1 - None of the 5 - A good bit of the

2 - A little of the 3 - Occasionally. 4 - Some of the 6 - Most of the 7 - All of the time.
time. Extremely time. Moderate time. Mild
time. Severe Moderately severe time. Very mild Independently
severe impairment impairment or
impairment or impairment or Impairment or impairments or managed in
or problems in problems in
probliems problems in problems in problems in community. No
Strengths functioning. functioning. functioning. functioning. Low fuctioning. functioning. Low impairment or
Continuous level of continuous Moderate level or
Extensive level of Moderate level of level or problem in
support and staff imtermittent staff
continuous paid continuous paid paid supports intermittent staff functioning requiring
intervention intervention
supports needed. supports needed. needed. interventions. staff intervention.
required. required.

Threatens suicide
Actively suicidal Has a history of Numerous threats Occasional threats of when upset, but
Multiple threats
with multiple suicidal ideation, of suicide, but no retracts statements Has no history of
with several suicide, but no actual when calm.
Suicidal Behavior attempts in the attempts in the last past attempts over actual attempt in Has suicidal behavior, no
attempts in the past history, but no
past year. Has plan year. No means. plan.two years. No
past past year. Has year. No ideation. actual attempts in threats or actions.
and means. ideation.
three years.

Has committed History of History of attempted No history of Makes homicidal

homicide in the attempted homicide. Has Makes serious
homicide, but has threats when
past. Has made homicide. Has made threats of homicidal threats, angered or upset, No history of
Homicidality made serious,
threats of made threats of homicide, with but has not acted on homicidal ideation.
intent and plan, in frequent threats but can be
homicide in the homicide in the them.
with no intent. redirected.
past 6 months. past year. the past two years.

Frequent, Frequent acts,

unpredictable acts sometimes Occasional Infrequent incidents,
Persistent
that have acute precipitated by behavior, brought on by
occurances, mostly stressful situations. History of behavior, No instances of self-
Self-injurious consequences events, that can motivated by
superficial in nature, no instance in past injurious behavior.
Behavior requiring medical cause dangerous circumstance. Possesses coping
that do not require year.
treatment. consequences and Does not require skills to avoid self
medical treatment.
Multiple episodes may require medical attention. harm.
in past 6 months. medical treatment.
 1 - None of the 5 - A good bit of the
2 - A little of the 3 - Occasionally. 4 - Some of the 6 - Most of the 7 - All of the time.
time. Extremely time. Moderate time. Mild
time. Severe Moderately severe time. Very mild Independently
severe impairment impairment or
impairment or impairment or Impairment or impairments or managed in
or problems in problems in
probliems problems in problems in problems in community. No
Strengths functioning. functioning. functioning. functioning. Low fuctioning. functioning. Low impairment or
Continuous level of continuous Moderate level or
Extensive level of Moderate level of level or problem in
support and staff imtermittent staff
continuous paid continuous paid paid supports intermittent staff functioning requiring
intervention intervention
supports needed. supports needed. needed. interventions. staff intervention.
required. required.

History of fire setting History of fire

Long history of fire History of fire settting or careless
History of fire or careless behavior,
setting. Several setting or careless History of fire behavior, no active No history of fire
setting with one no active attempts in
Fire Safety incidents in past behavior with a setting, incident in attempts in past setting or careless
incident in past past three years, but
year, most recent few incidents in the past year. five years, behavior.
two years. has made threats
in past 6 months. the past year. occasional threats
when upset. when angry.

Has history of Occasional atypical Makes unwanted

sexually deviant Sometimes will make Intermittently
Has history of behavior, including sexual suggestions
behavior: rape, sexual statements to makes sexual
criminal deviant peeping, exposure, or advances
Sexual Behaviors child pornography, others that are comments to No sexual behavioral
behavior but not unwanted sexual towards others,
molestation, public inappropriate and others, but concerns noted.
charged in past advances towards makes obscene
nudity. Has unwanted, but will understands it is
year. others, explicit guestures or
committed offense not act on them. wrong.
language. statements.
in past year.

Occasional use,
Using substances, Infrequent use, in
Actively using Occasional use, attends treatment Rarely uses, in
but not daily. Not treatment, not
Substance Use substances. Not in open to treatment program treatment, attends No substance abuse
in treatment, but attending AA/NA
treatment. Denies intake but not sporadically, not meetings, has issues known.
recognizes meetings regularly,
problem. committed. committed to sponsor.
problem. no sponsor.
program.
 1 - None of the 5 - A good bit of the
2 - A little of the 3 - Occasionally. 4 - Some of the 6 - Most of the 7 - All of the time.
time. Extremely time. Moderate time. Mild
time. Severe Moderately severe time. Very mild Independently
severe impairment impairment or
impairment or impairment or Impairment or impairments or managed in
or problems in problems in
probliems problems in problems in problems in community. No
Strengths functioning. functioning. functioning. functioning. Low fuctioning. functioning. Low impairment or
Continuous level of continuous Moderate level or
Extensive level of Moderate level of level or problem in
support and staff imtermittent staff
continuous paid continuous paid paid supports intermittent staff functioning requiring
intervention intervention
supports needed. supports needed. needed. interventions. staff intervention.
required. required.

Has made threats

In the past 30 days, Has demostrated Has made threats of of physical Has made frequent Makes occasional
has injured others physical aggression physical aggression, aggression, or threats of physical threats of violence No history of physical
Physical or displayed towards others, or been aggressive acted aggressive aggression when towards others, aggression towards
Aggression aggressive possibly caused causing injury to towards others angry, but has not but has not acted others.
behavior towards injury to others, in others, in the past without injury, in acted on the threats. on them.
others. past 6 months. year. the past year.

Has displayed
In the past 30 days, Has demostrated antagonistic Periodically, will be
behavior towards Has been belligerent
has displayed Has been hostile argumentative, but
aggressive verbal aggression towards others, but
Verbal Aggression verbally with others on others on will be reasonable No issues of verbal
towards others in will occasionally
behavior towards past 6 months multiple occasions, numerous with others the aggression noted.
on occasions, causing apologize for
others on multiple multiple occasions. in the past year. majority of the
behavior.
occasions. strife with others in time.
the past year.

Currently
incarcerated, Off probation or
felony record. Has Recently released, On probation or On probation or
Legal parole, on an IOC. On IOC, with
parole for a year or parole for three or
Involvement committed a crime in past 6 months. more. Follows rules with minimal assistance. No legal involvement.
more years.
against person or some mistakes.
property.
 1 - None of the 5 - A good bit of the
2 - A little of the 3 - Occasionally. 4 - Some of the 6 - Most of the 7 - All of the time.
time. Extremely time. Moderate time. Mild
time. Severe Moderately severe time. Very mild Independently
severe impairment impairment or
impairment or impairment or Impairment or impairments or managed in
or problems in problems in
probliems problems in problems in problems in community. No
Strengths functioning. functioning. functioning. functioning. Low fuctioning. functioning. Low impairment or
Continuous level of continuous Moderate level or
Extensive level of Moderate level of level or problem in
support and staff imtermittent staff
continuous paid continuous paid paid supports intermittent staff functioning requiring
intervention intervention
supports needed. supports needed. needed. interventions. staff intervention.
required. required.

Is able to use
Is hospitalized a Is hospitalized a coping skills prior
Goes to the few times couple of times a to hospitalizations
Currently hospital multiple Is inpatient throughout the year, but will use to allow for No history of
Psychiatric hospitalized.
Hospitalization History of multiple Uses hospital as a throughout the year. occasionally utilize current
times a month. numerous times year, but will treatment diversion of most psychiatric
providers to divert hospitalizations. hospitalizations.
hospitalizations. coping skill. Crisis Residential as some Hospitalized no
alternative. hospitalizations. more than once a
year.

