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Sandhills Center for MH/DD/SA Services NC Division of MH/DD/SA Services TARGET POPULATION ENROLLMENT/SPECIAL POPULATION FOR MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES CONSUMER NAME: RECORD # Provider Agency: Admission Consumer Current Admission Date: Update – Please check appropriate box below: New Population Group being added that is concurrent with existing population group OR End existing Population Group and begin new population group identified below REMINDER: Please review all target population criteria before enrolling the consumer in the target populations. IPRS Target Population(s) for Active Client (check all that apply): MENTAL HEALTH MEDTP CMECD CMSED CMMED CMPAT CMDEF AMSPM AMSMI AMPAT AMDEF AMSRE TANF Medicaid consumers receiving enhanced services that are direct billed by provider Early Childhood Disorder Child seriously emotionally disturbed with out-of-home placement (CTSP approved clients only) Child seriously emotionally disturbed Child with MH diagnosis; SED and is homeless or at imminent risk of homelessness Child deaf or hard-of-hearing with MH diagnosis Adult GAF score 40 or less whose functioning interferes with capacity to remain in community Adult GAF score 50 or below with a diagnosis of serious mental illness Adult who is homeless or at imminent risk of homelessness Adult who is deaf or hard-of-hearing with MH diagnosis Stable Recovery – must have prior enrollment in AMSPM or AMSMI, or be eligible for enrollment in these target populations 200% of poverty or less and has qualifying child SUBSTANCE ABUSE CSSAD CSIP CSSP CSCJO CSMAJ CSWOM CSDWI ASCDR ASWOM ASDSS ASDWI ASHMT ASCJO ASDHH ASHOM ASTER Child with substance abuse primary diagnosis Child using alcohol or other drugs at a pre-clinical level; must be diagnosed V65.42 Child at elevated risk of SA; school problems or involvement with law or abused, or guardian has SA disorder Criminal Justice Offender Child enrolled in MAJORS Juvenile Court Justice Program only Adolescent woman with primary substance abuse diagnosis who is pregnant or has dependent children Adolescent with substance abuse diagnosis; arrested for DWI and in need of treatment for primary alcohol or drug diagnosis Adult injecting drugs with communicable disease risk Adult woman with primary SA diagnosis; pregnant or has dependent children, or is seeking custody of children Adult DSS-involved parents with primary diagnosis of substance abuse; legal custody of children Adult arrested for DWI and in need of treatment for alcohol or drug diagnosis Adult high management; primary substance abuse diagnosis; involuntarily committed Adult with primary substance abuse diagnosis; in CJ system; authorized by TASC case manager Adult with primary substance abuse diagnosis; deaf/hard-of-hearing Adult who meets any primary substance abuse category above and is considered homeless Adult with primary substance abuse disorder who requires SA assessment and treatment initiation, engagement and/or continuity of treatment and supports for relapse prevention and recovery stability Name of Staff Completing Form / Title Form No. AP-01-01-07 Revised 2/08 Date Target Population Enrollment HIM #119-MH/SA Sandhills Center for MH/DD/SA Services NC Division of MH/DD/SA Services TARGET POPULATION ENROLLMENT/SPECIAL POPULATION REVIEW CONSUMER NAME: RECORD # *Signature certifies Target Population remains the same based on the services provided. If Target Population has changed, a new form must be completed. Signature Review Date Signature Review Date Signature Review Date Signature Review Date Signature Review Date Signature Review Date Signature Review Date Signature Review Date Signature Review Date Signature Review Date Form No. AP-01-01-07 Revised 2/2008 Target Population Enrollment HIM #119-MH/SA
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