Block Grant Reporting Section 

FY 2016

FY2017

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

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

C. State Agency Expenditure Reports

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

MHBG Table 3 MHBG Expenditures by Service

MHBG Table 4 Set-aside for Children’s Mental Health Services

MHBG Table 5 (URS Table 8) Profile Of Mental Health Block Grant Expenditures for Non-Direct Service Activities. 

MHBG Table 6 (URS Table 10) – Statewide Entity Inventory

MHBG Table 7 Maintenance of Effort for Statewide Expenditures on Mental Health Services

D. Population and Services Reports

MHBG Table 8A and MHBG Table 8b Profile of Clients by Type of Funding Support (URS Tables 5A and 5B)

MHBG Table 9 (URS Table 1) Profile of the State Population by Diagnosis. 

MHBG Table 10 (URS Table 12) State Mental Health Agency Profile. 
MHBG Table 11A and MHBG Table 11B (URS Tables 2A and 2B) Profile of Persons Served, All Programs by Age, Gender and 

Race/Ethnicity

MHBG Table 12 (URS Table 3) Profile of Persons Served In the Community Mental Health Settings, State Psychiatric Hospitals and

Other Settings

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

Race/Ethnicity

MHBG Table 14 (URS Table 5) Profile of Client Turnover; Performance Indicators and Accomplishments

E: Performance Indicators and Accomplishments

MHBG Table 15 (URS Table 17) Profile of Adults with Serious Mental Illnesses Receiving Specific Services during the Year

MHBG Table 16A (URS Table 4) Profile of Adult Clients by Employment Status

MHBG Table 16B (URS Table 4A) Profile of Adult Clients by Employment Status: By Primary Diagnosis Reported

MHBG Table 17 (URS Table 15) Living Situation Profile

MHBG Table 18 (URS Table 19B) Profile of Change in School Attendance

MHBG Table 19 (URS Table 9) Social Connectedness and Improved Functioning

MHBG Table 20A (URS Table 11) Summary Profile of Client Evaluation of Care

MHBG Table 20B (URS Table 11A) Consumer Evaluation of Care by Consumer Characteristics: Race/Ethnicity

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

MHBG Table 22 (URS Table 16) Profile of Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances 

Receiving Specific Services

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

Days of Discharge 

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 
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 not 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 for which the state

is applying for funds

Application

Due

Plan

Due

Planning Period MHBG Report 

Due

2016 9/1/2015 Yes 7/1/15 – 6/30/17 12/1/2015

Report year is Last 

Completed SFY

2017 9/1/2016 No* Updates only 12/1/2016

Report year is Last 

Completed SFY

States and Jurisdictions are required to complete the Reporting Document. The Reporting Document is comprised of the following sections:

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 that the State or Jurisdiction identified in that Block Grant Plan as needing 

improvement and changes that 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 that were 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 as well as 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 2016/2017

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 2016/2017 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 as well as the 

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, MHP, MHS):

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

4. Goal of the priority area:

5. Strategies to attain the goal:

6. 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 2016):

c) Second-year target/outcome measurement (Final – end of SFY 2017):

d) Data source: 

e) Description of data:

f) Data issues/caveats that affect outcome measures:

7. 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 State fiscal year (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 data base maintained by the URS Contractor. Please complete the 

tables described below.

MHBG Table 2 (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 3 - MHBG Expenditures by Service MHBG. Table 3 is to be used to report MHBG expenditures by unduplicated individual and 

specific services.

MHBG Table 4 - Set-aside for Children’s Mental Health Service. This table provides a report of state-wide expenditures for children’s mental 

health services during the last completed State fiscal year (SFY). 

MHBG Table 5 (URS Table 8) - Profile of Mental Health Block Grant Expenditures for Non-Direct Service Activities. MHBG Table 5 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 State fiscal year (SFY).

MHBG Table 6 (URS Table 10) - Statewide Entity Inventory. 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 State fiscal year. 