Contacts 911 or Inappropriately Inappropriately Inappropriately

uses emergency Inappropriately Inappropriately
contacts 911 or uses contacts 911 or contacts 911 or
Emergency services several contacts 911 or contacts 911 or uses Does not abuse
emergency services uses emergency uses emergency
Services times a week. uses emergency emergency services emergency services.
several times a services more than services several
Abuses emergency services weekly. monthly.
month. once a month. times a year.
services.

Has persistent health No physcial health

Has life threatening Has serious health Has persistent concerns, is in Sees physicians for concerns. Follows all
Has persistent
heatlh issues, is health issues but treatment, but appointments and doctor's
Physical Health illness, not in issues, not in open to treatment struggles with follows doctor's recommendations
Issues treatment. Denies treatment. Denies but not currently attends treatment following orders with and attends all
issue issue. sporadically.
enrolled. recommendations assistance. appointments
without assistance. independently.
 1 - None of the 5 - A good bit of the
2 - A little of the 3 - Occasionally. 4 - Some of the 6 - Most of the 7 - All of the time.
time. Extremely time. Moderate time. Mild
time. Severe Moderately severe time. Very mild Independently
severe impairment impairment or
impairment or impairment or Impairment or impairments or managed in
or problems in problems in
probliems problems in problems in problems in community. No
Strengths functioning. functioning. functioning. functioning. Low fuctioning. functioning. Low impairment or
Continuous level of continuous Moderate level or
Extensive level of Moderate level of level or problem in
support and staff imtermittent staff
continuous paid continuous paid paid supports intermittent staff functioning requiring
intervention intervention
supports needed. supports needed. needed. interventions. staff intervention.
required. required.

Has persistent
mental health Sees psychiatrist No mental health
Has serious mental Has persistent Has persistent concerns. Follows all
concerns, is in and /or therapist
health issues, not issues, isheatlh
mental mental health doctor's
Behavioral Health issues but attends treatment, but for appointments
open to recommendations
Service Use in treatment. struggles with and follows
treatment but not treatment and attends all
Significant mental Denies issue. currently enrolled. sporadically. following doctor's orders appointments
illness, currently recommendations with assistance. independently.
not in treatment. without assistance.
Denies significant
mental illness.

Declines all Will attend Is willing to attend

recommendations Will agree to a few Some appointments appointments and appointments, follow Manages physcial Manages all physical
Physical Health by medical follow
appointments but kept, will follow recommendations, health with minor health needs
professionals; recommentdations
Service Use refuses to attend will not follow some but needs frequent prompts or
recommendations. recommendations. ,achieve
but cannot independently.
prompts or assistance.
scheduled without assistance.
appointments. active support.

Refuses all Takes medications as Takes medications

Does not take Not taking Always takes
medication prescribed with with prompts,
medications, but is medications, but will Takes medications medications as
Medication without clear strong a lot of refuses dose when
able to state meet with doctor to intermittently or prescribed. Does not
Management reason. Denies assistance. Will upset, but will
reasons for non- discuss medications selectively. need to take any
need for occasionally refuse sometimes take it
adherance. or alternatives. medications.
medication. medication. later.
 1 - None of the 5 - A good bit of the
2 - A little of the 3 - Occasionally. 4 - Some of the 6 - Most of the 7 - All of the time.
time. Extremely time. Moderate time. Mild
time. Severe Moderately severe time. Very mild Independently
severe impairment impairment or
impairment or impairment or Impairment or impairments or managed in
or problems in problems in
probliems problems in problems in problems in community. No
Strengths functioning. functioning. functioning. functioning. Low fuctioning. functioning. Low impairment or
Continuous level of continuous Moderate level or
Extensive level of Moderate level of level or problem in
support and staff imtermittent staff
continuous paid continuous paid paid supports intermittent staff functioning requiring
intervention intervention
supports needed. supports needed. needed. interventions. staff intervention.
required. required.

States that they Will discuss

Unaware of Admits to having Makes plan and
have a desire to options for change, Makes plan, will will follow through Has made meaningful
problem, unwilling problem but
Motivation change, but not makes plan, but follow through, but change and is
or too discouraged cannot commit to with minimal
willing to make a does not follow inconsistently. committed to it.
to change. change. assistence.
plan. through.

