OMB Number: 0930-0168 

Expiration Date: 6/30/2026 

Block Grant Reporting Section 

CFDA 93.958

Community Mental Health Services Block Grant

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration
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Table of Contents

A. Introduction..................................................................................................................................................................................................... 1

B. Implementation Report.................................................................................................................................................................................... 3

MHBG Table 1 - Priority Area and Annual Performance Indicators – Progress Report........................................................................ 3

C. State Agency Expenditure Reports.................................................................................................................................................................. 4

MHBG Table 2A (URS Table 7A) - State Agency Expenditure Report................................................................................................... 6

MHBG Table 2B (URS Table 7B)- MHBG State Agency Early Serious Mental Illness including First Episode Psychosis Expenditure 

Report........................................................................................................................................................................................................ 8

MHBG Table 2C (URS Table 7C) - MHBG State Agency Crisis Services Expenditures Report ............................................................ 9

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

MHBG Table 4 (URS Table 8) Profile of Community Mental Health Block Grant Expenditures for Non-Direct Service Activities... 11

MHBG Table 5 (URS Table 10) Profiles of Agencies Receiving Block Grant Funds Directly from the State Mental Health Authority

................................................................................................................................................................................................................. 12

MHBG Table 6 Maintenance of Effort for State Expenditures on Mental Health Services................................................................... 13

D. Populations and Services Report................................................................................................................................................................... 15

MHBG Table 7 (URS Table 1) Profile of State Population by Diagnosis............................................................................................. 17

MHBG Table 8A (URS Table 2A) Profile of Persons Served, All Programs, by Age, Gender, and Race............................................ 18

MHBG Table 8B (URS Table 2B) Profile of Persons Served, All Programs by Age, Gender, and Ethnicity....................................... 21

MHBG Table 8C (URS Table 2C) Profile of Persons Served, All Programs by Sexual Orientation and Race (Optional Reporting 

Table)...................................................................................................................................................................................................... 23

MHBG Table 8D (URS Table 2D) Profile of Persons Served, All Programs by Sexual Orientation and Ethnicity (Optional Reporting 

Table)...................................................................................................................................................................................................... 24

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

Other Settings.......................................................................................................................................................................................... 25
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MHBG Table 10A (URS Table 5A) Profile of Clients by Type of Funding Support............................................................................. 27

MHBG Table 10B (URS 5B) Profile of Clients by Type of Funding Support ....................................................................................... 30

MHBG Table 11 (URS Table 6) Profile of Client Turnover.................................................................................................................. 31

MHBG Table 12 (URS Table 12) State Mental health Agency Profile.................................................................................................. 33

MHBG Table 13A (URS Table 14A) Profile of Persons with SMI/SED Served by Age, Gender, and Race ........................................ 36

MHBG Table 13B (URS Table 14B) Profile of Persons with SMI/SED Served by Age, Gender, and Ethnicity .................................. 39

MHBG Table 14 (URS Table 14C) Profile of Persons Served in Community Mental Health Setting, State Psychiatric Hospitals, and 

Other Settings for Adults with SMI and Children with SED................................................................................................................... 41

E. Performance Indicators and Accomplishments............................................................................................................................................. 43

MHBG Table 15A (URS Table 4) Profile of Adult Clients by Employment Status ............................................................................... 46

MHBG Table 15B (URS Table 4A) Profile of Adult Clients by Employment Status and Primary Diagnosis...................................... 48

MHBG Table 16 (URS Table 9) Social Connectedness and Improved Functioning ............................................................................. 49

MHBG Table 17A (URS Table 11) Summary Profile of Client Evaluation of Care ............................................................................. 51

MHBG Table 17B (URS Table 11A) Consumer Evaluation of Care by race and Ethnicity (Optional Reporting Table) .................... 54

MHBG Table 18 (URS Table 15) Living Situation Profile .................................................................................................................... 55

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

Disturbances Receiving Specific Services............................................................................................................................................... 57

MHBG Table 19B (URS Table 16B) Profile of Adults with Serious Mental Illness Receiving Specific Services During the Year...... 59

MHBG Table 19C (URS Table 16C) Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances 

Receiving Evidence-Based Services for First Episode Psychosis........................................................................................................... 61

MHBG Table 19D (URS Table 16D) Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances 

