Block Grant Reporting Section 

CFDA 93.958 

(Mental Health)
U.S. Department of Health and Human Services 

Substance Abuse and Mental Health Services Administration

Table of Contents 

A. Introduction 

B. Implementation Report 

a. MHBG Table 1 Priority Area and Annual Performance Indicators – Progress Report

C. State Agency Expenditure Reports 

a. MHBG Table 2a (URS Table 7) State Agency Expenditure Report

b. MHBG Table 2b - State Agency Early Serious Mental Illness (ESMI) Expenditures Report 

c. MHBG Table 3 Set-aside for Children’s Mental Health Services

d. MHBG Table 4 (URS Table 8) Profile Of Mental Health Block Grant Expenditures for Non-Direct Service Activities. 

e. MHBG Table 5 (URS Table 10) – Profiles of Agencies Receiving Block Grant Funds Directly from the State MHA 

f. MHBG Table 6 Maintenance of Effort for Statewide Expenditures on Mental Health Services 

D. Population and Services Reports 

a. MHBG Table 7 (URS Table 1) Profile of the State Population by Diagnosis 
b. MHBG Table 8A and MHBG Table 8B (URS Tables 2A and 2B) Profile of Persons Served, All Programs by Age, 

Gender and Race/Ethnicity 

c. MHBG Table 9 (URS Table 3) Profile of Persons Served In the Community Mental Health Settings, State Psychiatric 

Hospitals and Other Settings

d. MHBG Table 10A and MHBG Table 10b (URS Tables 5A and 5B) Profile of Clients by Type of Funding Support 

e. MHBG Table 11 (URS Table 6) Profile of Client Turnover. 

f. MHBG Table 12 (URS Table 12) State Mental Health Agency Profile. 

g. MHBG Tables 13A and 13B (URS Tables 14A and 14B) Profile of Persons with SMI/SED Served By Age, Gender and

Race/Ethnicity

h. MHBG Table 14 (URS Table 15A) Profile of Persons Served in the Community Mental Health Settings, State 

Psychiatric Hospitals, and Other Settings for Adults with Serious Mental Illness (SMI) and Children with Serious 

Emotional Disturbance (SED) 

E. Performance Indicators and Accomplishments 

a. MHBG Table 15A (URS Table 4) Profile of Adult Clients by Employment Status 

b. MHBG Table 15B (URS Table 4A) Profile of Adult Clients by Employment Status: By Primary Diagnosis Reported 

c. MHBG Table 16 (URS Table 9) Social Connectedness and Improved Functioning 

d. MHBG Table 17A (URS Table 11) Summary Profile of Client Evaluation of Care 

e. MHBG Table 17B (URS Table 11A) Consumer Evaluation of Care by Consumer Characteristics: Race/Ethnicity

f. MHBG Table 18 (URS Table 15) Living Situation Profile 

g. MHBG Table 19 (URS Table 16) Profile of Adults with Serious Mental Illnesses and Children with Serious Emotional 

Disturbances Receiving Specific Services 

h. NEW TABLE: MHBG Table 19a (URS Table 16a) Adults with Serious Mental Illnesses and Children with Serious 

Emotional Disturbances Receiving Evidence Based Services for First Episode Psychosis. 

i. MHBG Table 20 (URS Table 17) Profile of Adults with Serious Mental Illnesses Receiving Specific Services during 

the Year

j. MHBG Table 21 (URS Table 19A) Profile of Criminal Justice or Juvenile Justice Involvement 

k. MHBG Table 22 (URS Table 19B) Profile of Change in School Attendance 

l. MHBG Table 23A (URS Table 20A) Profile of Non-Forensic (Voluntary and Civil-Involuntary) Patients Readmission 

to Any State Psychiatric Inpatient Hospital within 30/180 Days of Discharge 
m. MHBG Table 23B (URS Table 20B) Profile of Forensic Patients Readmission to Any State Psychiatric Inpatient 

Hospital within 30/180 Days of Discharge 

n. MHBG Table 24 (URS Table 21) Profile of Non-Forensic (Voluntary and Civil-Involuntary Patients) Readmission to 

Any Psychiatric Inpatient Care Unit (State Operated or Other Psychiatric Inpatient Unit) within 30/180 Days of 

Discharge
States and jurisdictions are required to complete the reporting document. The reporting document is comprised of the following 

sections: 

Section A. Introduction

Title XIX, Part B, Subpart III of the Public Health Service Act (42 U.S.C. 300x-52(a)), requires the secretary of the Department of Health 

and Human Services, acting through the administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), to 

determine the extent to which states and jurisdictions have implemented the state plan for the prior fiscal year. The purpose of the annual 

report is to provide information to assist the secretary in making this determination. 

States and jurisdictions are requested to prepare and submit their reports for the last completed state fiscal year (SFY), in the format 

provided in this guidance. The report will address the purposes for which the MHBG were expended, the recipients of grant funds, and the 

authorized activities conducted, and services purchased with such funds. Particular attention should be given to the progress made toward 

accomplishing the goals and performance indicators identified in the states and jurisdictions’ plans. 

All states and jurisdictions are required to prepare and submit their respective reports utilizing SAMHSA’s Web Block Grant Application 

System (BGAS). This report must be received by SAMHSA no later than December 1, in order for the state or jurisdiction to receive its 

next grant. If the due date falls on a weekend or federal holiday, the report will be due on the next business day. The following schedule 

includes specific due dates for annual reports: 

Due Dates for MH and Combined BG Components

FY the state is 

applying for funds

Application

Due

Plan

Due

Planning Period MHBG Report 

Due

2018 9/1/2017 Yes 7/1/17 – 6/30/19 12/1/2017

Report year is Last 

Completed SFY

2019 9/1/2018 No Updates only 12/1/2018

Report year is Last 

Completed SFY

Section B: Implementation Report - In this section, states, and jurisdictions are required to provide a brief review of the extent to which 

their respective plans were implemented, the progress towards the priorities and goals identified in the Block Grant plan, covering the last 

completed fiscal year. The report should also include a brief review of areas, the state, or jurisdiction identified in that Block Grant Plan, as 

needing improvement and changes, the state, or jurisdiction would propose to achieve the goals established for the priorities. 
Section C: State Agency Expenditure Reports - In this section, states and jurisdictions should provide information regarding expenditures 

for authorized activities and services for mental health. 

Section D: Populations and Services Report - In this section, states, and jurisdictions must provide specific information regarding the 

number of individuals, served with MHBG funds. In addition, states and jurisdictions should provide specific information regarding the 

services, these individuals received. 

Section E: Performance Indicators and Accomplishments - In this section of the report, states, and jurisdictions are required to complete the 

Performance Indicator tables. Performance indicators should be reported using the table format provided in this document. The purpose of 

the performance indicator tables is to show progress made over time as measured by SAMHSA’s National Outcome Measures (NOMS) for 

mental health services including any state- or jurisdiction-selected performance indicators. 
B. Implementation Report

The information states and jurisdictions entered into the performance indicator tables (Plan Table 1) in the planning section of the 

2018/2019, Behavioral Health Assessment and Plan will automatically populate cells 1 – 6 in the progress report tables below. States and 

jurisdictions are required to indicate whether each first-year performance target/outcome measurement identified in the 2018/2019 Plan was 

“Achieved” or “Not Achieved” in Cell 7, Report of Progress toward goal attainment. If a target was not achieved, a detailed explanation 

must be provided and remedial steps proposed to meet the target.

MHBG Table 1 - Priority Area and Annual Performance Indicators – Progress Report

Priority Areas and Annual Performance Indicators

1. Priority Area: 2. Priority Type (SAP, SAT, MHS):

3. Population(s) (SMI, SED, ESMI, PWWDC, IVDUs, HIV EIS, TB, OTHER): 

4. Goal of the priority area:

5. Objective:

6. Strategies to attain the objective:

7. Annual Performance Indicators/objectives to measure goal success:

Indicator #1:

a) Baseline measurement (Initial data collected prior to the first-year target/outcome): 

b) First-year target/outcome measurement (Progress – end of SFY 2018):

c) Second-year target/outcome measurement (Final – end of SFY 2019):

d) Data source: 

e) Description of data:

f) Data issues/caveats that affect outcome measures:

8. Report of Progress toward Goal Attainment:

First-year Target: ____ Achieved _____ Not Achieved (If not achieved, explain why.) 
Reason why target was not achieved, and changes proposed to meet target:

C. State Agency Expenditure Reports

States and jurisdictions should provide information regarding MHBG and state funds expended for authorized activities to prevent and treat 

mental illness during the last completed SFY. Please complete the tables described below. 

Please Note: Data for all tables contained in the Uniform Reporting System (URS) will continue to be submitted into the URS database 

maintained by the URS Contractor. Please complete the tables described below.

MHBG Table 2a (URS Table 7) - State Agency Expenditure Report. MHBG Table 2 provides information on Mental Health Expenditures 

and Sources of Funding. This includes funding from Medicaid, the MHBG and other federal funding sources, state, local and other funds. 

MHBG Table 2b - State Agency Early Serious Mental Illness (ESMI) Expenditures Report: MHBG Table 2b provides information on 

Mental Health Expenditures and Sources of Funding specifically for the First Episode Programs as well as other Early Serious Mental 

Illness programs through the set-aside. This includes funding from Medicaid, the MHBG and other federal funding sources, state, local and 

other funds. The inclusion of local funds is important, but is optional. 