Communicates Will discuss Struggles at times

feelings once in a problems when with informing Confides in others
Non while. Frequent prompted. Will others when there but sometimes keeps Good
communicative Communicates
issues or disagreements sometimes tell is a problem, but problems to self. communication.
Communication regarding appropriately. Voices
feelings. Frequent with others. Has others or write will discuss when Argues with others Has some difficulty concerns, makes
issues but not down concerns, but prompted. sometimes, but is expressing self
arguments with wishes known.
inclined to discuss. not ready to discuss. Becomes angry at quick to apologize when upset.
others. Has not sought Not ready to work times, but willing and talk it out.
help for behavior. on issue. to work it out.

Has developed
some natural
Has natural familial Has limited family Has family and Has positive natural supports
supports, but has and friend
Natural Supports No natural friend involvement, supports, and independently Has solid natural
conflictual involvement, but is but does not
supports. initiates contact through the support network.
relationship at positive interaction initiate contact. occasionally. community in
times. when occurs. addition to friends
and family
 1 - None of the 5 - A good bit of the
2 - A little of the 3 - Occasionally. 4 - Some of the 6 - Most of the 7 - All of the time.
time. Extremely time. Moderate time. Mild
time. Severe Moderately severe time. Very mild Independently
severe impairment impairment or
impairment or impairment or Impairment or impairments or managed in
or problems in problems in
probliems problems in problems in problems in community. No
Strengths functioning. functioning. functioning. functioning. Low fuctioning. functioning. Low impairment or
Continuous level of continuous Moderate level or
Extensive level of Moderate level of level or problem in
support and staff imtermittent staff
continuous paid continuous paid paid supports intermittent staff functioning requiring
intervention intervention
supports needed. supports needed. needed. interventions. staff intervention.
required. required.

Will shower a few Showers and brushes

Does not shower, Will shower weekly, times a week,
Does not shower, teeth every couple of
brushes teeth brushes teeth
brush teeth, or brush teeth, or days. Will wash Handles personal No issues with
sometimes, and sporadically.
Personal Care shave. Does not shave. Will change shaves occasionally. clothing weekly with care with minimal hygiene or personal
Washes clothes
wash or change clothes, but will lots of prompts. Can assistance. care.
Washes clothes twice a month, but
clothes. not wash them. be prompted to put
monthly. will still wear dirty on clean clothing.
clothing at times.

Needs a Needs a
Can make change Representative Representative Payee
from a dollar, count
Has income, but Payee. Can make for bill pay Can manage own
money, but cannot
requires change from a assistance. Can money but Has income. Can
manage
Managing Money No current income. Representative dollar, count make change from a occasionally will manage own money
independently
Payee, unable to money. Needs bill dollar, count money, have budgeting independently.
without a
manage money. pay assistance and and can manage issues.
Representative weekly spending weekly spending
Payee. budgeted. money.

Two or more Never been

Chronically Homeless for past Sporadically One incident of One incident of
incidents of homeless. Lives
Housing homeless for the homeless for past homelessness in the homelessness in
6 months homelessness or past year. independently in own
past year. year. past 5 years.
more in past year. home.
 7 - All of the time.
1 -None of the time. 2 - A little of the 3 - Occasionally. 4 - Some of the 5 - A good bit of the 6 - Most of the Extremely severe
Independently time. Very mild Mild impairment or time. Moderate time. Moderately time. Severe impairment or
managed in impairments or problems in Impairment or severe impairment impairment or problems in
community. No problems in fuctioning. problems in or problems in probliems
Domains functioning.
impairment or functioning. Low Moderate level or functioning. Low functioning. functioning. Continuous
problem in level or imtermittent staff level of continuous Moderate level of Extensive level of support and staff
functioning requiring intermittent staff intervention paid supports continuous paid continuous paid intervention
staff intervention. interventions. required. needed. supports needed. supports needed. required.

