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
Date
MCO/MCO Provider #
Diagnosis
Contact Number
Please enter a valid phone number.
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

YesNo
Needs assistance with access to housing, vocational, medical, social, educational, community services or supports

YesNo
At least one (1) of the following apply:

Been involved with at least 1 child welfare agency or criminal justice agencyIn the custody of DCBSAt risk of out-of-home placementAt risk of inpatient mental health treatment
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:

Self-care – provide, sustain, and protect self at age appropriate levelInterpersonal relationships -- satisfactory relationships with peers and adultsFamily life – capacity to live in a family/family type environmentSelf-direction – ability to learn social and intellectual skills
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

YesNo
Needs assistance with access to housing, vocational, medical, social, educational, community services or supports

YesNo
At least one (1) of the following apply:

Been involved with at least 1 child welfare agency or criminal justice agencyIn the custody of DCBSAt risk of out-of-home placementAt risk of inpatient mental health treatment
Significant impairment in major area of living (check all that apply):

Support GroupSocialEducationalOccupationalHousingEconomicHealthcareLegal
Clinically significant symptoms which have persisted continuously for at least 2 years OR Hospitalization for mental illness more than once inthe past 2 years

YesNo
Significantly impaired in the ability to function socially and/or occupationally

YesNo
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

YesNo
At least one (1) of the following apply:

A lack of access to recovery supportsNeeds assistance with access to housing, vocational, medical, social, educational, community services or supportsInvolvement with 1 or more child welfare or criminal justice agencies but not be an inmate of a public institution
A recipient of a public institution

YesNo
Between the age of 21 years and 64 years while receiving services in an institution for mental disease

YesNo
Clinician Signature

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Date

MonthDayYear
Date
Case Manager*

Tina Smajlagic
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