MHBG Table 7 - 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 State fiscal year (SFY). 
MHBG Table 2 (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 MH Block Grant.

* States may only use MH Block Grant funds to provide primary prevention services to the priority populations of adults with serious mental illness and children with serious 

emotional disturbance.

MHBG State Agency Expenditures Report

MHBG Table 2 

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. EBP for Early Intervention (5 percent) $ $ $ $

4. Tuberculosis Services

5. HIV Early Intervention Services

5. State Hospital

6. Other 24 Hour Care $ $ $ $ $ $

7. Ambulatory/Community Non-24 Hour Care $ $ $ $ $ $

8. Administration (excluding program / provider 

level

$ $ $ $ $ $

9. Total $ $ $ $ $ $
MHBG Table 3 (Requested) – MH Block Grant Expenditures by Service

This table provides a report of MHBG expenditures during the state fiscal year immediately preceding the federal fiscal year for which the State is 

applying for funds.

Service

SABG

Expenditures

MHBG 

Expenditures

Healthcare Home/Physical Health $ $

General and Specialized Outpatient Medical Services

Acute Primary Care

General Health Screens, Tests and Immunizations

Comprehensive Care Management

Care Coordination and Health Promotion

Comprehensive Transitional Care

Individual and Family Support

Referral to Community Services

Prevention including Promotion $ $

Screening, Brief Intervention and Referral to Treatment 

Brief Motivational Interviews

Screening and Brief Intervention for Tobacco Cessation

Parent Training

Facilitated Referrals

Relapse Prevention/Wellness Recovery Support

Warm Line

Substance Abuse Primary Prevention $

Classroom and/or small group sessions (Education)

Media campaigns (Information Dissemination)

Systematic Planning/Coalition and Community Team Building (Community- Based Process)

Parenting and family management (Education)

Education programs for youth groups (Education)

Community Service Activities (Alternatives)

Student Assistance Programs (Problem Identification and Referral)

Employee Assistance Programs (Problem Identification and Referral)

Community Team Building (Community-Based Process)

Promoting the establishment or review of alcohol, tobacco, and drug use policies (Environmental) 

Engagement Services $ $

Assessment

Specialized Evaluations (Psychological and Neurological)

Service Planning (including crisis planning)

Consumer/Family Education
Service

SABG

Expenditures

MHBG 

Expenditures

Outreach

Outpatient Services $ $

Individual Evidenced-based Therapies

Group Therapy

Family Therapy 

Multi-family Therapy

Consultation to Caregivers

Medication Services $ $

Medication Management

Pharmacotherapy (including MAT)

Laboratory Services

Community Support (Rehabilitative) $ $

Parent/Caregiver Support

Skill Building (social, daily living, cognitive)

Case Management

Behavior Management

Supported Employment

Permanent Supported Housing

Recovery Housing

Therapeutic Mentoring

Traditional Healing Services

Recovery Supports $ $

Peer Support

Recovery Support Coaching

Recovery Support Center Services

Supports for Self-directed Care

Other Supports (Habilitative) $ $

Personal Care

Homemaker

Respite

Supported Education

Transportation

Assisted Living Services

Recreational Services

Trained Behavioral Health Interpreters

Interactive Communication Technology Devices
Service

SABG

Expenditures

MHBG 

Expenditures

Intensive Support Services $ $

Substance Abuse Intensive Outpatient (IOP)

Partial Hospital

Assertive Community Treatment

Intensive Home-based Services

Multi-systemic Therapy

Intensive Case Management 

Out of Home Residential Services $ $

Crisis Residential/Stabilization

Clinically Managed 24-hour Care (SA)

Clinically Managed Medium Intensity Care (SA) 

Adult Mental Health Residential 

Youth Substance Abuse Residential Services

Children's Residential Mental Health Services 

Therapeutic Foster Care

Acute Intensive Services $ $

Mobile Crisis

Peer-based Crisis Services

Urgent Care

23-hour Observation Bed

Medically Monitored Intensive Inpatient (SA) 

24/7 Crisis Hotline Services

Other (please list) $ $

Total $ $
101

MHBG Table 4 Set-Aside for Children’s Mental Health Services

States and Jurisdictions are required not to spend less than the amount expended in FY 2008. 

