Mental Health and Substance Use Disorder Functional Screen Instructions: Module 2 - Basic Information and Demographics

Download the complete Mental Health and Substance Use Disorder Instruction Manual and Best Practices, P-00934 (PDF).

2.1 Introduction

Demographic information collected for the screen does not determine eligibility for services. Some demographic information may be used by state and county officials for resource and budget planning.

Screeners should use the other box to fill in answers that may not be provided in the screen.

2.2 Basic information

Agency information - assigned to
This is a read-only field that the application will fill in automatically with the name of the screening agency. Use the transfer utility to move a screen to another agency.

Screener information - referral date and screener’s name

Referral date: Enter the date someone requested that a screen be done. If no one requested the screen or the original referral was made years ago, enter the date you start it.
Screener name: Select your name. If your name is not present or the email that auto-populates is incorrect, contact the agency screen lead.

Screener information - screen type
Select one option.

Screen type 01, initial screen – The first mental health and substance use disorder functional screen completed for the applicant. If the applicant has been enrolled in CSP for years but this is their first screen, check initial screen.
Screen type 02, annual screen – Annual recertification screens may be required to continue in some mental health and substance use disorder programs.
Screen type 03, change of condition – At any time when an applicant’s physical, emotional, or living condition changes significantly they may request and/or receive additional screenings. For the mental health and substance use disorder functional screen, a change in condition screen should be completed if a significant change occurs that is likely to last six months or more.

Applicant’s information - first name, middle name, and last name

Enter the name of the applicant.
Middle name is optional; middle initial is sufficient.
Last name: If the applicant has a generational suffix title (examples: Jr. or IV) list this in the last name box, following the last name.

Applicant’s information - gender
Select the gender identity of the applicant. If the applicant identifies as an option not listed, select their birth sex and note their gender identity and pronouns in the notes section.

Applicant’s information - date of birth
The minimum age to enroll in a program connected to the screen is 18. However, to allow for advance planning for youth entering adult services, the screen can be completed for individuals as young as 16.

Enter the applicant’s date of birth in MMDDYYYY format (example: 01/01/2002). The “/” auto-fills between the field elements.

Dates of birth that make the applicant younger than 16 or older than 150 are not allowed to be entered. The date of birth must be earlier than the screen begin date.

Applicant’s information - Social Security Number
Enter the applicant’s Social Security Number with dashes (###-##-####). This is a required field. The Social Security Number is hidden after entry except for the last four digits to strengthen security and privacy.

Applicant’s information - MCI ID
The applicant is automatically assigned a Master Customer Index (MCI) ID when a screen profile is created with their name. This ID allows for DHS to track unique individuals through programs. Avoid creating duplicate profiles for a single individual. If you have questions, contact the agency screen leader.

Applicant’s information - address/city/state/zip and phone number(s)
Enter the full address of the applicant.

If the applicant has a street address and a PO Box, enter the street address on line 1, PO Box on line 2, and use the PO Box ZIP code.

For an applicant who is housing insecure, enter the address they lived at the most in the last six months. If the applicant is homeless, enter “homeless.”

If the applicant is currently in a hospital or other facility (nursing home, community-based residential facility) with no intention of moving into their own independent residence, then the hospital or other facility may be considered their permanent residence.

If the applicant is in a hospital or other facility but maintains an apartment or home in the community with the intention of returning in the next few weeks, the apartment or home is considered the permanent residence.

The phone number field(s) is optional. Still, try your best to enter at least one phone number. This information is important for clinicians to contact the applicant. If the applicant doesn’t have a phone number, leave the fields blank and mention the best way to reach them or a place to find them in the notes section.

Applicant’s information - county/tribe of residence and county of responsibility
In most cases, the county/tribe of residence and the county of responsibility is the same. In some cases, an applicant may live in one county or tribe, but another county is responsible for services, costs, and/or protective services. For the purposes of the screen, residency is physical presence or the intent to reside. The screen assumes county of responsibility to be the same as county/tribe of residence. This can be overridden if different counties/tribes are involved.

2.3 Referral source and primary source for screen information

Referral source information - referral source
Select the box that best describes who referred the applicant for a screen. If the referral source is not included in the list provided, select other and write in the referral source in the text box.

Primary source information - primary source for screen information;
This question is meant as a quality assurance reminder that screeners must not take shortcuts and complete a screen by only talking with caregivers, staff, etc. If the applicant is not the primary source of information, it is expected that in most cases other parts of the screen will indicate significant cognitive limitations.

Primary means the majority, over 50 percent. Please select the one source that most accurately reflect the primary source for screen information. In most cases, the primary source for screen information should be the applicant themselves. Often, screeners will also need to have collateral (additional) contacts with family, residential staff, and health care providers, but these contacts are additional contacts, not primary contacts.