Threatens suicide
when upset, but threats of Numerous threats Has a history of Actively suicidal
retracts statements Occasional Multiple threats
Has no history of but no actual actual attempt no
of suicide, but suicidal ideation, with multiple
1. Suicidal suicidal behavior, no when calm. Has suicide, with several
attempts in the past past year. Has in past attempts over attempts in the last attempts in the
Behavior threats or actions. history, but no past two years. No year. No means. and means.Has plan
past year.
actual attempts in year. No ideation. ideation. plan.
three years.

History of attempted History of Has committed

Makes homicidal No history of
Makes serious homicide. Has attempted homicide in the
threats when homicide, but has
2. Homicidality No history of homicidal threats, made threats of homicide. Has past. Has made
angered or upset, made serious,
homicidal ideation. but has not acted on homicide, with made threats of threats of
but can be frequent threats
them. intent and plan, in homicide in the homicide in the
redirected. with no intent. the past two years. past year. past 6 months.

Frequent acts, Frequent,

Infrequent incidents, Occasional sometimes unpredictable acts
Persistent
History of behavior, brought on by behavior, precipitated by that have acute
occurances, mostly
3. Self-injurious No instances of self- no instance in past Possessessituations.
stressful motivated by events, that can consequences
Behavior injurious behavior. coping circumstance. superficial in nature, cause dangerous requiring medical
year. skills to avoid self Does not require that do not require consequences and treatment.
medical treatment.
harm. medical attention. may require Multiple episodes
medical treatment. in past 6 months.
 7 - All of the time.
1 -None of the time. 2 - A little of the 3 - Occasionally. 4 - Some of the 5 - A good bit of the 6 - Most of the Extremely severe
Independently time. Very mild Mild impairment or time. Moderate time. Moderately time. Severe impairment or
managed in impairments or problems in Impairment or severe impairment impairment or problems in
community. No problems in fuctioning. problems in or problems in probliems
Domains functioning.
impairment or functioning. Low Moderate level or functioning. Low functioning. functioning. Continuous
problem in level or imtermittent staff level of continuous Moderate level of Extensive level of support and staff
functioning requiring intermittent staff intervention paid supports continuous paid continuous paid intervention
staff intervention. interventions. required. needed. supports needed. supports needed. required.

History of fire History of fire setting

settting or careless History of fire Long history of fire
or careless behavior, History of fire
No history of fire behavior, no active History of fire setting or careless setting. Several
no active attempts in setting with one
4. Fire Safety setting or careless attempts in past setting, incident in behavior with a incidents in past
past three years, but incident in past
behavior. five years, the past year. few incidents in year, most recent
has made threats two years.
occasional threats the past year. in past 6 months.
when upset.
when angry.

Has history of
Makes unwanted Occasional atypical
Intermittently Sometimes will make sexually deviant
sexual suggestions behavior, including Has history of
makes sexual sexual statements to behavior: rape,
or advances peeping, exposure, criminal deviant
5. Sexual No sexual behavioral comments to others that are towards others, unwanted sexual behavior but not child pornography,
Behaviors concerns noted. others, but inappropriate and molestation, public
makes obscene advances towards charged in past
understands it is unwanted, but will nudity. Has
guestures or others, explicit year.
wrong. not act on them. committed offense
statements. language. in past year.

Occasional use,
Infrequent use, in Using substances,
Rarely uses, in attends treatment Occasional use, Actively using
treatment, not but not daily. Not
6. Substance Use No substance abuse treatment, attends program open to treatment substances. Not in
issues known. meetings, has attending AA/NA sporadically, not intake but not in treatment, but treatment. Denies
sponsor. meetings regularly, committed to committed. recognizes problem.
no sponsor. problem.
program.
 7 - All of the time.
1 -None of the time. 2 - A little of the 3 - Occasionally. 4 - Some of the 5 - A good bit of the 6 - Most of the Extremely severe
Independently time. Very mild Mild impairment or time. Moderate time. Moderately time. Severe impairment or
managed in impairments or problems in Impairment or severe impairment impairment or problems in
community. No problems in fuctioning. problems in or problems in probliems
Domains functioning.
impairment or functioning. Low Moderate level or functioning. Low functioning. functioning. Continuous
problem in level or imtermittent staff level of continuous Moderate level of Extensive level of support and staff
functioning requiring intermittent staff intervention paid supports continuous paid continuous paid intervention
staff intervention. interventions. required. needed. supports needed. supports needed. required.