MHBG Table 3 - Set-aside for Children’s Mental Health Service: This table provides a report of statewide expenditures for children’s 

mental health services during the last completed SFY. States are required to provide systems of integrated services for children with SED. 
Each year the State shall expend not less than the amount expended in FY 1994. If there is a shortfall in funding available for children’s 

mental health services, the state may request a waiver. A waiver may be granted if the Secretary determines that the State is providing an 

adequate level of comprehensive community mental health services for children with SED, as indicated by comparing the number of 

children in need of such services with the services actually available within the State. The Secretary shall approve or deny the request for a 

waiver no later than 120 days after the request has been made. A waiver granted by the Secretary shall be applicable only for the fiscal year 

in question. 

MHBG Table 4 (URS Table 8) - Profile of Mental Health Block Grant Expenditures for Non-Direct Service Activities. MHBG Table 4 is 

used to report expenditures of MHBG funds for non-direct service activities that are funded or conducted by the State Mental Health 

Authority during the last completed SFY. 

MHBG Table 5 (URS Table 10) - Profiles of Agencies Receiving Block Grant Funds Directly from the state MHA. This table, reports 

payments to recipients of MHBG funds including intermediaries, (e.g., administrative service organizations, and other organizations), which 

provided mental health services during the last completed SFY, including services for those with a first episode psychosis. 

MHBG Table 6 - Maintenance of Effort for Statewide Expenditures for Mental Health Service: This table reports, expenditures of all 

statewide, non-Federal expenditures for authorized activities to prevent and treat mental illness during the last completed SFY. 
MHBG Table 2a (URS Table 7) - MHBG State Agency Expenditure Report

This table describes expenditures for public mental health services provided or funded by the state mental health agency by source of 

funding. Include ONLY funds expended by the executive branch agency administering the Mental Health Block Grant.

MHBG State Agency Expenditures Report

MHBG Table 2a

Report Period From: To:

State Identifier:

Source of Funds

ACTIVITY

(See instructions for using Row 1.)

A.

Substance 

Abuse Block 

Grant

B. 

Mental

Health Block 

Grant

C. 

Medicaid

(Federal, State, 

and local)

D. 

Other Federal Funds 

(e.g., ACF (TANF), 

CDC, CMS 

(Medicare) 

SAMHSA, etc.)

E.

State 

funds

F.

Local funds

(excluding local

Medicaid)

G.

Other

1. Substance Abuse Prevention and 

Treatment

a. Pregnant Women and Women 

with Dependent Children

b. All Other 

2. Primary Prevention* $ $ $ $ $ $

3. Evidence-Based Practices for Early 

Serious Mental Illness.**

$ $ $ $ $ $ $ 

4. Tuberculosis Services

5. HIV Early Intervention Services

6. State Hospital

7. Other 24-Hour Care $ $ $ $ $ $
*States may only use MHBG funds to provide primary prevention services to the priority populations of adults with serious mental illness and children with severe

emotional disturbance.

**Column 3B is for expenditures related to ESMI including Frist Episode Psychosis programs funded through MHBG set-aside. These funds are not to be also counted in 

#8 Ambulatory/Community Non-24-Hour Care. 

MHBG Table 2b - MHBG State Agency First Episode Psychosis Expenditure Report

MHBG State Agency Early Serious Mental Illness and First Episode Psychosis Expenditures Report

MHBG Table 2b

Report Period From: To:

State Identifier:

Source of Funds

Activity

(See instructions for using Row 1

A.

Mental Health 

Block Grant

B. 

Medicaid 

(Federal, 

State, and 

local)

C. 

Other Federal 

Funds (e.g., 

ACF (TANF), 

CDC, CMS 

(Medicare), 

SAMHSA, 

etc.)

D.

State Funds

E.

Local funds 

(excluding 

local Medicaid)

F.

Other

1. CSC-Evidence-Based Practices for 

First Episode Psychosis*

$ $ $ $ $ $ 

2. Other Early Serious Mental 

Illnesses programs (other than 

FEP or partial CSC programs)

3.. Training

$ $ $ $ $ $ 

4.. Planning

*When reporting CSC- Evidence Based Practices for First Episode Psychosis, report only those programs that are providing all the 

components of a CSC model. If the state uses only certain components of a CSC model, please report them in row 2. 

8. Ambulatory/Community Non-24-Hour 

Care

$ $ $ $ $ $ 

9. Administration (excluding program/ 

provider level

$ $ $ $ $ $ 

10. Total $ $ $ $ $ $
MHBG Table 3 Set-Aside for Children’s Mental Health Services 

States and jurisdictions are required not to spend less than the amount expended in FY 1994. 

Statewide Expenditures for Children’s Mental Health Services

MHBG Table 3:

State Identifier:

Report Period: From: To:

Actual SFY 1994 Actual SFY 2017
MHBG Table 4 (URS Table 8) Profile of Community Mental Health Block Grant Expenditures for Non-Direct Service Activities

This table is used to describe the use of MHBG funds for non-direct service activities that are sponsored, or conducted, by the State Mental Health 

Authority. 

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.

Please enter the total amount of the block grant expended for each activity. 

Non-Direct-Services/System Development

MHBG Table 4

State Identifier:

Report Period- From: To:

Activity A. MHBG B. SABG 

Treatment 

C. SABG 

Prevention

D. SABG 

Combined 

*

1. Information Systems $ $ $ $

2. Infrastructure Support $ $ $ $

3. Partnerships, community outreach, and needs 

assessment $ $ $ $ 

4. Planning Council Activities (MHBG required, SABG 

optional) $ $ $ $

5. Quality assurance and improvement $ $ $ $

6. Research and Evaluation $ $ $ $

7. Training and Education $ $ $ $

8. Total $ $ $ $

*Combined refers to non-direct service/system development expenditures that support both treatment and prevention systems
5.

6.

7.

8.
MHBG Table 5 (URS Table 10) Profiles of Agencies Receiving Block Grant Funds Directly from the State MHA

Profiles of Agencies Receiving Block Grant Funds Directly from the State MHA

MHBG Table 5

State Identifier:

Report Period- From: To:

Source of Funds

SA Block Grant MH Block Grant

A B C D E F G I

Entity

Number 

I-SATS

ID (for

SABG)

Area Served 

(Statewide or 

Sub-State 

Planning Area)

Provider/Program 

Name

Street 

Address 

City State Zip Total 

Block 

Grant 

Funds 

Prevention 

(other than 

primary 

prevention) 

and 

Treatment 

Services 

Pregnant 

Women 

and 

Women 

with 

Dependent 

Children

Primary 

Prevention 

Early 

Intervention 

Services for 

HIV

Adults 

with

serious 

mental 

illness

Children 

with a 

serious 

emotional 

disturbance 

Set-aside 

for FEP 

programs 

$ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $

Total $ $ $ $ $ $ $ $
MHBG Table 6 Maintenance of Effort for State Expenditures on Mental Health Services 

Maintenance of Effort for State Expenditures on Mental Health Services

MHBG Table 6:

State Identifier:

Report Period: From: To:

Total Expenditures for State:

Period

A

Expenditures

B

B1 (2015) + B2 (2016)

2 

C

SFY 2015

(1)

SFY 2016

(2)

SFY 2017

(3)

Are the expenditure amounts reported in Column B “actual” expenditures for the fiscal years involved? 

Yes No

SFY 2015

SFY 2016

SFY 2017

If any estimated expenditures are provided, please indicate when “actual” expenditure data will be submitted to SAMHSA: ___/___/_____ 

 mm/dd/yyyy
States are required to submit sufficient information for the Secretary to make a determination of compliance with the statutory 

maintenance of effort (MOE) requirements.1 MOE information is necessary to document that the State has maintained expenditures 

for community mental health services at a level that is not less than the average level of such expenditures maintained by the State 

for the 2-year period preceding the fiscal year for which the State is applying for the grant. The State shall only include community 

mental health services expenditures for individuals that meet the federal or state definition of SMI adults and SED children. States 

that received approval to exclude funds from the maintenance of effort calculation should include the appropriate MOE approval 

documents. 

A. MOE Exclusion

The Secretary may exclude from the aggregate amount any State funds appropriated to the principal agency for authorized activities 

of a non-recurring nature and for a specific purpose.2

A request for MOE exclusion should meet the following requirements: 

 

The State shall request the exclusion separately from the application.

The request shall be signed by the State’s Chief Executive Officer or by an individual authorized to apply for CMHS Block Grant 

on behalf of the Chief Executive Officer. 

The State shall provide documentation that supports its position that the funds were appropriated by the State legislature for 

authorized activities which are of a non-recurring nature and for a specific purpose; indicates the length of time the project is 

expected to last in years and months; and affirms that these expenditures would be in addition to funds needed to otherwise meet the 

State’s maintenance of effort requirement for the year for which it is applying for exclusion. 

The State may not exclude funds from the MOE calculation until such time as the SAMHSA Administrator has approved in writing 

the State’s request for exclusion.

 

1Section 1915(b)(1) of the PHS Act (42 USC 300x-4).

2Section 1915(b)(2) of the PHS Act (42 USC 300x-4).
B. MOE Shortfalls 

States are expected to meet the MOE requirement. If a state cannot meet the MOE requirement, the legislation permits relief, based 

on the recognition that extenuating circumstances may explain the shortfall. These conditions are described below. 

1. Waiver for Extraordinary Economic Conditions 

A state may request a waiver to the MOE requirement if it can be demonstrated that the MOE deficiency was the result of 

extraordinary economic conditions that occurred during the State Fiscal Year in question. An extraordinary economic condition is 

defined as a financial crisis in which the total tax revenues declined at least one and one-half percent, and either the unemployment 

increases by at least one percentage point, or employment declines by at least one and one-half percent.

2. Material Compliance 

If the state is unable to meet the requirements for a waiver under extraordinary economic conditions, the authorizing legislation does 

permit the Secretary, under certain circumstances, to make a finding that even though there was a shortfall on the MOE, the State 

maintained material compliance with the MOE requirement for the fiscal year in question. Therefore, the State is given an 

opportunity to submit information that might lead to a finding of material compliance. The relevant factors that SAMHSA considers 

in making a recommendation to the Secretary include: (1) whether the State maintained service levels; (2) the State’s mental health 

expenditure history; and (3) the State’s future commitment to funding mental health services.
D. Populations and Services Report

States and jurisdictions are requested to provide information regarding individuals that are served by the state mental health authority using 

MHBG Tables 7 through 14. 

MHBG Table 7 (URS Table 1) Profile of the State Population by Diagnosis: MHBG Table 7 provides the number of Adults with serious 

mental illness (SMI) and Children with serious emotional disturbance (SED) in the reporting year and in three years forward. 

MHBG Tables 8A and 8B (URS Tables 2A and 2B) Profile of Persons Served, All Programs by Age, Gender and Race/Ethnicity: MHBG

Tables 8A and 8B provide an aggregate profile of unduplicated persons in the reporting year. The reporting year should be the latest SFY

for which data are available. This profile is based on a client receiving services in programs provided or funded by the state mental health 

agency. The client profile takes into account all institutional and community services for all such programs. States and jurisdictions are to 

provide this information on all programs by age, gender, and race/ethnicity.

MHBG Table 9 (URS Table 3) Profile of Persons Served in the Community Mental Health Settings, State Psychiatric Hospitals, and Other 

Settings: MHBG Table 9 provides an aggregate profile of unduplicated persons in the reporting year for services funded through the 

MHBG. The reporting year should be the latest SFY for which data are available. This profile is based on a client receiving services in 

programs provided or funded by the MHBG. The client profile takes into account all institutional and community services for all such 

programs. States and jurisdictions are to provide this information on all programs by age, gender, and race/ethnicity.

MHBG Table 10A and 10bB (URS Tables 5A and 5B) Profile of Clients by Type of Funding Support MHBG Tables 10A and 10B provide 

the number of female and male clients by race and ethnicity that have Medicaid Only, Non-Medicaid Sources, Both Medicaid and NonMedicaid, and Status Not Available.

MHBG Table 11 (URS Table 6) Profile of Client Turnover MHBG Table 11 requests information regarding the profile of client turnover in 

various out-of-home settings (e.g. state hospitals, inpatient psychiatric hospitals, residential treatment centers). Information collected by this 

table requests admissions, discharges, and length of stay. 

MHBG Table 12 (URS Table 12) State Mental Health Agency Profile MHBG Table 12 provides the Populations covered in state hospitals 

and community program in age categories 0-3, 4-17 and 18 and above. 
MHBG Tables 13A and 13 B (URS Tables 14A and 14B) Profile of Persons with SMI/SED Served By Age, Gender and Race/Ethnicity 

MHBG Tables 13A, and 13B request counts for persons with SMI or SED using the definitions provided by the CMHS. MHBG Tables 13A 

and 13B included individuals receiving services in programs provided or funded by the state mental health agency. These tables count only 

clients who meet the CMHS definition of SMI or SED. States and jurisdictions should report using the Federal Definitions of SMI and SED 

if they can report them, if not, please report using the state’s definitions of SMI and SED and provide information in these tables describing 

your state’s definition. 

MHBG Table 14 (URS Table 15A) Profile of Persons Served in the Community Mental Health Settings, State Psychiatric Hospitals, 

and Other Settings for Adults with SMI and Children with SED This table provides a profile for Adults with Serious Mental Illnesses 

(SMI) and Children With Serious Emotional Disturbances (SED) that received public funded mental health services in community 

mental health settings, in state psychiatric hospitals, in other psychiatric inpatient programs, and in residential treatment centers for 

children. 

MHBG Table 7 (URS Table 1). Profile of the State Population by Diagnosis

This table summarizes the estimates of adults residing within the state with serious mental 

illness (SMI) and children residing within the state with serious emotional disturbances (SED). 

The table calls for estimates for two-time periods, one for the report year and one for three 

years into the future. CMHS will provide this data to states based on the standardized 

methodology developed and published in the Federal Register and the state level estimates for 

both adults with SMI and children with SED. 

MHBG Table 7

Report Period: From: To:

State Identifier:

Current Report 

Year

Three Years 

Forward

Adults with Serious Mental Illness (SMI)

Children with Serious Emotional Disturbances 

(SED)

Note: CMHS will complete this table for the states.
(Continued on next page) 

MHBG Table 8A (URS Table 2A). Profile of Persons Served, All Programs by Age, Gender, Race/Ethnicity

This table provides an aggregate profile of persons in the reporting year. The reporting year should be the latest state fiscal year for which data are available. 

This profile is based on a client receiving services in programs provided or funded by the state mental health agency. The client profile takes into account all 

institutional and community services for all such programs. Please provide unduplicated counts if possible.

Please report the data under the categories listed - "Total" are calculated automatically

MHBG Table 8A

Report Period: From: To:

State Identifier:

Total American Indian or Alaska 

Native

Asian Black or African 

American

Female Male Not 

Available

Total Female Male Not 

Available

Female Male Not 

Available

Female Male Not 

Availab

le

0-12 years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older

Age not Available

Total

Pregnant Women

Are these numbers unduplicated?

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (for 

Race/Ethnicity):

Comments on Data (Overall):
MHBG Table 8A

(Cont.)

Report Year: From: To:

State Identifier:

Native Hawaiian or Other 

Pacific Islander

White Hispanic * use only if data 

for MHBG Table 8b are not 

available.

More Than One Race 

Reported

Race Not Available

Female Male Not 

Available

Female Male Not 

Available

Female Male Not 

Available

Female Male Not 

Available

Female Male Not 

Available

0-12 years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older

Age not 

Available

Total

Pregnant 

Women
MHBG Table 8B (URS Table 2B). Profile of Persons Served, All Programs by Age, 

Of the total persons served, please indicate the age, gender and the number of persons who are Hispanic/Latino or not 

Hispanic/Latino. Total persons served would be the total as indicated in MHBG Table 8a.

Please report the data under the categories listed - "Total" are calculated automatically

MHBG Table 8B

Report Year: From: To: 

State Identifier:

Not Hispanic or Latino Hispanic or Latino

Hispanic or Latino Origin 

Not Available Total

Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Female Male Not Available Total

0-12 years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older

Age not available

Total

Pregnant Women

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (for Ethnicity):

Comments on Data (Overall):
MHBG Table 9 (URS Table 3). Profile of Persons served in the Community Mental Health Settings, State Psychiatric 

Hospitals and Other Settings

This table provides a profile for the clients that received public funded mental health services in community mental health 

settings, in state psychiatric hospitals, in other psychiatric inpatient programs, and in residential treatment centers for children.

MHBG Table 9

Report Year: From: To:

State 

Identifier:

MHBG 

Table 9 

Service 

Setting

Age 0-17 Age 18-20 Age 21-64 Age 65+

Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available

Community 

Mental 

Health 

Programs

State 

Psychiatric 

Hospitals

Other 

Psychiatric 

Inpatient

Residential 

Treatment 

Centers

(Continued on next page) 
MHBG Table 9 (cont.)

Report Year: From: To:

State Identifier:

Table 9

Service Setting

Age Not Available Total

Female Male Not Available Female Male Not Available

Community Mental Health Programs

State Psychiatric Hospitals

Other Psychiatric Inpatient

Residential Treatment Centers

Comments on Data (for Age):

Comments on Data (for Gender):

Comment on Data (Overall):
(Continued on next page) 

MHBG Table 10A. Profile of Clients by Type of Funding Support (URS Table 5A)

This table provides a summary of clients by Medicaid coverage. Since the focus of the reporting is on clients of the public mental health service delivery system, this table focuses on the clientele serviced by public programs that are funded or operated by the State 

Mental Health Authority. Persons are to be counted in the Medicaid row if they received a service reimbursable through Medicaid.

Please note that the same person may be served in both Medicaid and Non-Medicaid programs during the same reporting period.

MHBG Table 10A

Report Period From: To:

State Identifier:

Total American Indian or Alaska Native Asian Black or African American

Female Male Not Available Female Male Not 

Available

Female Male Not Available Female Male Not 

Available

Medicaid (only Medicaid)

Non-Medicaid Sources (only)

People Served by Both Medicaid and Non-Medicaid Sources

Medicaid Status Not Available

Total Served

☐Data Based on Medicaid Services ☐Data Based on Medicaid Eligibility, not Medicaid Paid Services ☐People Served by Both includes people with any Medicaid

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (Overall):

Each row should have a unique (unduplicated) count of clients: (1) Medicaid Only, (2) Non-Medicaid Only, (3) Both Medicaid and Other Sources funded their treatment, and (4) Medicaid Status Not Available.

If a state is unable to un-duplicate between people whose care is paid for by Medicaid only or Medicaid and other funds, then all data should be reported into the 'People Served by Both Medicaid and Non-Medicaid Sources' and the 'People Served by Both includes 

people with any Medicaid' check box should be checked.
MHBG Table 10A (Cont.) 

Report Period- From: To: 

State Identifier:

Native Hawaiian or Other 

Pacific Islander

White Hispanic * use only if data for MHBG 

Table 3b are not available.

More Than One Race Reported Race Not Available

Female Male Not Available Female Male Not Available Female Male Not Available Female Male Not Available Female Male Not Available

Medicaid (only Medicaid)

Non-Medicaid Sources (only)

People Served by Both Medicaid and 

Non-Medicaid Sources

Medicaid Status Not Available

Total Served
MHBG Table 10B. (URS Table 5B) Profile of Clients by Type of Funding Support

Of the total persons covered by Medicaid, please indicate the gender and number of persons who are Hispanic/Latino or not Hispanic/Latino. Total persons covered by Medicaid would be the total indicated in MHBG 

Table 10A. 

