Targeted Case Management Screening Tool

TARGETED CASE MANAGEMENT SCREENING TOOL

Eligibility Criteria - Children, Adults and Substance Use
Client Name

First NameMiddle NameLast NameSuffix
Client DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
MCO/MCO Provider #
Diagnosis
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Email
example@example.com
Client meets the minimum requirements in each area:

Severe Emotional Disability (CHILD)--clinically significant disorder of thought, mood, perception, orientation, memory or behavior per DSM
A recipient of a public institution
Needs assistance with access to housing, vocational, medical, social, educational, community services or supports
At least one (1) of the following apply:
Limitations that have persisted for at least 1 year OR at risk of continuing for 1 year without intervention in at least 2 of the following:
Kentucky Resident

DCBS has removed child from home and unable to maintain child in a stable setting due to behavioral or emotional disturbance OR Under 21 meeting criteria as stated above and was receiving services prior to age 18 and must be continued for therapeutic benefit
Severe Mental Illness (ADULT) – diagnosis of a major mental disorder (Schizophrenia spectrum and other psychiatric disorders; Bipolar and related disorders; Depressive disorders; Post-traumatic stress disorders (under trauma and stressor-related disorders)
A recipient of a public institution
Needs assistance with access to housing, vocational, medical, social, educational, community services or supports
At least one (1) of the following apply:
Significant impairment in major area of living (check all that apply):
Clinically significant symptoms which have persisted continuously for at least 2 years OR Hospitalization for mental illness more than once inthe past 2 years
Significantly impaired in the ability to function socially and/or occupationally
Moderate or Severe SUBSTANCE USE disorder diagnosis OR co-occurring moderate or severe substance use disorder and mental health diagnosis
Significantly impaired in the ability to function socially and/or occupationally
At least one (1) of the following apply:
A recipient of a public institution
Between the age of 21 years and 64 years while receiving services in an institution for mental disease
Clinician Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Case Manager
Should be Empty: