Intensity and frequency of services report

Extended Services Survey

Client Name
MM slash DD slash YYYY
Meets criteria for SED or SMI
How many days a week do you see this client? Enter a number 1 through 7.
How many minutes per session? example: 90, 105, 120, 135, 150, 180?
Please describe the risk factors for this client. Be sure to include suicidal ideation, previous suicide attempts, self-mutilation or cutting, thoughts of harming self, thoughts of harming others, aggressive behavior, previous acts of aggression to others, previous psychiatric hospitalizations, foster care placements, risk of disruption of placement in home or foster care, impulsive behavior, episodes of intoxication or substance use, psychotic or delusional behavior, fire setting, arrests, runaway behavior, gang involvement, loss of a relationship, severe or chronic health condition, transgender, or other factors putting the client at risk.
Does client have Case Management services?
Please include changes you are making in your services as well as adding natural resources to prevent relapse, risk behavior, or disruption of placement including hospitalization. If your client does not have case management, consider a referral for case management. The MCO provides case management too and you can contact the MCO for this service.