Has made threats Has made threats of Has demostrated In the past 30 days,
Makes occasional Has made frequent of physical physical aggression, physical aggression has injured others
No history of physical threats of violence threats of physical aggression, or
7. Physical or been aggressive towards others, or displayed
aggression towards towards others, aggression when acted aggressive
Aggression causing injury to possibly caused aggressive
others. but has not acted angry, but has not towards others others, in the past injury to others, in behavior towards
on them. acted on the threats. without injury, in year. past 6 months. others.
the past year.

Has displayed
Periodically, will be Has been belligerent antagonistic In the past 30 days,
Has demostrated
argumentative, but towards others, but behavior towards Has been hostile has displayed
verbal aggression
8. Verbal No issues of verbal will be reasonable others on with others on verbally aggressive
will occasionally towards others in
Aggression aggression noted. with others the numerous multiple occasions, behavior towards
apologize for past 6 months on
majority of the occasions, causing in the past year. others on multiple
behavior. multiple occasions.
time. strife with others in occasions.
the past year.

Currently
Off probation or incarcerated,
On probation or On probation or
9. Legal No legal involvement. minimal assistance. parole,
On IOC, with on an IOC. parole for three or parole for a year or in past 6 months. felony
Recently released, record. Has
Involvement Follows rules with committed a crime
more years. more.
some mistakes. against person or
property.
 7 - All of the time.
1 -None of the time. 2 - A little of the 3 - Occasionally. 4 - Some of the 5 - A good bit of the 6 - Most of the Extremely severe
Independently time. Very mild Mild impairment or time. Moderate time. Moderately time. Severe impairment or
managed in impairments or problems in Impairment or severe impairment impairment or problems in
community. No problems in fuctioning. problems in or problems in probliems
Domains functioning.
impairment or functioning. Low Moderate level or functioning. Low functioning. functioning. Continuous
problem in level or imtermittent staff level of continuous Moderate level of Extensive level of support and staff
functioning requiring intermittent staff intervention paid supports continuous paid continuous paid intervention
staff intervention. interventions. required. needed. supports needed. supports needed. required.

Is able to use
coping skills prior Is hospitalized a Is hospitalized a
to hospitalizations couple of times a few times Goes to the Currently
10. Psychiatric No history of to allow for year, but will use throughout the Is inpatient hospital multiple hospitalized.
psychiatric diversion of most current treatment year, but will numerous times times a month.
Hospitalization hospitalizations. History of multiple
hospitalizations. providers to divert occasionally utilize throughout the year. Uses hospital as a hospitalizations.
Hospitalized no some Crisis Residential as coping skill.
more than once a hospitalizations. alternative.
year.

Contacts 911 or
Inappropriately Inappropriately Inappropriately
Inappropriately Inappropriately uses emergency
contacts 911 or contacts 911 or contacts 911 or uses
11. Emergency Does not abuse contacts 911 or uses contacts 911 or services several
emergency services. uses emergency uses emergency emergency services
Services emergency services uses emergency times a week.
services several services more than several times a
monthly. services weekly. Abuses emergency
times a year. once a month. month. services.