If an interpreter is used, the applicant (not the interpreter) is still the primary source of information.

Screen interview information - where screen interview was conducted
Select one location where the screen was conducted. If the screen was conducted in different locations over a few days, select the most recent location and indicate such in the notes section.

Person’s current residence includes private homes, residential facilities, or nursing homes.

Nursing home: This refers to a place where five or more people who are not related to the operator or administrator reside. Because of their mental or physical condition, they require access to 24-hour nursing services, including limited nursing care, intermediate level nursing care and skilled nursing services. Nursing home does not include any of the following:

A convent or facility owned or operated exclusively by and for members of a religious order that provides reception and care or treatment of an individual.
A hospice, as defined in Wis. Stat. § 50.90 (1), that directly provides inpatient care.
A residential care apartment complex.

Temporary residence (non-institutional): This refers to an applicant staying with family or friends temporarily (example: The stay is to recuperate from an illness or surgery). This option also includes temporary stays in residential facilities, such as respite in a community-based residential facility. Do not select this option if the applicant is in an institution such as hospital, institution of mental disease, or nursing home.

Other includes locations not already specified in the above categories, such as telehealth, schools, local restaurant, etc. If other is selected, the screener must write where the screen was conducted in the notes section. If telehealth is used, the screener must note this in the notes section.

2.4 Demographics

Medical insurance information - Medical insurance
Check all that apply.

If Medicare is checked, enter the applicant’s Medicare number, and indicate if the applicant has Part A or Part B in the notes section.

Private insurance includes employer-sponsored insurances available as a job benefit and insurance purchased through the Affordable Care Act.

BadgerCare and Medicaid Purchase Plan (MAPP) are forms of Medicaid. If the person is on BadgerCare or MAPP, selecting the Medicaid box will autofill their Medicaid number. Make a comment about which coverage they have in the notes section.

Ethnicity and race information - Ethnicity
Hispanic or Latino ethnicity is included to provide data for federal reporting and quality improvement efforts. This is not a required field. It is expected that this field is completed unless the applicant objects. The content of this section follows federal standards.

Hispanic or Latino: A person of Mexican, Puerto Rican, Cuban, Central American, South American, or other Spanish culture or origin, regardless of race.

Ethnicity and race information - Race
Race is included to provide data for federal reporting and quality improvement efforts. This is not a required field. It is expected this field is completed unless the applicant objects. The content of this section follows federal standards.

American Indian or Alaska Native: People having origins in any of the original people of North and South America (including Central America) who maintain tribal affiliation or community attachment. It includes people who indicate their race or races as Lake Superior Chippewa, Ho-Chunk Nation, or Oneida Nation.
Asian or Pacific Islander: People having origins in any of the original peoples of the Far East, Southeast Asian, or the Indian subcontinent. It includes people who indicate their race or races as Asian Indian, Chinese, Filipino, Korean, Japanese, Vietnamese, or Other Asian, such as Burmese, Hmong, Pakistani, or Thai.
Black or African American: People having origins in any of the Black racial groups of Africa. It includes people who indicate their race as Black, African American, and Afro American, such as Nigerian or Haitian.
White: This refers to people having origins in any of the original peoples of Europe, the Middle East, or North Africa. It includes people who indicate their race as White, such as Irish, German, Italian, Lebanese, Near Easterner, Arab, or Polish.
Native Hawaiian or other Pacific Islander: This refers to people having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. It includes people who indicate their race or races as Native Hawaiian, Guamanian or Chamorro, Samoan, or Other Pacific Islander, such as Tahitian, Mariana Islander, or Chuukese.

Check all that apply for an applicant with mixed heritage.

Interpreter - if language interpreter is required
Health and human services providers are required under the Affordable Care Act to provide interpreters for people who need them. Leave this table blank if no interpreter is needed. Select the appropriate language if an interpreter is needed. If other is selected, write in the language needed.

Court order or negotiated settlement for treatment
Court orders are issued by a judge during a probable cause or final hearing to involuntarily commit an individual to a psychiatric institution or for community-based treatment. If an individual was involuntarily committed to treatment by a judge, select yes.

Applicants sometimes are offered a voluntary negotiated or contracted settlement agreement to abide by treatment orders in lieu of potentially being ordered into treatment during a court proceeding. If an individual has an active settlement agreement, select yes.

Conditions of probation are not considered court orders nor negotiated settlements. If there are conditions of probation related to an applicant’s treatment, indicate this in the notes section.

2.5 Contact information

For each contact listed in this section, select the relationship the contact has to the applicant. If one individual is the primary contact over any other listed contacts, list them first and indicate this in the best time to contact and/or comments section. The middle initial is optional for all contacts in this section. List details related to the collateral contacts in the notes section.

Legal guardian responsible for making decisions about medical care
If the applicant has a guardian of person, provide the guardian’s name, address, and phone number.

If a person has been found incompetent and has a court-appointed guardian of person, select yes.
If a person has not been found incompetent and does not have a court-appointed guardian of person or the applicant only has a court-appointed guardian of estate, select no.

This section focuses on medical care. The need for help with money management is captured elsewhere on the screen.

The guardian of person information is necessary to complete the screen for applicants with a guardian of person. The applicant and guardian of person must sign the screen to finalize it.

The contact information supplied may be used to notify the guardian of person of the applicant’s eligibility determination.

Please note in the best time to contact and/or comments section if this individual is the primary contact.

Activated power of attorney for health care responsible for making decisions about medical care
Some people may have a durable power of attorney for health care document drafted by their attorney that they think has been active from the time it was written. However, such documents do not count as activated power of attorney for health care. A power of attorney for health care is in force when it is filled out, but the applicant makes all their own decisions until they lose the ability to do so. The power of attorney for health care cannot make decisions for the person until after they are incapacitated. That is what is meant on the screen by activated. A power of attorney for health care is activated only when the applicant has lost their capacity to make their own health care decisions. Activation usually requires documentation by two physicians.

Leave this table blank if the applicant does not have an activated power of attorney for health care or a durable power of attorney.

Please note in the best time to contact and/or comments section if this individual is the primary contact.

Other contacts - adult child, ex-spouse, spouse, parent/stepparent, sibling, other family member, case manager, representative payee, and others
List individuals who may be primary contacts or important contacts during the screening process or in the future. It is not necessary to list the applicant’s probation officer or former spouse unless these people participated in the screen interview and the applicant agrees they are important contacts.

If the applicant is a minor, enter their parent’s name and contact information for a parent who has legal responsibilities for the child’s medical decisions (a parent who would receive mail from Medicaid and the county). A second parent can be entered by selecting the add new button.

Parental information can be added if the applicant is not a minor and the applicant gives permission for them to be listed as a contact.

Complete this section only with the applicant’s permission. Preserve confidentiality.

Please note in the best time to contact and/or comments section if one of these individuals is the primary contact.

2.6 Living situation

Current residence and where the applicant prefers to live
You may only select one option for both questions. If you select other, enter an explanation in the other box.

Once you determined where the applicant currently resides, ask the applicant where they want to live. Ask questions to help the applicant articulate their preference and select the answer that best describes what the applicant says. Explain their options. Do not select the answer that other people prefer for the applicant or the option that seems most realistic for the applicant. If the applicant says they want to have a place of their own, select own home or apartment. Do not select someone else’s apartment or residential care apartment complex even if that may be what the person will need.

This question allows researchers to track data regarding whether applicants are living where they want to live and changes over time.

Answer options:

Own home or apartment (alone or with someone): Select this option for applicants who live in their own home or apartment, either alone or with a roommate. Select this option for applicants up to age 19 still living in their parent's or guardian’s home.
Someone else’s home or apartment: Select this option for applicants age 19 or over still living in their parent’s or guardian’s home.
Residential care apartment complex (RCAC) or other supported apartment program: Select this option for an independent apartment complex where five or more adults reside. Apartments must each have a lockable entrance and exit; a kitchen, including a stove (or microwave oven); and individual bathroom, sleeping, and living areas. Residential care apartment complex is a type of assisted living.
Adult family home: This refers to a private residence where people who aren’t related to the caregiver live. The residents get care that’s beyond room and board. This can include up to seven hours per week of nursing care per person. An adult family home is a type of assisted living.
Group-home – CBRF (community-based residential facility, child caring institution): This refers to a place where five or more adults live who are not related to the operator or administrator. The residents do not require care above intermediate level nursing care. There may be treatment and other services that are above room and board but no more than 3 hours of nursing care per week per resident.
Transitional housing: This refers to certified or licensed housing provided by human services agencies or the corrections system.
Nursing home: This refers to a place where five or more people who are not related to the operator or administrator reside. Because of their mental or physical condition, they require access to 24-hour nursing services, including limited nursing care, intermediate level nursing care and skilled nursing services. Nursing home does not include any of the following:
- A convent or facility owned or operated exclusively by and for members of a religious order that provides reception and care or treatment of an individual.
- A hospice, as defined in Wis. Stat. § 50.90 (1), that directly provides inpatient care.
- A residential care apartment complex.
ICF-MR/FDD/DD center/state center for developmental disabilities: This refers to a facility serving people with development disabilities. These are residential facilities that serve four or more people for the purpose of diagnosis, treatment, or rehabilitation of people with intellectual disabilities and related conditions. Residents receive active treatment, ongoing evaluation, planning, 24-hour supervision, coordination, and integration of health or rehabilitative services to help them function at their greatest ability.
Mental health institute/state psychiatric hospital: This refers to a facility operated by DHS that provides specialized psychiatric services.
Other IMD – institution for mental disease: This refers to a hospital, nursing facility, or other facility of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of people with mental diseases.
No permanent residence: This refers to living on the street or in a shelter, living in a car, or temporary stays (days or weeks) at the homes of family and friends.