Please note that the same person may be served in both Medicaid and Non-Medicaid programs during the same reporting period.

MHBG Table 10B.

Report Period- From To:

State Identifier:

Not Hispanic or Latino Hispanic or Latino

Hispanic or Latino 

Origin Unknown Total

Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Total

Medicaid Only

Non-Medicaid Only

People Served by Both Medicaid and Non-Medicaid Sources

Medicaid Status Unknown

Total Served

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (Overall):

Each row should have a unique (unduplicated) count of clients: (1) Medicaid Only, (2) Non-Medicaid Only, (3) Both Medicaid and Other Sources funded their treatment, and (4) Medicaid Status Unknown.
MHBG Table 11 (URS Table 6): Profile of Client Turnover

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.

MHBG Table 11

Report Year: From: To:

State Identifier:

Profile of Service Utilization

Total Served at Beginning 

of Year (unduplicated)

Admissions During the 

year (duplicated)

Discharges During the 

year (duplicated)

Length of Stay (in Days): Discharged 

Patients

For Clients in Facility for Less Than 1 

Year: Length of Stay (in Days): 

Residents at end of year

For Clients in Facility More Than 1 

Year: Length of Stay (in Days): 

Residents at end of year

Average (Mean) Median Average (Mean) Median Average (Mean) Median

State Hospitals

Children (0 to 17 years)

Adults (18 years and over)

Age Not Available

Other Psychiatric Inpatient

Children (0 to 17 years)

Adults (18 years and over)

Age Not Available

Residential Tx Centers

Children (0 to 17 years)

Adults (18 years and over)

Age Not Available

Community Programs

Children (0 to 17 years)

Adults (18 years and over)

Age Not Available

Comments on Data (State Hospital):

Comments on Data (Other Inpatient):

Comments on Data (Residential Treatment):

Comments on Data (Community Programs):

Comments on Data (Overall):
MHBG Table 12 (URS Table 12): State Mental Health Agency Profile

The purpose of this profile is to obtain information that provides a context for the data provided in the tables. This profile covers the 

populations served, services for which the state mental health agency is responsible, data reporting capacities, especially related to 

duplication of numbers served as well as certain summary administrative information.

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.

MHBG Table 12

Report Year: From: To: 

State Identifier:

Populations Served

1 Which of the following populations receive services operated or funded by the state mental health agency? Please 

indicate if they are included in the data provided in the tables (Check all that apply.)

Populations Covered Included in Data

State 

Hospitals Community Programs State Hospitals

Community 

Programs

1. Aged 0 to 3 ☐Yes ☐Yes ☐No ☐Yes

2. Aged 4 to 17 ☐Yes ☐Yes ☐No ☐Yes

3. Adults Aged 18 and 

over ☐Yes ☐Yes ☐No ☐Yes

4. Forensics ☐Yes ☐Yes ☐No ☐Yes

Comment

s on Data:
2 Do all of the adults and children served through the state mental health agency meet the Federal 

definitions of serious mental illness and serious emotional disturbances?

☐Serious Mental Illness

☐Serious Emotional Disturbance 

2.a. If no, please indicate the percentage of persons served for the reporting period who met the federal 

definitions of serious mental illness and serious emotional disturbance?

2.a.1 Percent of adults meeting Federal definition of SMI:

2.a.2 Percentage of children/adolescents meeting Federal definition of SED 

 3 Co-Occurring Mental Health and Substance Abuse:

3.a. What percentage of persons served by the SMHA for the reporting period have a dual diagnosis of mental 

illness and substance abuse?

3.a.1 Percentage of adults served by the SMHA who also have a diagnosis of substance abuse problem:

3.a.2 Percentage of children/adolescents served by the SMHA who also have a diagnosis of substance abuse 

problem:

3.b.1 Percentage of adults meeting Federal definition of SMI who also have a diagnosis of substance abuse 

problem:

3.b.2 Percentage of children/adolescents meeting the Federal definition of SED who also have a diagnosis of 

substance abuse problem:

3b.3 

Please describe how you calculate and count the number of persons with co-occurring disorders

4

State Mental Health Agency 

Responsibilities

a. Medicaid: Does the State Mental Health Agency have any of the following responsibilities for mental health services 

provided through Medicaid? (Check All that Apply)

1. State Medicaid Operating Agency ☐Yes

2. Setting Standards ☐Yes

3. Quality Improvement/Program Compliance ☐Yes

4. Resolving Consumer Complaints ☐Yes

5. Licensing ☐Yes

6. Sanctions ☐Yes

7. Other

Are Data for 

these programs 

reported on 

URS Tables?

b. Managed Care (Mental Health 

Managed Care

4.b.1 Does the state have a Medicaid Managed Care initiative? ☐Yes ☐Yes

4.b.2 

Does the State Mental Health Agency have any 

responsibilities for mental health services provided 

through Medicaid Managed Care? ☐Yes ☐Yes

If yes, please check the responsibilities the SMHA has:
4.b.3 Direct contractual responsibility and oversight of the 

MCOs or BHOs ☐Yes

4.b.4 Setting Standards for mental health services ☐Yes

4.b.5 Coordination with state health and Medicaid agencies ☐Yes

4.b.6 Resolving mental health consumer complaints ☐Yes

4.b.7 Input in contract development ☐Yes

4.b.8 Performance monitoring ☐Yes

4.b.9 Other

5 

Data Reporting: Please describe the extent to which your information systems allows the generation of unduplicated 

client counts between different parts of your mental health system. Please respond in particular for Table MHBG13a 

and MHBG 13b, which require unduplicated counts of clients served across your entire mental health system.

Are the data reporting in the tables?

5.a. Unduplicated: counted once even if they were served in both State hospitals and 

community programs and if they were served in community mental health agencies 

responsible for different geographic or programmatic areas.

☐

5.b. Duplicated: across state hospital and community programs ☐

5.c. Duplicated: within community programs ☐

5.d. Duplicated: Between Child and Adult Agencies ☐

5.e.

Plans for Unduplication: If you are not currently able to provide unduplicated client counts across all parts of 

your mental health system, please describe your plans to get unduplicated client counts by the end of your Data 

Infrastructure Grant.

6 Summary Administrative Data

6.a. Report Year

6.b. State Identifier

Summary Information on Data Submitted by SMHA:

6.c.

Year being reported: 

From: To

6.d. Person Responsible for Submission

6.e. Contact Phone Number:

6.f. Contact Address

6.g. E-mail:
Table 13A (URS Table 14A) Profile of Persons with SMI/SED Served by Age, Gender and Race/Ethnicity

This table provides a profile for the clients that received public funded mental health services in community mental health 

settings, in state psychiatric hospitals, in other psychiatric inpatient programs, and in residential treatment centers for children.

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.

MHBG Table 13A

Report Year: From: To:

State Identifier:

MHBG 

Table 13A 

Service 

Setting

Age 0-17 Age 18-20 Age 21-64

Female Male

Not 

Available Female Male

Not 

Available Female Male Not Available

Community 

Mental 

Health 

Programs

State 

Psychiatric 

Hospitals

Other 

Psychiatric 

Inpatient

Residential 

Treatment 

Centers

(Continued on next page) 
MHBG Table 13B (URS Table 14B). Profile of Persons with SMI/SED served by Age, Gender and Race/Ethnicity

This table requests counts for persons with SMI or SED using the definitions provided by SAMHSA. MHBG Table 11A and 11B (URS Table 2A and 2B) included all clients served by publicly 

operated or funded programs. This table counts only clients who meet the federal definition of SMI or SED. For many states, this table may be the same as MHBG Tables 11 A and 11B (URS Table 

2A and 2B). For 2016, states should report using the Federal Definitions of SMI and SED if they can report them, if not, please report using your state’s definitions of SMI and SED and provide 

information below describing your state’s definition.

Please report the data under the categories listed - "Total" is calculated automatically. 

MHBG Table 13B

Report Year: From: To:

State Identifier:

Total American Indian or Alaska 

Native

Asian Black or African American Native Hawaiian or Other Pacific Islander

Female Male Not 

Available

Total Female Male Not 

Available

Female Male Not 

Available

Female Male Not 

Available

Female Male Not Available

0-12 Years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older

Age Not 

Available

Total

Comments on Data (for Age):

Comments on Data (for 

Gender):

Comments on Data (for Race/Ethnicity):

Comments on Data (Overall):

(Continued on next page)
(

MHBG Table 13B.

Report Year:

State Identifier:

White Hispanic *use only 

if data for MHBG 

Table 13c are not 

available

More Than One Race Reported Race Not Available

Female Male Not 

Available

Female Male Not 

Available

Female Male Not Available

0-12 Years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older

Age Not 

Available

Total

1. State Definitions Match the Federal Definitions:

☐Yes ☐No Adults with SMI, if No describe or attach state definition: 

☐Yes ☐No

Diagnoses included in state SMI definition:

☐Yes ☐No Children with SED, if No describe or attach state definition:

☐Yes ☐No Diagnoses included in State SED definition:
MHBG Table13B (URS Table 14B). Profile of Persons with SMI/SED served by 

Age, Gender and Ethnicity

Of the total persons served, please indicate the age, gender and the number of persons who meet the Federal definition of SMI and SED and who are 

Hispanic/Latino or not Hispanic/Latino. The total persons served who meet the Federal definition of SMI or SED should be the total as indicated in MHBG Table

13b.

Please report the data under the categories listed - "Total" is calculated automatically. 