Statewide Expenditures for Children’s Mental Health Services

MHBG Table 4:

State Identifier:

Report Period: From: To:

Actual SFY 2008 Actual SFY 2015
MHBG Table 5 (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 AND/OR CELLS!

MHBG Table 5 Profile of Community Mental Health Block Grant Expenditures for Non-Direct Service Activities

State Identifier:

Report Period- From: To:

Service Expenditures

MHA Technical Assistance Activities

MHA Planning Council Activities

MHA Administration

MHA Data Collection/Reporting

MHA Activities Other Than Those Above

Total Non-Direct Services

Comments on Data:
103

MHBG Table 6 (URS Table 10) Statewide Entity Inventory

Statewide Entity Inventory

MHBG Table 6 

State Identifier:

Report Period- From: To:

Source of Funds

SA Block Grant MH Block Grant

A B B D E F G H

Entity

Number 

I-SATS 

ID (for 

SABG)

Area 

Served 

(Statewide 

or SubState 

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

Non-Direct 

Service 

Activities

$ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $

Total $ $ $ $ $ $ $ $
MHBG Table 7 Maintenance of Effort for State Expenditures on Mental Health Services

Maintenance of Effort for State Expenditures on Mental Health Services

MHBG Table 7: 

State Identifier:

Report Year: 

Total Expenditures for State _____

Period

A

Expenditures

B

B1 (2013) + B2 (2014)

2

C

SFY 2013

(1)

SFY 2014

(2)

SFY 2015

(3)

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

involved?

Yes No

SFY 2013

SFY 2014

SFY 2015

If any estimated expenditures are provided, please indicate when “actual” expenditure data will be 

submitted to SAMHSA: ___/___/_____

mm/dd/yyyy
105

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 8 through 14. 

MHBG Table 8A and 8b Profile of Clients by Type of Funding Support MHBG Tables 8A and 8B 

provide the number of female and male clients by race and by ethnicity that have: Medicaid Only, 

Non-Medicaid Sources, Both Medicaid and Non-Medicaid, and Status Not Available.

MHBG Table 9 (URS Table 1) Profile of the State Population by Diagnosis MHBG Table 9 

provides the number of Adults with SMI and Children with SED in the reporting year and in three 

years forward.

MHBG Table 10 (URS Table 12) State Mental Health Agency Profile MHBG Table 10 provides the 

Populations covered in State hospitals and Community program in age categories; 0-3, 4-17 and 18 

and above. 

MHBG Tables 11A and 11B (URS Tables 2A and 2B) Profile of Persons Served, All Programs by 

Age, Gender and Race/Ethnicity MHBG Tables 11A and 11B provide an aggregate profile of 

unduplicated 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. States and Jurisdictions are to provide this information on 

all programs by age, gender, race/ethnicity. 

MHBG Table 12 (URS Table 3) Profile of Persons Served In the Community Mental Health Settings, 

State Psychiatric Hospitals and Other Settings MHBG Table 12 provides an aggregate profile of 

unduplicated persons in the reporting year for services funded through the MHBG. 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 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, race, and ethnicity. 

MHBG Tables 13A,13 B and 13C (URS Tables 14A and 14B) Profile of Persons with SMI/SED 

Served By Age, Gender and Race/Ethnicity MHBG Tables 13A, 13B and 13C request counts for 

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

13C 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 6) Profile of Client Turnover MHBG Table 14 requests information 

regarding the profile of client turnover in various out-of-home settings (e.g. state hospitals, inpatient 
106

psychiatric hospitals, residential treatment centers). Information collected by this table requests 

admissions, discharges, and length of stay.
 

