Conditions Cognitive/Organic 294.11 Dementia Due to Parkinson's Disease Cognitive/Organic 294.12 Dementia Due to Head Trauma Cognitive/Organic

Code Diagnosis Grouping 294.13 Dementia Due to Huntington's Disease Cognitive/Organic 294.8 Dementia NOS Cognitive/Organic 299.00 Autistic Disorder Cognitive/Organic 299.10 Childhood Disintegrative Disorder Cognitive/Organic 299.80 Pervasive Developemental Disorder NOS Cognitive/Organic 299.801 Rett's Disorder Cognitive/Organic 299.802 Asperger's Disorder Cognitive/Organic 295.10 Schizophrenia Disorganized Type Psychosis 295.20 Schizophrenia Catatonic Type Psychosis 295.30 Schizophrenia Paranoid Type Psychosis 295.40 Schizophreniform Disorder Psychosis 295.60 Schizophrenia Residual Type Psychosis 295.70 Schizoaffective Disorder Psychosis 295.90 Schizophrenia Undifferentiated Type Psychosis 297.1 Delusional Disorder Psychosis 297.3 Shared Psychotic Disorder Psychosis 297.70 Schizo-Affective Disorder Psychosis 298.9 Psychotic Disorder NOS Psychosis 301.0 Paranoid Personality Disorder Personality 301.20 Schizoid Personality Disorder Personality 301.22 Schizotypal Personality Disorder Personality 301.4 Obsessive-Compulsive Personality Disorder Personality 301.50 Histrionic Personality Disorder Personality 301.6 Dependent Personality Disorder Personality 301.7 Antisocial Personality Disorder Personality 301.81 Narcissistic Personality Disorder Personality 301.82 Avoidant Personality Disorder Personality 301.83 Borderline Personality Disorder Personality 301.9 Personality Disorder NOS Personality 301.91 Personality Disorder NOS with Antisocial Features Personality 307.23 Tourette's Disorder Behavioral 307.3 Stereotypic Movement Disorder Behavioral 307.52 Pica Behavioral 307.53 Rumination Disorder Behavioral 307.6 Enuresis(Not Due to a General Medical Condition) Behavioral 307.7 Encopresis,wo Constipation & Overflow Incontinence Behavioral 309.21 Separation Anxiety Disorder Behavioral 312.30 Impulse-Control Disorder NOS Behavioral 312.31 Pathological Gambling Behavioral 312.32 Kleptomania Behavioral 312.33 Pyromania Behavioral 312.34 Intermittent Explosive Disorder Behavioral 312.39 Trichotillomania Behavioral 312.8 Conduct Disorder Behavioral 312.9 Disruptive Behavior Disorder NOS Behavioral 313.23 Selective Mutism Behavioral

Code Diagnosis Grouping 313.81 Oppositional Defiant Disorder Behavioral 313.89 Reactive Attachment Disorder of Infancy or Early Childhood Behavioral 313.9 Disorder of Infancy, Childhood, or Adolescence NOS Behavioral 314.00 Attention-Deficit/Hyperactivity Disorder Predominantly Inattentive Type Behavioral 314.01 Attention-Deficit/Hyperactivity Disorder Combined Type Behavioral 314.011 Attention-Deficit/Hyperactivity Disorder Predominantly Hyperactive- Impulsive Type Behavioral 314.02 Attention Deficit Hyperactivity Disorder By History Behavioral 314.9 Attention-Deficit/Hyperactivity Disorder NOS Behavioral 787.6 Encopresis,w Constipation & Overflow Incontinence Behavioral V61.13 Physical Abuse of Adult Behavioral V61.211 Physical Abuse of Child Behavioral V61.212 Neglect of Child Behavioral V71.01 Adult Antisocial Behavior Behavioral V71.02 Child or Adolescent Antisocial Behavior Behavioral 303.90 Alcohol Dependence Substance Use 304.00 Opioid Dependence Substance Use 304.10 Sedative, Hypnotic, or Anxiolytic Dependence Substance Use 304.20 Cocaine Dependence Substance Use 304.30 Cannabis Dependance Substance Use 304.31 Cannabis Dependence with Early Full Remission Substance Use 304.40 Amphetamine (or Amphetamine-Like) Dependence Substance Use 304.50 Hallucinogen Dependence Substance Use 304.60 Inhalant Dependence Substance Use 304.80 Polysubstance Dependence Substance Use 304.90 Phencyclidine Dependence Substance Use 304.901 Other (or Unknown) Substance Dependence Substance Use 305.10 Nicotine Dependence Substance Use 300.11 Conversion Disorder Somatoform/Factitious 300.16 Factitious Disorder w/predominantly Psychological Signs & Somatoform/Factitious Symptoms 300.19 Factitious Disorder w/combined Psychological\\Physical Signs & Somatoform/Factitious Symptoms 300.191 Factitious Disorder w/predominantly Physical Signs & Symptoms Somatoform/Factitious 300.192 Factitious Disorder NOS Somatoform/Factitious 300.7 Hypochondriasis Somatoform/Factitious 300.71 Body Dysmorphic Disorder Somatoform/Factitious 300.81 Undifferentiated Somatoform Disorder Somatoform/Factitious 300.811 Somatoform Disorder NOS Somatoform/Factitious 300.812 Somatization Disorder Somatoform/Factitious 307.80 Pain Disorder Associated w/psychological Factors Somatoform/Factitious 307.89 Pain Disorder Associated w/psychol. Factors & Gen. Medical Cond. Somatoform/Factitious

Positive Factors Social support system Family support system or surrogate family support system Engages in treatment Insight into mental health condition System involvement (Court, Children Services) Living arrangement (ie. Group home, foster care etc.) Medication Does not use social support person on a weekly basis No contact with family for support 1 2 3 Talk with support persons 1-2 times per week Has failed to schedule appointments for treatment or has missed more than 50% of scheduled appointments or does not participate in sessions when forced to attend or this is first appointment Does not understand diagnosis and has no insight into factors contributing to mental health issues No external systems involved Lives independently with no supervision/structure other than selfimposed or lives in a chaotic home environment Refuses to take prescribed medication, reports no benefits from medication prescribed Utilizes family support 1-2 times per week Has missed 25% of scheduled appointments or has scheduled appointments less than the recommended frequency or actively resists engaging in sessions Has limited understanding of diagnosis and has some insight into contributing factors 1 external system that provides monitoring Has imposed supervision and structure to a moderate degree Complies with medication by taking prescribed medication at least 4 days out of the week Can identify 5 or more support people and talks with support person 3 times a week or more Utilizes family support 3 or more times per week Has attended appointments at the recommended frequency and engages in the treatment process Understands diagnosis and is aware of factors that contribute to increased mental health symptoms Has 2 or more systems involved Has imposed rules and supervision 24 hours a day Complies with recommended medication regime and reports medication is effective OR does not require medication

Negative Factors Alcohol/ Illicit Substance Use Engages in regular social interaction with persons who affiliate with the criminal subculture Current acute stressor(s) (rejection, loss of significant support, etc.) 1 2 3 No reported use 3-4 drinks per More than 5 drinks per week and/or uses week and/or uses illicit illicit substance 1- substances 3 times or 2 times per week more per week and/or has unlimited access to alcohol/illicit Spends no time with antisocial peers No significant stressors (0-3 on a 10 point scale of severity) Spends some free time with antisocial peers Some stressors (4-7 on a 10 point scale) non-life threatening illness, breakup of long term relationship, unplanned move substances Spends most of free time with antisocial peers Significant stressors (8-10 on a 10 point scale) death of loved one, expulsion from school, recent victimization, multiple moderate stressors