MHBG Table 13B

Report Year: From: To:

State Identifier:

Not Hispanic or Latino Hispanic or Latino

Hispanic or Latino Origin 

Not Available Total

Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Total

0 - 12 Years

13 - 17 years

18 - 20 years

21-24 years

25-44 years

45-64 years

65-74 years

75and older

Age Not Available

Total

Comments on Data (for 

Age):

Comments on Data (for 

Gender):

Comments on Data (for 

Race/Ethnicity):

Comments on Data 

(Overall):
MHBG Table 14 Profile of Persons served in the community mental health setting, State Psychiatric Hospitals and Other Settings for Adults with SMI and Children with SED

MHBG Table 14

Report Year: From: To:

State Identifier:

MHBG Table 14 

Service Setting

Age 65+ Age Not Available Total

Female Male Not Available Female Male Not Available Female Male

Not 

Available Total

Community Mental Health Programs

State Psychiatric Hospitals

Other Psychiatric Inpatient

Residential Treatment Centers

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (Overall):

Note: Clients can be duplicated between Rows (e.g., The same client may be served in both state psychiatric hospitals and community mental health centers during the same year and thus would be reported in counts for both rows).

☐Data Based on Medicaid Services

☐Data Based on Medicaid Eligibility, not Medicaid Paid Services ☐People Served by Both, includes people with any Medicaid

Instructions:

1 States that have county psychiatric hospitals which serve, as surrogate state hospitals should report persons served in such settings as receiving services in state hospitals.

2 If forensic hospitals are part of the state mental health agency system, include them.

3 Persons who receive non-inpatient care in state psychiatric hospitals should be included in the Community MH Program Row

4 Persons, who receive inpatient psychiatric care through a private provider or medical provider licensed, or contracted through the SMHA, should be counted in the "Other Psychiatric Inpatient" row. Persons who 

receive Medicaid funded inpatient services through a provider that is not licensed or contracted by the SMHA should not be counted here.

5 A person who is served in both community settings and inpatient settings should be included in both rows

6 RTC: CMHS has a standardized definition of RTC for Children: “An organization, not licensed as a psychiatric hospital, whose primary purpose is the provision of individually planned programs of mental health 

treatment services in conjunction with residential care for children and youth primarily 17 years old and younger. It has a clinical program that is directed by a psychiatrist, psychologist, social worker, or psychiatric 

nurse who has a master’s degree or doctorate. The primary reason for the admission of the clients is mental illness that can be classified by either DSM-V or ICD-10 codes other than the codes for mental retardation, 

developmental disorders, and substance-related disorders such as drug abuse and alcoholism (unless these are co-occurring with a mental illness).”
E. Performance Data and Outcomes 

MHBG Table 15A (URS Table 4) Profile of Adult Clients by Employment Status, MHBG Table 15A describes the status of adults clients 

served in the report year by the public mental health system in terms of employment status. The focus is on employment for the working 

age population, recognizing, however, that there are clients who are disabled, retired or who are homemakers, care-givers, etc., and not a 

part of the workforce. These persons should be reported under the, “Not in Labor Force” category. This category has two subcategories: 

retired and other (The total of these two categories should equal the number listed in the "Not in Labor Force" column). Unemployed refers 

to persons who are looking for work but have not found employment. Data should be reported for clients in non-institutional settings, at 

time of discharge or last evaluation. 

MHBG Table 15B (URS Table 4A) Profile of Adult Clients by Employment Status, by Primary Diagnosis Reported, MHBG Table 15B 

request information on the status of adult clients served in the report year by the public mental health system in terms of employment status 

by primary diagnosis reported. 

MHBG Table 16 (URS Table 9), Social Connectedness and Improved Functioning, MHBG Table 16 requests states and jurisdictions to 

provide information for youth and adults regarding Social Connectedness. In addition, states are requested to provide information on 

functional domains that provide a general sense of an individual’s ability to develop and maintain relationships, cope with challenges and a 

sense of community belonging. 

MHBG Table 17A (URS Table 11), Summary Profile of Client Evaluation of Care, MHBG Table 17A requests information that evaluates 

the “experience” of care for individuals that participate in the public mental health system. Specifically, the evaluation focuses on several 

areas including access, quality and the appropriateness of services, participation in treatment planning and general satisfaction with services. 

Please provide unduplicated counts, if possible. This table provides an aggregate profile of persons served in the reporting year. The 

reporting year should be the latest state fiscal year for which data are available. This profile is based on a client's last known Living 

Situation. 

MHBG Table 17B (URS Table 11A), Consumer Evaluation of Care by Consumer Characteristics: Race/Ethnicity, MHBG Table 17B 

requests information that evaluates the “experience” of care for individuals that participate in the public mental health system, broken down 

by race, ethnicity, and age category (adult or child/adolescent). 

MHBG Table 18 (URS Table 15), Living Situation Profile, MHBG Table 18 requests information regarding the number of Individuals in 

Each Living Situation as collected by the most recent assessment in the reporting period. Specifically, information is collected on the 

individual’s last known living situation. Living situations include, but are not limited to, private residence, foster care, residential care, 

jail/correctional facility, homeless shelter and other.
MHBG Table 19 (URS Table 11), Summary Profile of Client Evaluation of Care, MHBG Table 19 Profile of Adults with Serious Mental 

Illness and Children with Serious Emotional Disturbances Receiving Specific Services. MHBG Table 19 requests information regarding the 

number and demographics of individuals that are receiving specific evidenced-based services. In addition, the table requests information on 

if and how States and Jurisdictions monitor the fidelity for the evidenced based services. 

New Table: MHBG Table 19a (URS Table 16a), Adults with Serious Mental Illness and Children with Serious Emotion Disturbances 

receiving Service for First Episode Psychosis. Table 19a requests information regarding the number of individuals that are receiving 

evidenced-based services for first Episode Psychosis (FEP). In addition, the table requests information on if, and how, states and 

jurisdictions monitor the fidelity for the FEP evidenced-based services.

MHBG Table 20A (URS Table 16), Profile of Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances 

Receiving Specific Services, MHBG Table 20A requests information regarding the number and demographics of individuals that are 

receiving specific evidenced-based services. In addition, the table requests information on if, and how states and Jurisdictions monitor the 

fidelity for the evidenced based services. 

MHBG Table 20B (URS Table 17), Profile of Adults with Serious Mental Illnesses Receiving Specific Services during the Year, MHBG 

Table 20B provides the number of unduplicated Adults with SMI receiving family psycho education, integrated treatment for co-occurring 

disorders, illness self-management and medication management.

MHBG Table 21 (URS Table 19A), Profile of Criminal Justice or Juvenile Justice Involvement, MHBG Table 21 requests information to 

measure the change in Arrests over time. 

MHBG Table 22 (URS Table 19B), Profile of Change in School Attendance, MHBG Table 22 measures the change in days attended over 

time. Information requested includes information on suspensions, expelled, and changes in the school attendance. 

MHBG Table 23A (URS Table 20A), Profile of Non-Forensic (Voluntary and Civil-Involuntary) Patients Readmission to Any State 

Psychiatric Inpatient Hospital Within 30/180 Days of Discharge, MHBG Table 23A provides the total number of discharges within the 

year, the number of readmissions within 30-days and 180-days and the percent readmitted by age, gender, race, and ethnicity. 

MHBG Table 23B (URS Table 20B), Profile of Forensic Patients Readmission to Any State Psychiatric Inpatient Hospital within 30/180 

Days of Discharge, MHBG Table 23B provides the total number of discharges within the year, the number of readmissions within 30-days 

and 180-days and the percent readmitted by age, gender, race, and ethnicity. 
MHBG Table 24 (URS Table 21), Profile of Non-Forensic (Voluntary and Civil-Involuntary Patients) Readmission to Any Psychiatric 

Inpatient Care Unit (State Operated or Other Psychiatric Inpatient Unit) within 30/180 Days of Discharge, MHBG Table 24 provides the 

total number of discharges from inpatient care units within the year, the number of readmissions within 30-days and 180-days and the 

percent readmitted by age, gender, race, and ethnicity. 
MHBG Table 15A (URS Table 4) Profile of Adult Clients 

by Employment Status

This table describes the status of adult clients served in the reporting year by the public mental health system, in terms of employment status. The focus is on 

employment for the working age population, recognizing, however, there are clients who are disabled, retired, or who are homemakers, care-givers, etc., and not a 

part of the workforce. These persons should be reported in the “Not in Labor Force” category. This category has two subcategories: retired and other, (The total of 

these two categories should equal the number listed in the "Not in Labor Force" column). Unemployed refers to persons who are looking for work but have not found 

employment. Data should be reported for clients in non-institutional settings at time of discharge or last evaluation.

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.

MHBG Table 15 A

Report Year: From: To:

State Identifier:

Adults Served

18-20 21-64 65+ Age Not Available Total

Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Total

Employed: 

Competitively 

Employed Full or Part 

Time (includes 

Supported 

Employment)

Unemployed

Not In Labor Force: 

Retired, Sheltered 

Employment, Sheltered 

Workshops, Other 

(homemaker, student, 

volunteer, disabled, 

etc.)

Not Available

Total

How Often Does your State Measure Employment Status?

What populations are included:

Comments on Data (for 

Age):

Comments on Data (for 

Gender):

Comments on Data 

(Overall):
MHBG Table 15B (URS Table 4A), Optional Profile of Adult Clients by Employment Status: by Primary Diagnosis Reported

The workgroup exploring employment found that, the primary diagnosis of consumer results in major differences in employment status. The workgroup has recommended that 

we explore the ability of states to report employment by primary diagnosis and the impact of diagnosis on employment. The workgroup recommended 5 diagnostic clusters for 

reporting.

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.

