ࡱ>  sbjbjA A h~#JHc#JHc"4WWW${{{PoT{@BDVX>6789<QR%&'RUǿڭtmimmamZma hxhm+Mhxh.DG5h ' hxh.DGh ?h.DGCJaJhUh.DG5h 'h.DGCJaJh 'h"qCJaJh]CJaJh"qCJaJh!%CJaJ h5 h]5hxh]5hxh]56>*h.DG56>*h.DGjh.DGUmHnHujh.DGUj<hA[sU#D89:;<QR&'wh^hgd ' & F gd.DGgd.DGgdXgd"q3'&#$$d%d&d'd+D[/NOPQgd.DG3'&#$$d%d&d'd+D[/NOPQgd] ./An<Dgd] $ *$gd] $ *$gd] 0*$gdO 2gdO 2gdXgd.DG & F gd.DGh^hgd.DGU./J$%&'>ABPQRno}~ȽȽrdVjhq.h]Ujhq.h]Ujhq.h]Uhq.h]B*phj&hq.h]U hq.h]jhq.h]U#jhq.h]OJQJUhq.h]OJQJjhq.h]OJQJUhghO 2OJQJhP( hxhO 2hxhO 25hO 2 hxh.DG!$%&<=KLMitb#jhq.h]OJQJU#jHhq.h]OJQJU#jhq.h]OJQJU#j\hq.h]OJQJUjhq.h]OJQJUhq.h]OJQJjhq.h]Ujphq.h]Ujhq.h]Ujhq.h]U hq.h]%DEFSTUV`a  02FHJTVZ\^~ʹթʹ՞ՓʹՈʹ́ h]h]jh]Uj h]UhO 2h]CJaJjh]Ujh]UmHnHuj4h]Ujh]Uh]hxh]5 hxh] h]5hxhO 25h'rh]OJQJ1DE^4 6 !$!p!r!!!"*#+#F$H$%% & 8h^8`hgd'3 0^`0gdO 2gdO 2`gd]gd]68LNPZ\hj~  " $ & 0 2 4 !!!! !"!ڶګڠ朔~jXh]Ujh]Ujh]Uh]jlhA[sUjhA[sUjhA[sUjhO 2UmHnHuj hA[sUhO 2jhO 2U hxhO 2hxhO 25 hO 25 hrV51"!$!H!J!^!`!b!l!n!p!r!t!!!!!!!!!!!""!"""#"%" #(#+#,#:#;#<#>#$B$H$J$f$h$j$n$%%%ŵŚŚŚjhA[sUj0hA[sUh$hO 26jhA[sUhxhO 25 hrV5jDhA[sU hxhO 2hO 2hO 2CJaJjhO 2UmHnHujhA[sUjhO 2UhO 2h].%%%%%% & &(&*&,&.&V&X&t&v&x&z&'','.'0'4'3(4(5(6(D(E(F(H((()~zo~kk~z`~kXhxhO 25jhA[sUhO 2j~hA[sUh'3jh'3U.j *h'3hA[sCJOJQJUaJ.j *h'3hA[sCJOJQJUaJ hxhO 2h'3CJOJQJaJ.j *h'3hA[sCJOJQJUaJ *h'3CJOJQJaJ"j *h'3CJOJQJUaJ" &V& ''4(5((())))*>++,,--`TbTdTfThTjTgdiO 0^`0gdO 2 0^`0gdO 2gdO 2^gd'3))")#)$)&)n))))))********>+@+\+^+`+b+++,öÒözÒöbÒö.j *h'3hA[sCJOJQJUaJ.jV *h'3hA[sCJOJQJUaJh'3CJOJQJaJ.j *h'3hA[sCJOJQJUaJ *h'3CJOJQJaJ"j *h'3CJOJQJUaJh$hO 26 hxhO 2hO 2jjhA[sUh'3jh'3U,,, ,,,--- ---------------.TTT T"T*T0TûÜwèeècQè#j"h'3hA[sCJUaJU#j!h'3hA[sCJUaJhhO 2CJaJ#j.!h'3hA[sCJUaJh'3CJaJjh'3CJUaJhO 2j hA[sUh'3jh'3U hxhO 2h'3CJOJQJaJ"j *h'3CJOJQJUaJ.jB  *h'3hA[sCJOJQJUaJ FORMCHECKBOX VA  FORMCHECKBOX  Other  FORMCHECKBOX  3. Displays maladaptive, dangerous, and impulsive behaviors.  FORMCHECKBOX  damages or destroys property  FORMCHECKBOX  is self-injurious, expresses suicide threats, or has made suicide attempts  FORMCHECKBOX  verbally assaults others, threatens physical violence towards others, or physically harms others  FORMCHECKBOX  abuses drugs or alcohol  FORMCHECKBOX  creates public disturbances, gets arrested, or has spent time in jail  FORMCHECKBOX  requires use of involuntary mental health services.  FORMCHECKBOX  4. Lacks supportive social systems in the community.  