IMCAT Rating Sheet Version 1 7 1 18 (Word) - Illinois



Illinois Medicaid – Crisis Assessment Tool (IM-CAT)Rating and Summary Sheet1. CLIENT INFORMATIONFirst Name:Last Name:RIN:Date of Birth: Gender: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Insurance Coverage: FORMCHECKBOX Medicaid - FFS FORMCHECKBOX Medicaid – Managed Care FORMCHECKBOX Private Insurance FORMCHECKBOX None FORMCHECKBOX Unknown Insurance Company: FORMCHECKBOX N/A FORMTEXT ?????GuardianshipStatus: FORMCHECKBOX Own guardian FORMCHECKBOX Biological Parent FORMCHECKBOX Adoptive Parent FORMCHECKBOX Youth in Care FORMCHECKBOX Other court appointed FORMCHECKBOX Other: FORMTEXT ?????Interpreter Services: FORMCHECKBOX None required FORMCHECKBOX American Sign Language FORMCHECKBOX Spoken Language: FORMTEXT ????? FORMCHECKBOX TDD/TYY FORMCHECKBOX Other: FORMTEXT ?????Guardian Consent Received: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A 2. SCREENING FORMCHECKBOX Initial crisis screening FORMCHECKBOX 24-hour non-emergency FORMCHECKBOX Discharge FORMCHECKBOX Other: FORMTEXT ?????Date of Call:Time of Call:Crisis Screener (name): Screener Credentials: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX am FORMCHECKBOX pm FORMTEXT ????? FORMCHECKBOX MHP FORMCHECKBOX QMHP FORMCHECKBOX LPHADate of Screening:Begin Time of Screening:End Time of Screening:Diagnosis: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX am FORMCHECKBOX pm FORMTEXT ????? FORMCHECKBOX am FORMCHECKBOX pm FORMTEXT ?????3. TRANSFERS FORMCHECKBOX N/A FORMCHECKBOX Hospital to HospitalSending Hospital: FORMTEXT ?????City/State: FORMTEXT ?????Transfer Date:Receiving Hospital: FORMTEXT ?????City/State: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX SASS to SASSSending SASS: FORMTEXT ?????City/State: FORMTEXT ?????Transfer Date:Receiving SASS: FORMTEXT ?????City/State: FORMTEXT ????? FORMTEXT ?????4. DISPOSITION FORMCHECKBOX Community stabilized (list community resources below) City/State: FORMTEXT ????? Date: FORMTEXT ?????1. Name: FORMTEXT ?????Resource Type: FORMTEXT ?????Phone #: FORMTEXT ?????2. Name: FORMTEXT ?????Resource Type: FORMTEXT ?????Phone #: FORMTEXT ?????3. Name: FORMTEXT ?????Resource Type: FORMTEXT ?????Phone #: FORMTEXT ????? FORMCHECKBOX Hospitalized at: FORMTEXT ?????City/State: FORMTEXT ?????Admission Date: FORMTEXT ?????5. MENTAL STATUS: Document clinical observations to support client’s current mental status as noted below. Appearance and Behavior: FORMTEXT ?????Threatening: FORMCHECKBOX Yes FORMCHECKBOX NoMood: FORMCHECKBOX WNL FORMCHECKBOX Depressed FORMCHECKBOX Manic FORMCHECKBOX Anxious FORMCHECKBOX AngrySuicidal: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Expansive FORMCHECKBOX Labile Homicidal: FORMCHECKBOX Yes FORMCHECKBOX NoAffect: FORMCHECKBOX WNL FORMCHECKBOX Sad FORMCHECKBOX Angry FORMCHECKBOX Flat FORMCHECKBOX ConstrictedImpulse Control: FORMCHECKBOX Poor FORMCHECKBOX Good FORMCHECKBOX InappropriateHallucinatory: FORMCHECKBOX Yes FORMCHECKBOX NoInsight: FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorDelusional: FORMCHECKBOX Yes FORMCHECKBOX NoOrientation: FORMCHECKBOX WNL FORMCHECKBOX ImpairedJudgment: FORMCHECKBOX WNL FORMCHECKBOX ImpairedCognition: FORMCHECKBOX WNL FORMCHECKBOX Loose Associations/DisorganizedMemory: FORMCHECKBOX WNL FORMCHECKBOX ImpairedPlease note: WNL = Within Normal LimitsFor all CAT domains, the following categories and action levels are used:0No evidence of any needs.2Action or intervention is required to ensure that the identified need is addressed.1Need that requires monitoring, watchful waiting, or preventive action. This may have been a risk behavior in the past.3Intensive and/or immediate action is required to address the need or risk behavior.Please note: Individual CAT items that are not applicable to the entire lifespan have specific age ranges for which the item must be completed indicated in front of the item name. If the item does not apply to the individual’s age, rate the item “N/A.”6. ASSESSMENTRISK BEHAVIORSN/A0123N/A01230-6: Self-Harm FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Sexually Problematic Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 1-6: Aggressive Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Fire Setting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3-6: Flight Risk FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Danger to Others FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3+: Suicide Risk FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Other Self-Harm (Recklessness) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3+: Decision-Making FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Non-Suicidal Self-Injur. Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3+: Intentional Misbehavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Delinquent/Criminal Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6-21: Runaway FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Community Safety FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX BEHAVIORAL/EMOTIONAL NEEDSN/A0123N/A0123Depression FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3-18: Oppositional FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Anxiety FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3+: Anger Control/Frustration Tol. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Adjustment to Trauma FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3+: Impulsivity/Hyperactivity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-6: Atypical/Repetitive Behaviors FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Conduct/Antisocial Behavior FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-6: Emotional Control FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Psychosis (Thought Disorder) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-6: Failure to Thrive FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6+: Substance Use FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-21: Attachment Difficulties FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FUNCTIONING NEEDSN/A0123N/A0123Living Situation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 1+: Sleep FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Family Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-6: Feeding/Elimination FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Social Functioning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-21: School/Preschool/Daycare FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Developmental/Intellectual FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 16+: Parental/Caregiving Role FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medication Compliance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 21+:Employment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX PROTECTIONN/A0123N/A0123Safety FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Marital/Partner Violence in the Home FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CAREGIVER RESOURCES & NEEDSClient is their own guardian: FORMCHECKBOX Yes FORMCHECKBOX No (if YES, skip this section)N/A0123N/A0123Supervision FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Health/Behavioral Health FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Involvement with Care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Family Stress FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Social Resources FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 0-21: Empathy with Children FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Caregiver Residential Stability FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7. NOTES/COMMENTS/CLARIFICATIONS: FORMTEXT ?????8. SIGNATURESScreener (print name)SignatureDate FORMTEXT ????? FORMTEXT ?????QMHP/LPHA Consult (when applicable)SignatureDate of Consultation FORMTEXT ????? FORMTEXT ????? ................
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