MHBG Table 15B

Report Year: From: To:

State Identifier:

Clients

Primary Diagnosis

Employed: Competitively 

Employed Full or Part Time 

(includes Supported 

Employment) Unemployed

Not In Labor Force: 

Retired, Sheltered 

Employment, Sheltered 

Workshops, Other 

(homemaker, student, 

volunteer, disabled, etc.)

Employment 

Status Not 

Available Total

Schizophrenia & Related Disorders (F20, F25)

Bipolar and Mood Disorders 

(F30,F31,F32,F33,F34.1,F60.89,F34.0,F32.9)

Other Psychoses (F22,F23,F24,F29)

All Other Diagnoses

No DX and Deferred DX (R69,R99,Z03.89)

Diagnosis Total

Comments on Data (for Diagnosis):
MHBG Table 16 (URS Table 9): SOCIAL CONNECTEDNESS AND IMPROVED FUNCTIONING

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.

MHBG Table 16: NOMS Social Connectedness & Functioning

Report Year (Year Survey was Conducted):

State Identifier:

Adult Consumer Survey Results: Number of Positive 

Responses

Responses Percent Positive (calculated)

1. Social Connectedness

2. Functioning

Child/Adolescent Consumer Survey Results: Number of Positive 

Responses

Responses Percent Positive (calculated)

3. Social Connectedness

4. Functioning

Comments on Data:

Adult Social Connectedness and Functioning Measures

1. Did you use the recommended new Social Connectedness Questions? ☐Yes ☐No Measure used

2: Did you use the recommended new Functioning Domain Questions? ☐Yes ☐No Measure used

3. Did you collect these as part of your MHSIP Adult Consumer Survey? ☐Yes ☐No 

If no, what source did you use?

Child/Family Social Connectedness and Functioning Measures

4: Did you use the recommended new Social Connectedness Questions? ☐Yes ☐No Measure used

5: Did you use the recommended new Functioning Domain Questions? ☐Yes ☐No Measure used

6. Did you collect these as part of your YSS-F Survey? ☐Yes ☐No 

If No, what source did you use?

Recommended Scoring Rules

Please use the same rules for reporting Social connectedness and Functioning Domain scores as for calculating

other Consumer Survey Domain scores for Table MHBG Table 18a: E.g.:

1. Recode ratings of “not applicable” as missing values.

2. Exclude respondents with more than 1/3 of the items in that domain missing.
3. Calculate the mean of the items for each respondent.

4. FOR ADULTS: calculate the percent of scores less than 2.5 (percent agree and strongly agree).

5. FOR YSS-F: calculate the percent of scores greater than 3.5 (percent agree and strongly agree).

MHBG Table 17A (URS Table 11): Summary Profile of Client Evaluation of Care

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.

MHBG Table 17A

Report Year (Year Survey was Conducted):

State Identifier:

Adult Consumer Survey Results: Number of Positive 

Responses

Responses Confidence Interval*

1. Reporting Positively About Access

2. Reporting Positively About Quality and Appropriateness for Adults

3. Reporting Positively About Outcomes

4. Adults Reporting on Participation In Treatment Planning

5. Adults Positively about General Satisfaction with Services

Child/Adolescent Consumer Survey Results: Number of Positive 

Responses

Responses Confidence Interval*

1. Reporting Positively About Access

2. Reporting Positively about General Satisfaction for Children

3. Reporting Positively about Outcomes for Children

4. Family Members Reporting on Participation In Treatment Planning for their Children

5. Family Members Reporting High Cultural Sensitivity of Staff

Please enter the number of persons responding positively to the questions and the number of total responses within each group. Percent positive will be calculated from these data.

* Please report Confidence Intervals at the 95% level. See directions below regarding the calculation of confidence intervals.

Comments on Data:

Adult Consumer Surveys

1. Was the Official 28 Item MHSIP Adult Outpatient Consumer Survey Used?

1. a. If no, which version:

1. Original 40 Item Version

2. 21-Item Version 

3. State Variation of MHSIP

4. Other Consumer Survey

1. b. If other, please attach instrument used.

1. c. Did you use any translations of the MHSIP into another language?

2. Other Language:
Adult Survey Approach:

2. Populations covered in survey? (Note all surveys should cover all regions of state)

2.a. If a sample was used, what sample methodology was used?

4. Other Sample:

Adult Consumer Surveys (Continued)

2.b Do you survey only people currently in services, or do you also Survey Persons no longer in service?

3. Please Describe the populations included in your sample: (e.g., all adults, only adults with SMI, etc.)

3.4 Other: describe: (for example, if you survey anyone served in the last 3 months, describe that here):

4. Methodology of collecting data? (Check all that apply)

Self-Administered Interview

Phone

Mail

Face-to-face

Web-Based

4.b Who administered the Survey? (Check all that apply)

 6. Other: describe:

5. Are Responses Anonymous, Confidential, or Linked to other Patient Databases?

6. Sample Size and Response Rate

6a How many Surveys were Attempted (sent out or calls initiated)?

6.b How many survey Contacts were made? (surveys to valid phone numbers or addresses)

6.c How many surveys were completed? (survey forms returned or calls completed)

6.d What was your response rate? (number of Completed surveys divided by number of Contacts)

6. e If you receive "blank" surveys back from consumers (surveys with no responses on them), did you count these surveys as "completed" for the 

calculation of response rates?

7. Who Conducted the Survey

7.a. SMHA Conducted or contracted for the Survey (survey done at state level)

7.b. Local Mental Health Providers/County mental health providers conducted or contracted for the survey

 (survey was done at the local or regional level)

7.c Other: Describe:
* Report Confidence Intervals at the 95 percent confidence level

Note: The confidence interval is the plus-or-minus figure usually reported in newspaper or television opinion poll results. For example, if you use a confidence interval of 4 

and 47 percent of your sample picks an answer you can be "sure" that if you had asked the question of the entire relevant population between 43 percent (47-4) and 51

percent (47+4) would have picked that answer.

The confidence level tells you how sure you can be. It is expressed as a percentage and represents how often the true percentage of the population who would pick an 

answer lies within the confidence interval. The 95 percent confidence level means you can be 95 percent certain; the 99 percent confidence level means you can be 99

percent certain. Most researchers use the 95 percent confidence level.

When you put the confidence level and the confidence interval together, you can say that you are 95 percent sure that the true percentage of the population is between 43

percent and 51 percent. (From www.surveysystem.com)

Child/Family Consumer Surveys

1. Was the MHSIP Children/Family Survey (YSS-F) Used?

If No, what survey did you use?

 If no, please attach instrument used.

1.c. Did you use any translations of the Child MHSIP into another language?

2. Other Language:

Child Survey Approach:

2. Populations covered in survey? (Note: all surveys should cover all regions of state)

2.a. If a sample was used, what sample methodology was used?

4. Other Sample:

2.b Do you survey only people currently in services, or do you also Survey Persons no longer in service?

 2a. If yes to 2, please describe how your survey persons no longer receiving services.

3. Please Describe the populations included in your sample: (e.g., all children, only children with SED, etc.)

 3.4 Other: describe: (for example, if you survey anyone served in the last 3 months, describe that here):

4. Methodology of collecting data? (Check all that apply)

Self-Administered Interview

Phone

Mail

Face-to-face

Web-based

4.b. Who administered the Survey? (Check all that apply)

6. Other: describe:

5. Are Responses Anonymous, Confidential, or Linked to other Patient Databases?

6. Sample Size and Response Rate

6a. How many Surveys were Attempted (sent out or calls initiated)?

6.b How many survey Contacts were made? (surveys to valid phone numbers or addresses)
6.c How many surveys were completed? (survey forms returned or calls completed)

6.d. What was your response rate? (number of Completed surveys divided by number of Contacts)

6.e. If you receive "blank" surveys back from consumers (surveys with no responses on them), did you count

 these survey's as "completed" for the calculation of response rates?

7. Who Conducted the Survey

7.a. SMHA Conducted or contracted for the Survey (survey done at state level)

7.b. Local Mental Health Providers/County mental health providers conducted or contracted for the survey

 (survey was done at the local or regional level)

7.c. Other: Describe:
Table 17b.

Report Year: From: To:

State Identifier:

Adult Consumer Survey Results:

*State used the 2 question version for

Hispanic Origin Yes No Please check the appropriate box on the left. The "Totals" formula will automatically adjust to account for which method your state used to ask about

Hispanic Origin/Status

Indicators Total

AmericanIndian or

Alaska Native Asian Black or African American

Native Hawaiian or Other

Pacific Islander White

More than One Race

Reported Other/ Not Available Hispanic Origin*

Adult Consumer

Survey Results: # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses

1. Reporting Positively

About Access. 

2. Reporting Positively

About Quality and

Appropriateness.

3. Reporting Positively

About Outcomes.

4. Reporting Positively

about Participation in

Treatment Planning

5. Reporting Positively

about General

Satisfaction

6. Social Connectedness

7. Functioning

Child/Adolescent Family Survey Results:

*State used the 2 question version for

Hispanic Origin Yes No Please check the appropriate box on the left. The "Totals" formula will automatically adjust to account for which method your state used to ask about

Hispanic Origin/Status

Indicators Total

AmericanIndian or

Alaska Native Asian Black or African American

Native Hawaiian or Other

Pacific Islander White

More than One Race

Reported Other/ Not Available Hispanic Origin*

Child/Adolescent

Family Survey Results:

# Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses # Positive Responses

Reporting Positively

About Access. 

Reporting Positively

About General

Satisfaction

Reporting Positively

About Outcomes.

Reporting Positively

Participation in Treatment

Planning for their

Children.

Reporting Positively

About Cultural Sensitivity 

of Staff.