No physcial health Has persistent health

concerns. Follows all Sees physicians for concerns, is in Has persistent
Has persistent Has serious health Has life threatening
doctor's appointments and treatment, but heatlh issues, is
12. Physical health issues but issues, not in illness, not in
recommendations follows doctor's struggles with open to treatment
Health Issues attends treatment treatment. Denies treatment. Denies
and attends all orders with following but not currently
sporadically. issue. issue
appointments assistance. recommendations enrolled.
independently. without assistance.
 7 - All of the time.
1 -None of the time. 2 - A little of the 3 - Occasionally. 4 - Some of the 5 - A good bit of the 6 - Most of the Extremely severe
Independently time. Very mild Mild impairment or time. Moderate time. Moderately time. Severe impairment or
managed in impairments or problems in Impairment or severe impairment impairment or problems in
community. No problems in fuctioning. problems in or problems in probliems
Domains functioning.
impairment or functioning. Low Moderate level or functioning. Low functioning. functioning. Continuous
problem in level or imtermittent staff level of continuous Moderate level of Extensive level of support and staff
functioning requiring intermittent staff intervention paid supports continuous paid continuous paid intervention
staff intervention. interventions. required. needed. supports needed. supports needed. required.

Has persistent
No mental health Sees psychiatrist mental health
concerns. Follows all Has persistent Has persistent
and /or therapist concerns, is in Has serious mental
13. Behavioral doctor's mental health mental heatlh
for appointments treatment, but health issues, not
Health Service recommendations issues but attends issues, is open to
and follows struggles with in treatment.
Use and attends all treatment treatment but not
doctor's orders following Denies issue. Significant mental
appointments sporadically. currently enrolled.
with assistance. recommendations illness, currently
independently. without assistance. not in treatment.
Denies significant
mental illness.

Will attend Declines all

Is willing to attend
physcial appointments, follow appointments and Some appointments Will agree to a few recommendations
14. Physical Manages all physical Manages follow appointments but by medical
health with minor recommendations, recommentdations kept, will follow
Health Service health needs professionals;
prompts or but needs frequent , but cannot some will not follow
Use independently. recommendations. recommendations. refuses to attend
assistance. prompts or achieve without scheduled
assistance. active support. appointments.

Takes medications Takes medications as Refuses all

Always takes Not taking Does not take
with prompts, prescribed with medication
15. Medication medications as Takes medications medications, but will medications, but is
refuses dose when strong a lot of without clear
Management need to take any not
prescribed. Does intermittently or meet with doctor to able to state
upset, but will assistance. Will reason. Denies
occasionally refuse selectively. discuss medications reasons for non-
sometimes take it need for
medications. or alternatives. adherance.
later. medication. medication.
 7 - All of the time.
1 -None of the time. 2 - A little of the 3 - Occasionally. 4 - Some of the 5 - A good bit of the 6 - Most of the Extremely severe
Independently time. Very mild Mild impairment or time. Moderate time. Moderately time. Severe impairment or
managed in impairments or problems in Impairment or severe impairment impairment or problems in
community. No problems in fuctioning. problems in or problems in probliems
Domains functioning.
impairment or functioning. Low Moderate level or functioning. Low functioning. functioning. Continuous
problem in level or imtermittent staff level of continuous Moderate level of Extensive level of support and staff
functioning requiring intermittent staff intervention paid supports continuous paid continuous paid intervention
staff intervention. interventions. required. needed. supports needed. supports needed. required.

3 - A good bit of the 7 - None of the

1 - All of the time. 2 - Most of the 4 - Some of the 5 - Occasionally. 6 - A little of the
time. Mild time. Extremely
Independently time. Very mild time. Moderate Moderately severe time. Severe
impairment or severe impairment
managed in impairments or Impairment or impairment or impairment or
problems in or problems in
community. No problems in problems in problems in probliems
Domains fuctioning. functioning.
impairment or functioning. Low functioning. Low functioning. functioning.
Moderate level or Continuous
problem in level or level of continuous Moderate level of Extensive level of
imtermittent staff support and staff
functioning requiring intermittent staff paid supports continuous paid continuous paid
intervention intervention
staff intervention. interventions. needed. supports needed. supports needed.
required. required.

Will discuss States that they

Makes plan and Admits to having Unaware of
Has made meaningful will follow through Makes plan, will options for change, have a desire to problem but problem, unwilling
16. Motivation change and is follow through, but makes plan, but change, but not
with minimal cannot commit to or too discouraged
committed to it. inconsistently. does not follow willing to make a
assistence. change. to change.
through. plan.