MHBG Table 8A. 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 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 Available

Medicaid (only Medicaid)

Non-Medicaid Sources (only)

People Served by Both Medicaid and 

Non-Medicaid Sources

Medicaid Status Not Available

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 Not Available.

If a state is unable to unduplicate 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.
(continued on next page)

MHBG Table

8A (Con’t)

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)

NonMedicaid 

Sources 

(only)

People 

Served by 

Both 

Medicaid and 

NonMedicaid 

Sources

Medicaid 

Status Not 

Available

Total Served
109

MHBG Table 8B. (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 8A. 

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

MHBG Table 8B.

Report Period- From To:

State Identifier:

Not Hispanic or Latino Hispanic or Latino

Hispanic or Latino 

Origin Unknown Total

Female Male

Not 

Available Female

Ma

l

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Total

Medicaid Only

Non-Medicaid Only

People Served by Both Medicaid and NonMedicaid 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 9 (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 9

Report Year:

State Identifier:

Current Report Year Three Years Forward

Adults with Serious Mental Illness (SMI)

Children with Serious Emotional Disturbances (SED)

Note: This Table will be completed for the States by CMHS.
111

MHBG Table 10 (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 AND/OR CELLS!

MHBG Table 10

Report Year:

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

2. Aged 4 to 17

3. Adults Aged 18 and over

4. Forensics

Comments 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?

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?
112

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. What percentage of persons served for the reporting period who met the Federal definitions of adults with SMI and 

children/adolescents with SED have a dual diagnosis of mental illness and substance abuse.

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

2. Setting Standards

3. Quality Improvement/Program Compliance

4. Resolving Consumer Complaints

5. Licensing

6. Sanctions

7. Other

Are Data for 

these programs 

reported on URS 

b. Managed Care (Mental Health Managed Care Tables?

4.b.1

Does the State have a Medicaid Managed Care initiative?

4.b.2 Does the State Mental Health Agency have any responsibilities for mental health services 

provided through Medicaid Managed Care?

If yes, please check the responsibilities the SMHA has:

4.b.3 Direct contractual responsibility and oversight of the MCOs or BHOs

4.b.4 Setting Standards for mental health services

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

4.b.6 Resolving mental health consumer complaints

4.b.7 Input in contract development

4.b.8 Performance monitoring

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 MHBG 11a and 

MHBG 11b, which require unduplicated counts of clients served across your entire mental health system.
113

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:
MHBG Table 11A (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

11A.

Report Year:

State Identifier:

Total American Indian or Alaska 

Native

Asian Black or African American

Female Male Not 

Availab

le

Total Female Male Not 

Availabl

e

Female Male Not 

Availabl

e

Female Male Not 

Availabl

e

0-17 years

18-24 years

25-44 years

45-64 years

65+ years

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):

(continued on next page)
115

MHBG Table

11A.

Report Year:

State Identifier:

Native Hawaiian or Other 

Pacific Islander

White Hispanic * use only if data for 

MHBG Table 11b are not 

available.

More Than One Race Reported Race Not 

Available

Female Male Not 

Availabl

e

Female Male Not 

Availabl

e

Female Male Not 

Availabl

e

Female Male Not 

Availabl

e

Female Male Not 

Availabl

e

0-17 years

18-24 years

25-44 years

45-64 years

65+ years

Total

Pregnant 

Women
116

MHBG Table 11B (URS Table 2B). Profile of Persons Served, All Programs by Age, Gender and 

Race/Ethnicity

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 11A.

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

MHBG Table 11B.