6. Social Connectedness

7. Functioning

Comments on Data:

Please enter the number of persons responding positively to the questions and the number of total responses within each group. 

Percent positive will be calculated from these data.

MHBG Table 17b (URS Table 11A) Consumer Evaluation of Care by Consumer Characteristics: (Optional Table by 

Race/Ethnicity.)

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.
(Continued on next page)

MHBG Table 18 (URS Table 15). 

Living Situation Profile: 

Number of Clients in Each Living Situation as Collected by the Most Recent Assessment in the Reporting Period 

All Mental Health Programs by Age, Gender, and Race/Ethnicity

Please provide unduplicated counts, if possible. This table provides an aggregate profile of persons served in the reporting year. The reporting year should be the latest state fiscal 

year for which data are available.This profile is based on a client's last known Living Situation. 

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.

MHBG Table 18

Report Year: From: To:

State Identifier:

Private 

Residence

Foster 

Home

Residential 

Care

Crisis 

Residence

Children's 

Residential 

Treatment

Institutional 

Setting

Jail/ 

Correctional 

Facility

Homeless/ 

Shelter Other NA Total

0-17

18-64

65 +

Not Available

TOTAL

Female

Male

Not Available

TOTAL

American Indian/Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White/Caucasian

Hispanic *

More than One Race Reported

Race/Ethnicity Not Available

TOTAL
MHBG Table 18 (cont.) Living 

Situation Profile: 

Number of Clients in Each Living Situation as Collected by the Most Recent Assessment in the Reporting Period 

All Mental Health Programs by Age, Gender, and Race/Ethnicity

Please provide unduplicated counts, if possible. This table provides an aggregate profile of persons served in the reporting year. The reporting year should be the latest state fiscal 

year for which data are available. This profile is based on a client's last known Living Situation. 

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.

Please report the data under the Living Situation categories listed - "Total" is calculated automatically. 

MHBG Table 18

Report Year: From: To:

State Identifier:

Private 

Residence

Foster 

Home

Residential 

Care

Crisis 

Residence

Children's 

Residential 

Treatment

Institutional 

Setting

Jail/ 

Correctional 

Facility

Homeless/ 

Shelter Other NA Total

Hispanic or Latino Origin

Non-Hispanic or Latino Origin

Hispanic or Latino Origin Not Available

TOTAL

Comments on Data:

How Often Does your State Measure Living 

Situation?

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as an Ethnic Origin are not available
Table 19: Profile of Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances Receiving Specific

Services:

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.

Table 19:

Report Year:

State Identifier:

Adults with Serious Mental Illness (SMI) Children with Serious Emotional Disturbance (SED)

N Receiving 

Supported 

Housing

N Receiving 

Supported 

Employment

N Receiving 

Assertive 

Community 

Treatment

Total 

unduplicated N -

Adults with 

SMI served

N Receiving 

Therapeutic 

Foster Care

N Receiving 

Multi-Systemic 

Therapy

N Receiving 

Family 

Functional 

Therapy

Total 

unduplicated N -

Children with 

SED

Age

0-12

13-17

18-20

21-64

65-74

75+

Not Available

TOTAL 0 0 0 0 0 0 0 0

Gender

Female

Male

Not Available

Race/Ethnicity

American Indian/Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Hispanic*

More than one race

Not Available

Hispanic/Latino Origin

Hispanic/Latino Origin

Non Hispanic/Latino

Not Available

Comments on Data (overall):

Comments on Data (Supported Housing):

Comments on Data (Supported 

Employment):

Comments on Data (Assertive 

Community Treatment):

Comments on Data (Therapeutic Foster 

Care):

Comments on Data (Multi-Systemic 

Therapy):

Comments on Data (Family Functional 

Therapy):

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available

Do You monitor fidelity

for this service?

IF YES,

What fidelity measure do you use? 

Who measures fidelity?

How often is fidelity measured?

Is the SAMHSA EBP Toolkit used to 

guide EBP Implementation?

Have staff been specifically trained to 

implement the EBP?

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No Yes / No

Yes / No Yes / No

* Hispanic is part of the total served. Yes No
MHBG Table 19a Adults with Serious Mental illness and Children with Serious Emotional Disturbances 

Receiving Evidence-Based Services for First Episode Psychosis.

The number of individuals, divided by Adults with SMI and Children with SED, who were admitted and who received 

Coordinated Specialty Care (CSC) First Episode Psychosis Services (FEP). Indicate if program fidelity was 

monitored, the fidelity-monitoring instrument used, who monitors and the frequency of monitoring. Indicate if staff 

were trained on the use of the specific evidence based program model

Individuals Served in an CSC Evidence 

Based First Episode Psychosis Program

MHBG Table 19a:

State Identifier:

Report Period: 

From:

To:

Program Name

Number of Adult 

Admissions during FY##

Current 

Number 

of Adults 

Receiving 

CSC FEP 

Services

Number of 

Child/Adol.Admissions 

during FY##

Current Number of 

Child/Adol.Receiving 

CSC FEP Services

Do you monitor fidelity for 

this service? 

Yes/No

 

IF YES,

*What fidelity measure do 

you use?

* Who measures fidelity?

* How often is fidelity 

measure?

Has staff been specifically 

trained to implement the 

CSC EBP?

Yes/No

 
MHBG Table 20 (URS Table 17): Profile of Adults with Serious Mental Illnesses Receiving Specific Services 

During The Year:

MHBG Table 20

Report Year From To:

State Identifier:

ADULTS WITH SERIOUS MENTAL 

ILLNESS

Receiving Family 

Psychoeducation

Receiving Integrated 

Treatment for Co-occurring 

Disorders (MH/SA)

Receiving 

Illness SelfManagement

Receiving Medication 

Management

Age

18-20

21-64

65-74

75+

Not Available

TOTAL

Gender

Female

Male

Not Available

Ethnicity

Hispanic/Latino Origin

Non-Hispanic/Latino

Hispanic origin not available

Race

American Indian/ Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Hispanic*

More than one race

Unknown

Do You monitor fidelity for

this service?

 ☐Yes ☐No ☐Yes ☐No Yes ☐No Yes ☐No

IF YES,

What fidelity measure do you use?

Who measures fidelity?

How often is fidelity measured?

Have staff been specifically trained to 

implement the EBP? ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
* Hispanic is part of the total served.

Comments on Data (overall):

Comments on Data (Family Psycho-education):

Comments on Data (Integrated Treatment for Co-occurring Disorders):

Comments on Data (Illness Self-Management):

Comments on Data (Medication Management):

* Hispanic: Only use the "Hispanic" row under Race, if data for Hispanic as an Ethnic Origin, are not available
MHBG Table 21 (URS Table 19a) Profile of Criminal Justice or Juvenile Justice Involvement:

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.

1. The SAMHSA National Outcome Measure for Criminal Justice measures the change in Arrests over time. The DIG Outcomes Workgroup pilot tested 3 consumer self-report items that can be used to provide this information. If your state has used the 3 Consumer self-report items on criminal justice, you may report them here.

2. If your SMHA has data on Arrest records from alternatives sources, you may also report that here. If you only have data for arrests for consumers in this year, please report that in the T2 columns. If you can calculate the change in Arrests from T1 to T2, please use all those columns.

3. Please complete the check boxes at the bottom of the table to help explain the data sources that you used to complete this table.

4. Please tell us anything else that would help us to understand your indicator (e.g., list survey or MIS questions; describe linking methodology and data sources; specify time period for criminal justice involvement; explain whether treatment data are collected).

State: Time period in which services were received:______________________________

For Consumers in Service for at least 12 months

T1 T2 T1 to T2 Change Assessment of the Impact of Services

"T1" Prior 12 months

(more than 1 year ago)

"T2" Most Recent 12 months

(this year) If Arrested at T1 (Prior 12 Months) If Not Arrested at T1 (Prior 12 Months) Over the last 12 months,my encounterswith the police have...

Arrested

Not

Arrested

No

Response

Not No

Arrested Arrested Response

# with an # with No No

Arrest in T2 Arrest at T2 Response

# with an # with No No

Arrest in T2 Arrest at T2 Response

# Reduced 

(fewer 

encounters

# Stayed 

the Same

# 

Increased

# Not

Applicable

No

Response

Total

Responses

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total Children/Youth (under age 18) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Male 0

Female 0

Gender NA 0

Total Adults (age 18 and over) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Male 0

Female 0

Gender NA 0

For Consumers Who Began Mental Health Services during the past 12 months

T1 T2 T1 to T2 Change Assessment of the Impact of Services

"T1" 12 months prior to beginning 

services

"T2" Since Beginning Services

(this year) If Arrested at T1 (Prior 12 Months) If Not Arrested at T1 (Prior 12 Months) Since starting to receive MH Services, my encounters with the police have...