2.7 Vocational information

Wisconsin is committed to removing barriers to employment for people with disabilities who want to work. This section gathers work-related information. The information collected is used to improve employment outcomes for people receiving mental health and substance use services.

Current work status
Select only one option. If you select other, enter an explanation in the other box.

Full-time competitive employment is work that is performed on a full-time basis (30 hours per week or more) for which an individual is:
- Compensated at or above minimum wage and comparable to the customary rate paid by the employer to employees without disabilities performing similar duties and with similar training and experience.
- Receiving the same level of benefits provided to other employees without disabilities in similar positions.
- At a location where the employee interacts with other individuals without disabilities.
- Presented opportunities for advancement similar to other employees without disabilities in similar positions.
- If the individual is self-employed, their self-employment is considered full-time competitive employment if their work yields an income that is comparable to the income received by other individuals who are not individuals with disabilities and who are self-employed in similar occupations or on similar tasks and who have similar training, experience, and skills.
Part-time competitive employment is work that is performed on a part-time basis (less than 30 hours per week) for which an individual is:
- Compensated at or above minimum wage and comparable to the customary rate paid by the employer to employees without disabilities performing similar duties and with similar training and experience.
- Receiving the same level of benefits provided to other employees without disabilities in similar positions.
- At a location where the employee interacts with other individuals without disabilities.
- Presented opportunities for advancement similar to other employees without disabilities in similar positions.
- If the individual is self-employed, their self-employment is considered part-time competitive employment if their work yields an income that is comparable to the income received by other individuals who are not individuals with disabilities and who are self-employed in similar occupations or on similar tasks and who have similar training, experience, and skills.
Sheltered workshop/pre-voc (or prevocational services) is defined as a non-competitive, non-integrated job which is not open to the public. The person does not have to apply for nor compete for the job. Human services staff are present to assist participants. This category includes group supported employment, transitional employment, temporary work experiences, and any other employment opportunity where the place they are working for is not the employer of record.
Retired is defined as withdrawal from one's position, occupation, or from active working life while receiving retirement benefits. Applicants can be considered retired if they are younger than 65 and have retired early, however their retirement cannot be due to health issues. Do not check if the applicant stopped work due to disabilities, mental illness, or other physical health problems, even if applicant prefers to use the term retire.
Not employed is defined as an individual who is not retired, is of working age (at least age 16), and is currently not working. Do not check if the person is on medical leave from a job. In this case, they are still employed.
Unpaid work covers someone who is a homemaker, caregiver, volunteer, or student. This category does not influence eligibility. It was added to recognize unpaid labor.
Other includes any situations that are not captured in the above categories.

Interest in a job
Select only one option.

Interested in having a job or interested in having a new job is defined as when the applicant is not currently working but wants a job or if the applicant has a job but wants a different one.
Not interested in having a job or a new job is defined as when the applicant is not interested in having a job or if the applicant is employed and does not want to change jobs.
Wants to work but is afraid of losing MA and SSA benefits is defined as when the applicant wants a paying job but does not have one because they are afraid of losing their benefits due to earning too much money.

Needs assistance to find/apply for work

Select NA if the applicant does not want a job or if the applicant is not interested in finding a new job.
Select Independent if the applicant wants to find a job but does not need assistance to do so.
Select Needs Assistance if the applicant needs help finding a job, such as looking through employment ads, completing an application, developing a resume, etc.

Needs assistance to work

Select NA if the applicant does not work nor wants to work in the future.
Select Independent if the applicant has applied for and maintained jobs without assistance from support staff.
Select any of the other options (based on an estimated frequency of assistance needed) if the applicant needs assistance to function at a job. Assistance includes monitoring, supervision, reminders, coaching, and/or direct service. Assistance may help the applicant show up on time, dress appropriately, perform expected tasks, perform in cooperation with others, and complete other work-related tasks. (This does not include transportation, which is covered elsewhere.)

Needs assistance with schooling

Select NA if the applicant does not attend school nor wants to attend school in the future.
Select Independent if the applicant has applied for and maintained schooling without assistance from support staff.
Select any of the other options (based on an estimated frequency of assistance needed) if the applicant requires assistance finding or applying for school and to function at school. This includes registering for school, scheduling classes, showing up on time, performing in cooperation with others, etc. This does not include educational tutoring nor assistance due to a learning or intellectual disability.