Report Year:

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

0-17 years

18-24 years

25-44 years

45-64 years

65+ years

Total

Pregnant Women

Comments on Data 

(for Age):

Comments on Data 

(for Gender):

Comments on Data 

(for Ethnicity):

Comments on Data 

(Overall):
117

MHBG Table 12 (URS Table 3). Profile of Persons served in tCommunity Mental Health Settings, State Psychiatric Hospitals and 

OtherSettings

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

12

Report Year:

State 

Identifier:

MHBG Table

12

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)
118

MHBG Table 12 (cont.) Profile of Persons served in Community Mental Health Settings, State Psychiatric Hospitals and Other Settings

Table 12

Report Year:

State Identifier:

Table 12

Service Setting

Age Not Available Total

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.

Instructions:

1

States that have county psychiatric hospitals that serves 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 and/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 DSM-IV 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).”
119

Table 13A 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 AND/OR CELLS!

MHBG Table

13A

Report Year:

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)
120

MHBG Table 13A (cont.) Profile of Persons served in the community mental health setting, State Psychiatric Hospitals and Other Settings

MHBG Table 13A

Report Year:

State Identifier:

MHBG Table 13A

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.

Instructions:

1 States that have county psychiatric hospitals that 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 and/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 DSM-IV 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).”
121

MHBG Table 13B (URS Table 14A). Profile of Persons with SMI/SED served by Age, 

Gender and Race/Ethnicity

This is a developmental table similar to MHBG Tables 11a and 11b (URS Table 2A. and 2B). This table requests counts for persons with SMI or SED using the 

definitions provided by the CMHS. 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 CMHS 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 2013, 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" are calculated automatically. 

MHBG Table

13B

Report Year:

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

21-64 years

65-74 years

75+ years

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)
122

(

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

21-64 years

65-74 years

75+ years

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:
123

MHBG Table 13C (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" are calculated automatically. 

MHBG Table 13C

Report Year:

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

21-64 years

65-74 years

75+ years

Not Available

Total

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (for 

Race/Ethnicity):

Comments on Data (Overall):
124

MHBG Table 14 (URS Table 6): Profile of Client Turnover

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

MHBG Table 14.

Report Year:

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: 

Average Length of 

Stay (in Days): 

Residents at end of 

year

For Clients in Facility More 

Than 1 Year: Average 

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 yrs and over)

 Age Not Available

Other Psychiatric Inpatient

 Children (0 to 17 years)

 Adults (18 yrs and over)

 Age Not Available

Residential Tx Centers

 Children (0 to 17 years)

 Adults (18 yrs and over)

 Age Not Available

Community Programs

 Children (0 to 17 years)

 Adults (18 yrs 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):
E. Performance Data and Outcomes

MHBG Table 15 (URS Table 17) Profile of Adults with Serious Mental Illnesses Receiving Specific 

Services during the Year MHBG Table 15 provides the number of unduplicated Adults with SMI 

receiving family psycho education, integrated treatment for co-occurring disorders, illness selfmanagement and medication management.

MHBG Table 16A (URS Table 4) Profile of Adult Clients by Employment Status MHBG Table 16A 

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 homemakers, caregivers, are 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 totals of these two 

categories should equal the number in the row for “Not in Labor Force”). 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 16B (URS Table 4A) Profile of Adult Clients by Employment Status, by Primary 

Diagnosis Reported MHBG Table 16B 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 17 (URS Table 15) Living Situation Profile MHBG Table 17 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 18 (URS Table 19B) Profile of Change in School Attendance MHBG Table 18 

measures the change in days attended over time. Information requested includes information on 

suspensions, expelled, and changes in the school attendance.

MHBG Table 19 (URS Table 9) Social Connectedness and Improved Functioning MHBG Table 19 

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 20A (URS Table 11) Summary Profile of Client Evaluation of Care MHBG Table

20A 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 
126

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

Situation.