Arrested

Not

Arrested

No

Response

Not No

Arrested Arrested Response

# with an # with No No

Arrest in T2 Arrest at T2 Response

# with an # with No No

Arrest in T2 Arrest at T2 Response

# Reduced 

(fewer 

encounters)

# Stayed 

the Same

# 

Increased

# Not

Applicable

No

Response

Total

Responses

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total Children/Youth (under age 18) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Male 0

Female 0

Gender NA 0

Total Adults (age 18 and over) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Male 0

Female 0

Gender NA 0

 State Time period in which services were received
Please Describe the Sources of your Criminal Justice Data

Source of adult criminal justice information ☐1) Consumer survey (recommended questions) ☐2) Other Consumer Survey: Please send copy of questions ☐3) Mental health MIS

 ☐4) State criminal justice agency ☐5) Local criminal justice agency ☐6) Other (specify)________________________________

Sources of children/youth criminal justice

Information: ☐1)Consumer survey (recommended questions) ☐2) Other Consumer Survey: Please send copy of questions ☐3)Mental health MIS

 ☐4) State criminal/juvenile justice agency ☐5) Local criminal/juvenile justice agency ☐6) Other (specify)________________________________

Measure of adult criminal

Involvement: ☐1) Arrests ☐2) Other (specify):

Measure of children/youth criminal justice 

Involvement: ☐1) Arrests ☐2) Other (specify):

Mental health programs included: ☐1)Adults with SMI only ☐2) Other adults (specify)____________________________________ ☐3) Both (all adults)

 ☐1) Children with SED only ☐2) Other Children (specify) ☐3) Both (all Children)

Region for which adult data are reported: ☐1) The whole state ☐2) Less than the whole state (please describe):

Region for which children/youth data are 

reported: ☐1) The whole state ☐2) Less than the whole state (please describe):

What is the Total Number of Persons Surveyed, or for whom Criminal Justice Data are Reported

 Child/Adolescents Adults

1. If data is from survey, what is the total number of people from which the sample was drawn? 

2. What was your sample size (How many individuals were selected for the sample)? 

3. How many survey Contracts were made (surveys to valid phone numbers or addresses)? 

4. How many surveys were completed (survey forms returned or calls completed), if data source 

 was not a Survey. How many persons were CJ data available for?

5. What was your response rate? (number of completed surveys divided by number of Contracts): 

State Comments/Notes:

Instructions:

If you have responses to a survey by person not in the expected age group, you should include those responses with other responses from the survey (e.g., if a 16 or 17 year old responds to the Adult MHSIP survey, please include their 

responses in the Adult categories, since that was the survey they used).
Table 22 (URS Table 19b) Profile of Change in School Attendance

PLEASE DO NOT ADD, DELETE, OR MOVE ROWS, COLUMNS, OR CELLS.

1. The SAMHSA National Outcome Measure for School Attendance measures the change in days attended over time. The DIG Outcomes Workgroup pilot tested 3 consumer self-report items that can be used to provide this information. If your state has used the 3

Consumer Self-Report items on School Attendance, you may report them here.

2. If your SMHA has data on School Attendance from alternatives sources, you may also report that here. If you only have data for School attendance for consumers in this year, please report that in the T2 columns. If you can calculate the change in Attendance from T1 to T2, please use all these columns.

3. Please complete the check boxes at the bottom of the table to help explain the data sources that you used to complete this table.

4. Please tell us anything else that would help us to understand your indicator (e.g., list survey or MIS questions; describe linking methodology and data sources; specify time period for criminal justice involvement; explain whether treatment data are collected).

Table22. Profile of Change in School Attendance

State: Time period in which services were received:

For Consumers in Service for at least 12 months

T1 T2 T1 to T2 Change Impact of Services

"T1" Prior 12 months

(more than 1 year ago)

"T2" Most Recent 12 months

(this year) If Suspended at T1 (Prior 12 Months) If Not Suspended at T1 (Prior 12 Months) Over the last 12 months, the number of days my child was in school have

# Suspended or

Expelled

# Not 

Suspended or 

Expelled

No

Response

# Suspended or

Expelled

# Not 

Suspended or 

Expelled

No

Response

# with an 

Expelled or 

Suspended in 

T2

# with No 

Suspension or

Expulsion at

T2 No Response

# with an 

Expelled or 

Suspended in 

T2

# with No 

Suspension or

Expulsion at

T2

No

Response

# Greater

(Improved)

# Stayed 

the Same

# Fewer days

(gotten worse) # Not

Applicable

No 

response

Total

Responses

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Gender

Male 0

Female 0

Gender NA 0

Age

Under 18 0

For Consumers Who Began Mental Health Services during the past 12 month

T1 T2 T1 to T2 Change Impact of Services

"T1" 12 months prior to beginning 

services

"T2" Since Beginning Services

(this year) If Suspended at T1 (Prior 12 Months)

If Not Suspended at T1 

(Prior 12 Months)

Since starting to receive MH Services, the number of days my child was in school 

have

# Suspended or

Expelled

# Not 

Suspended or 

Expelled

No

Response

# Suspended or

Expelled

# Not 

Suspended or 

Expelled

No

Response

# with an

Expelled or 

Suspended in 

T2

# with No 

Suspension or

Expulsion at

T2 No Response

# with an 

Expelled or 

Suspended in 

T2

# with No 

Suspension or

Expulsion at

T2

No

Response

# Greater

(Improved)

# Stayed 

the Same

# Fewer days

(gotten worse) # Not

Applicable

No 

response

Total

Responses

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Gender

Male 0

Female 0

Gender NA 0

Age

Under 18 0

See Page 2 for additional Questions about the source of this data.

Source of School Attendance Information 1) Consumer survey (recommended items) 2) Other Survey: Please send us items 3) Mental health MIS

4) State Education Department 5) Local Schools/Education Agencies 6) Other (specify)

Measure of School Attendance 1) School Attendance 2) Other: (Specify)

Mental health programs include: ☐ 1) Children with SED only ☐ 2) Other Children (specify) ☐ 3) Both.

Region for which data are reported: 1) The whole state 2) Less than the whole state (please describe)

What is the Total Number of Persons Surveyed or for whom School Attendance Data Are Reported

Child/Adolescents

1. If data is from a survey, What is the total Number of people from which the sample was drawn?

2. What was your sample size? (How many individuals were selected for the sample)?

3. How many survey Contacts were made? (surveys to valid phone numbers or addresses)

4. How many surveys were completed? (survey forms returned or calls completed) If data source was not a Survey, 

How many persons were data available for?

5. What was your response rate? (number of Completed surveys divided by number of Contacts):
Items to Score in the Functioning Domain:

Adult MHSIP Functioning Domain:

1 I do things that are more meaningful to me. 

2 I am better able to take care of my needs. 

3 I am better able to handle things when they go wrong. 

4 I am better able to do things that I want to do. 

5 My Symptoms are not bothering me as much (this question already is part of the MHSIP Adult Survey)

YSS-F Functioning Domain Items:

1 My child is better able to do things he or she wants to do. 

2 My child is better at handling daily life. (existing YSS-F Survey item)

3 My child gets along better with family members. (existing YSS-F Survey item)

4 My child gets along better with friends and other people. (existing YSS-F Survey item)

5 My child is doing better in school and/or work. (existing YSS-F Survey item)

6 My child is better able to cope when things go wrong. (existing YSS-F Survey item)

Items to Score in the Social Connectedness Domain:

Adult MHSIP Social Connectedness Domain:

1 I am happy with the friendships I have. 

2 I have people with whom I can do enjoyable things.

3 I feel I belong in my community. 

4 In a crisis, I would have the support I need from family or friends. 

YSS-F Social Connectedness Domain Items:

1 I know people who will listen and understand me when I need to talk

2 I have people that I am comfortable talking with about my child's problems.

3 In a crisis, I would have the support I need from family or friends.

4 I have people with whom I can do enjoyable things
MHBG Table 23A (URS Table 20A). Profile of Non-Forensic (Voluntary and Civil-Involuntary) Patients Readmission to 

Any State Psychiatric Inpatient Hospital Within 30/180 Days of Discharge

MHBG Table 23A.

Report Year: From: To:

State Identifier:

Total number of 

Discharges in 

Year

Number of Readmissions to 

ANY STATE Hospital within

Percent Readmitted

30 days 180 days 30 days 180 days

TOTAL 0 0 0

Age

0-12

13-17

18-20

21-64

65-74

75+

Not Available

Gender

Female

Male

Gender Not Available

Race

American Indian/ Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Hispanic*

More than one race

Race Not Available

Hispanic/Latino Origin

Hispanic/Latino Origin

Non-Hispanic/Latino

Hispanic/Latino Origin Not Available

Are Forensic Patients Included?

Comments on Data:

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as an Ethnic Origin are not available
MHBG Table 23B (URS Table 20B). Profile of Forensic Patients Readmission to Any State Psychiatric Inpatient 

Hospital Within 30/180 Days of Discharge

MHBG Table 23B.

Report Year: From: To:

State Identifier:

Total number of 

Discharges in 

Year

Number of Readmissions to 

ANY STATE Hospital within

Percent Readmitted

30 days 180 days 30 days 180 days

TOTAL 0 0 0

Age

0-12

13-17

18-20

21-64

65-74

75+

Not Available

Gender

Female

Male

Gender Not Available

Race

American Indian/ Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Hispanic*

More than one race

Race Not Available

Hispanic/Latino Origin

Hispanic/Latino Origin

Non-Hispanic/Latino

Hispanic/Latino Origin Not Available

Comments on Data:

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as an Ethnic Origin are not available
MHBG Table 24 (URS Table 21). Profile of Non-Forensic (Voluntary and Civil-Involuntary Patients) Readmission 

to Any Psychiatric Inpatient Care Unit (State Operated or Other Psychiatric Inpatient Unit) Within 30/180 Days of 

Discharge

MHBG Table 24

Report Year: From: To: 

State Identifier:

Total number of 

Discharges in Year

Number of Readmissions to ANY 

Psychiatric Inpatient Care Unit Hospital 

within

Percent Readmitted

30 days 180 days 30 days 180 days

TOTAL 0 0 0

Age

0-12

13-17

18-20

21-64

65-74

75+

Not Available

Gender

Female

Male

Gender Not Available

Race

American Indian/ 

Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Hispanic*

More than one race

Race Not Available

Hispanic/Latino Origin

Hispanic/Latino Origin

Non-Hispanic/Latino

Hispanic/Latino Origin 

Not Available

1. Does this table include readmission from state psychiatric hospitals?

2. Are Forensic Patients Included? 

Comments on Data:

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as an Ethnic Origin are not available