Case Staffing

CASE STAFFING Consumer’s Name: _______________________________ Date of Staffing:

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CID #: ________________

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Part I: Participants in Staffing Printed Name

Title

Signature

__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Part II: Staffing Note A. BEHAVIORS (Check All That Apply): Sleep Disturbance

Poor Concentration

Inattentive/Not focusing

Mood Liability

Isolating from others

Runaway behavior

Irritability

Appetite Disturbance

Truancy

RX Meds Drug/Alcohol Use or Abuse Social Withdrawal

Anxiety

Panic Attacks

Feelings of worthlessness

Bed Wetting

Stealing

Impulsivity

Lying/ Manipulative

Self-injurious Behavior

Hyperactivity

Sexual Acting Out

Obsessions/ Compulsions

Delusions

Paranoid Ideations

Loose Associations

Suicidal or Homicidal thoughts/ behaviors

Episodic crying

Depressed Mood

Oppositional/Defiant

Hallucinations Low Energy

B. INTERVENTIONS BY: Title: ________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Title: ________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Title: ________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ BH601-Case Staffing

Est MAR 2008

PAGE 2 of 2 Case Staffing

C. RESPONSE/PROGRESS:

 ___________________________________________________________________________________  ___________________________________________________________________________________  ___________________________________________________________________________________  ___________________________________________________________________________________

D. PLAN (Include concerns, risks, needs):

 ___________________________________________________________________________________  ___________________________________________________________________________________  ___________________________________________________________________________________  ___________________________________________________________________________________

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Name of Staff Completing Form: ________________________________ Title: ________________ Date Submitted for Chart: ___________________ Witness: _________________________________

BH601-Case Staffing

Est MAR 2008