Struggles at times Will discuss Communicates

Confides in others with informing problems when feelings once in a Non
Good but sometimes keeps others when there prompted. Will while. Frequent
Communicates communicative
appropriately. Voices Has some difficulty problems
communication. to self. is a problem, but sometimes tell disagreements
17. regarding issues or
Argues with others will discuss when others or write with others. Has
Communication concerns, makes feelings. Frequent
expressing self sometimes, but is prompted. down concerns, but issues but not
wishes known. when upset. quick to apologize Becomes angry at not ready to discuss. inclined to discuss. arguments with
others.
and talk it out. times, but willing Not ready to work Has not sought
to work it out. on issue. help for behavior.
 7 - All of the time.
1 -None of the time. 2 - A little of the 3 - Occasionally. 4 - Some of the 5 - A good bit of the 6 - Most of the Extremely severe
Independently time. Very mild Mild impairment or time. Moderate time. Moderately time. Severe impairment or
managed in impairments or problems in Impairment or severe impairment impairment or problems in
community. No problems in fuctioning. problems in or problems in probliems
Domains functioning.
impairment or functioning. Low Moderate level or functioning. Low functioning. functioning. Continuous
problem in level or imtermittent staff level of continuous Moderate level of Extensive level of support and staff
functioning requiring intermittent staff intervention paid supports continuous paid continuous paid intervention
staff intervention. interventions. required. needed. supports needed. supports needed. required.

Has developed
some natural Has limited family Has natural familial
supports Has positive natural Has family and
friend involvement, and friend supports, but has No natural
18. Natural Has solid natural independently supports, and involvement, but is conflictual
Supports support network. through the initiates contact but does not supports.
positive interaction relationship at
community in occasionally. initiate contact. when occurs. times.
addition to friends
and family

Will shower a few

Showers and brushes times a week, Will shower weekly,
teeth every couple of Does not shower, Does not shower,
brushes teeth brushes teeth
No issues with Handles personal days. Will wash brush teeth, or brush teeth, or
sporadically. sometimes, and
19. Personal Care hygiene or personal care with minimal clothing weekly with shave. Will change shave. Does not
Washes clothes shaves occasionally.
care. assistance. lots of prompts. Can clothes, but will wash or change
twice a month, but Washes clothes
be prompted to put not wash them. clothes.
will still wear dirty monthly.
on clean clothing. clothing at times.
 7 - All of the time.
1 -None of the time. 2 - A little of the 3 - Occasionally. 4 - Some of the 5 - A good bit of the 6 - Most of the Extremely severe
Independently time. Very mild Mild impairment or time. Moderate time. Moderately time. Severe impairment or
managed in impairments or problems in Impairment or severe impairment impairment or problems in
community. No problems in fuctioning. problems in or problems in probliems
Domains functioning.
impairment or functioning. Low Moderate level or functioning. Low functioning. functioning. Continuous
problem in level or imtermittent staff level of continuous Moderate level of Extensive level of support and staff
functioning requiring intermittent staff intervention paid supports continuous paid continuous paid intervention
staff intervention. interventions. required. needed. supports needed. supports needed. required.

Needs a Needs a Can make change

Representative Payee Representative from a dollar, count
Can manage own for bill pay Payee. Can make Has income, but
money, but cannot
Has income. Can money but assistance. Can change from a requires
20. Managing manage
manage own money occasionally will make change from a dollar, count Representative
Money independently
independently. have budgeting dollar, count money, money. Needs bill Payee, unable to
without a
issues. and can manage pay assistance and manage money.
Representative
weekly spending weekly spending Payee.
money. budgeted.

Never been Two or more

One incident of One incident of Sporadically
homeless. Lives incidents of Homeless for past Chronically
21. Housing independently in own homelessness in homelessness in the homelessness or homeless for past homeless for the
6 months
past 5 years. past year. year. past year.
home. more in past year.