MHBG Table 20B (URS Table 11A) Consumer Evaluation of Care by Consumer Characteristics: 

Race/Ethnicity

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 16) Profile of Adults with Serious Mental Illnesses and Children with

Serious Emotional Disturbances Receiving Specific Services MHBG Table 22 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 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 w/I the year, the number of readmissions w/I 30-days and 180-

days and the percent readmitted by age, gender, race, and ethnicity.
127

MHBG Table 15 (URS Table 17): Profile of Adults with Serious Mental Illnesses Receiving Specific Services 

During The Year:

MHBG Table 15

Report Year:

State Identifier:

ADULTS WITH SERIOUS MENTAL 

ILLNESS

Receiving Family 

Psychoeducation

Receiving Integrated 

Treatment for Co-occurring 

Disorders (MH/SA)

Receiving 

Illness Self 

Management

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 Yes No Yes No Yes No Yes No

for this service?

IF YES,

What fidelity measure do you use?

Who measures fidelity?

How often is fidelity measured?

 Yes No Yes No Yes No Yes No

Is the SAMHSA EBP Toolkit used to guide EBP Implementation?
128

Have staff been specifically trained to implement the EBP?

* Hispanic is part of the total served.

Comments on Data (overall):

Comments on Data (Family Psychoeducation):

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 a Ethnic Origin are not available

 
MHBG Table 16A (URS Table 4) Profile of Adult Clients by 

Employment Status

This table 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 in 

the “Not in Labor Force” category. This category has two subcategories: retired and other. (The totals of these two categories should equal the number in the row for “Not in Labor Force”). 

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 AND/OR CELLS!

MHBG Table 16 A

Report Year:

State Identifier:

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

Adults Served 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 16B (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 consumers 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 AND/OR 

CELLS!

MHBG Table 10020

Report Year:

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 

(295)

Bipolar and Mood Disorders (296, 300.4, 

301.11, 301.13, 311)

Other Psychoses (297, 298)

All Other Diagnoses

No Dx and Deferred DX (799.9, V71.09)

Diagnosis Total

Comments on Data (for Diagnosis):
MHBG Table 17 (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 AND/OR CELLS!

MHBG Table 18

Report Year:

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

(continued on next page)
MHBG Table 17 (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 AND/OR CELLS!

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

MHBG Table 17

Report Year:

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 18 (URS Table 19b) Profile of Change in School Attendance

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

1. This is a developmental measure. To assist in the development process, we are asking states to report information on the school attendance outcomes of mental health consumers with their December 2007 MHBG submission.

2. 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.

3. 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.

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

5. 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).

Table 19b. 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):
MHBG Table 19 (URS Table 9): SOCIAL CONNECTEDNESS AND IMPROVED FUNCTIONING

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS 

AND/OR CELLS!

MHBG Table 19: 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?
135

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 

20a: E.g.:

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

2. Exclude respondents with more than 1/3rd 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).
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
137

MHBG Table 20A (URS Table 11): Summary Profile of Client 

Evaluation of Care

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR 

CELLS!

MHBG Table 20A

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)
138

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 and/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:

* Report Confidence Intervals at the 95% confidence level
139

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% (47-4) and 51% (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% confidence level means you can be 95% certain; the 99% 

confidence level means you can be 99% certain. Most researchers use the 95% confidence level.

When you put the confidence level and the confidence interval together, you can say that you are 95% sure that the true percentage of the 

population is between 43% and 51%. (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:
140

5. Are Responses Anonymous, Confidential and/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 20b.

Report Year:

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

American Indian 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

American Indian 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

MHBG Table 20b (URS Table 11A) Consumer Evaluation of Care by Consumer Characteristics: (Optional Table by Race/Ethnicity.)

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

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.
142

MHBG Table 21 (URS Table 19a) Profile of Criminal Justice or Juvenile Justice Involvement:

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!

1. This is a developmental measure. To assist in the development process, we are asking states to report information on the arrest histories of mental health consumers with their December 2007 MHBG submission.

2. 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.

3. 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.

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

5. 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 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

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
143

 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:

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 a Ethnic Origin are not available
146

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:

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 a 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:

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 a Ethnic Origin are not available