FORMCHECKBOX  no close friends or group affiliations  FORMCHECKBOX  lives alone  FORMCHECKBOX  is highly transient  FORMCHECKBOX  has an inability to coexist within family setting or group living situation  FORMCHECKBOX  5. Requires assistance in basic life and survival skills.  FORMCHECKBOX  must be reminded to take medication  FORMCHECKBOX  must have transportation to mental health clinic or other supportive services  FORMCHECKBOX  needs assistance in household management (budgeting, shopping, meal preparation, etc.)  FORMCHECKBOX  is homeless or is at risk of becoming ho0T2TNTPTRT`TbTnTpTrTtTTTTTUUUU2U4U6U8UrUtUUUUU*V,VһҨҖqeҖMeҨ.j# *h'3hA[sCJOJQJUaJh'3CJOJQJaJ.j|# *h'3hA[sCJOJQJUaJ *h'3CJOJQJaJ"j *h'3CJOJQJUaJhO 2j#hA[sUh'3jh'3U hxhrVhrVhiO hxhO 2#j"h'3hA[sCJUaJh'3CJaJjh'3CJUaJjTlTnTpTUUrU,VWfWXXX6Y8YYY2ZZZ[[[\ ^gds@* ^`gdrV ^gd'3gdO 2,V.VJVLVNVPVWW0W2W4W6WdWfWhWWWWWXX4X6X8X:XXXXXXjc[Whs@*jhs@*U hxh '.j% *hs@*hA[sCJOJQJUaJ.jT% *hs@*hA[sCJOJQJUaJhO 2.j$ *hs@*hA[sCJOJQJUaJ hxhO 2hs@*CJOJQJaJ.jh$ *hs@*hA[sCJOJQJUaJ *hs@*CJOJQJaJ"j *hs@*CJOJQJUaJXXXX8Y:YVYXYZY\YYYYYYYYYZZZ Z2Z4ZPZRZTZVZZZ[ªϞ†ϞnϞVϞRhs@*.j( *hs@*hA[sCJOJQJUaJ.j' *hs@*hA[sCJOJQJUaJ.j,' *hs@*hA[sCJOJQJUaJhiOCJOJQJaJ.j& *hs@*hA[sCJOJQJUaJ *hs@*CJOJQJaJ"j *hs@*CJOJQJUaJ hxhO 2hO 2jhs@*Uj@&hA[sU[[[[[[[[[[[[\\\\\\\\\\]]]]]]^jjj,jªϞ†ϞnϞVϞTU.jf* *hs@*hA[sCJOJQJUaJ.j) *hs@*hA[sCJOJQJUaJ.jz) *hs@*hA[sCJOJQJUaJhs@*CJOJQJaJ.j) *hs@*hA[sCJOJQJUaJ *hs@*CJOJQJaJ"j *hs@*CJOJQJUaJ hxhO 2hO 2jhs@*Uj(hA[sU \]jjjjjrkllllmmmJn0o2o ^gd.DG ^gd!% ^gd.DG &d P gd.DGgd.DG^gd.DGgdX ^gds@* ^`gdrVmeless  FORMCHECKBOX  inability to access and use community services Summary of Eligibility Part A: Diagnosis and GAF criteria met:  FORMCHECKBOX  YES  FORMCHECKBOX  NO Part B: At least 1 criterion met:  FORMCHECKBOX  YES  FORMCHECKBOX  NO Part C: At least 2 criteria met:  FORMCHECKBOX  YES  FORMCHECKBOX  NO ACTION: Designated Agency check only one:  FORMCHECKBOX  Criteria are met. Enroll in CRT.  FORMCHECKBOX  Criteria are not currently met. Enroll provisionally in CRT for up to six months.  FORMCHECKBOX  Criteria are not met. Notify client of appeal rights and refer to other appropriate program(s).     Revised 3/15/2016 Revised 3/15/16 NOTE: This form is to be used to report enrollment changes in program assignment and/or change of Designated Agency (DA) for CRT clients. DMH must receive this form from the receiving DA with applicable sections completed, before the transfer enrollment can be completed. This form must be filled out by authorized staff of a DMH Designated Agency (DA). 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