Receiving Evidence-Based Services for First Episode Psychosis who have Experienced No Psychiatric Hospitalization or Arrest.... 64

MHBG Table 20 (URS Table 17) Profile of Persons Receiving Crisis Response Services................................................................... 65
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MHBG Table 21 (URS Table 19A) Profile of Criminal Justice or Juvenile Justice Involvement ......................................................... 67

MHBG Table 22 (URS Table 19B) Profile of Change in School Attendance ........................................................................................ 70

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 .......................................................................................................... 73

MHBG Table 23B (URS Table 20B) Profile of Forensic Patients Readmission to any State Psychiatric Inpatient Hospital within 

30/180 Days of Discharge....................................................................................................................................................................... 74

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 (Optional 

Reporting Table) ..................................................................................................................................................................................... 75

F. State General Data Notes ............................................................................................................................................................................... 76
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States and jurisdictions are required to complete the reporting document. The reporting document is comprised of the following sections:

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 Assistant Secretary 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. 

Additionally, SAMHSA is directed by Congress through the Consolidated Appropriations Act, 2021 and the Coronavirus Response and 

Relief Supplement Appropriations Act, 2021 [P.L. 116-260], to set aside 5 percent of the Mental Health Block Grant (MHBG) allocation for 

each state to support evidence-based crisis systems. States are required to provide services to those in crisis through three core services. 

SAMHSA will collect related data in Sections C and F. 

States and jurisdictions are required 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, 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 Reporting Period MHBG Report Due

2024 9/1/2023 Report year is Last Completed SFY 12/1/2023

2025 9/1/2024 Report year is Last Completed SFY 12/1/2024
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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 including crisis services. 

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

of individuals served that are the focus of the state’s Mental Health Bock Grant plan. States should report all mental health clients whose 

care is funded by MHBG, State funds, and any other funds the SMHA considers part of their behavioral health system. 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.

Section F: State General Data Notes - In this section, states and jurisdictions may provide data notes deemed necessary to provide context 

for the data reported.
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B. Implementation Report 

The information states and jurisdictions entered into the performance indicator table (Plan Table 1) in the planning section of the 2024/2025 

Behavioral Health Assessment and Plan will automatically populate cells 1 – 6 in the progress report table below. States and jurisdictions 

are required to indicate whether each year performance target/outcome measurement identified in the 2024/2025 Plan was “Achieved” or 

“Not Achieved” in Cell 8, 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, BHCS, PWWDC, PP, PWID, EIS/HIV, 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 2024):

c) Second-year target/outcome measurement (Final – end of SFY 2025):

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:

SMI – adults with serious mental illness; SED – children with serious emotional disturbance; ESMI – individuals with early serious mental illness including 

psychosis; BHCS – individuals receiving behavioral health crisis services; PWWDC – pregnant women with dependent children who are receiving SUD 

treatment services; PP – individuals in need of substance use primary prevention; PWID – individuals who inject drugs (formerly knowns as intravenous drug 

users (IVDU); EIS – early intervention services/HIV – individuals with or at risk for HIV/AIDS who are receiving SUD treatment services; TB – individuals 

with or at risk of tuberculosis who are receiving SUD treatment services; other – specify .
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C. State Agency Expenditure Reports

States and jurisdictions should provide information regarding MHBG, Medicaid, other federal funding sources, state, local and other funds 

expended for authorized activities to 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.

MHBG Table 2A (URS Table 7A) State Agency Expenditure Report: MHBG Table 2 provides information on mental health expenditures 

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

supplemental MHBG funds including COVID-19, ARP, and BSCA.

MHBG Table 2B (URS Table 7B) State Agency Early Serious Mental Illness (ESMI) including First Episode Psychosis Expenditures 

Report: MHBG Table 2b provides information on mental health expenditures and sources of funding specifically for the First Episode 

Psychosis (FEP) Programs as well as other Early Serious Mental Illness (ESMI) programs through the MHBG 10% set-aside. This includes 

funding from the MHBG, Medicaid, other federal funding sources, state, local, other, and supplemental MHBG funds including COVID-19, 

ARP, and BSCA.

MHBG Table 2C (URS Table 7C) MHBG State Agency Crisis Services Expenditures Report: MHBG Table 2c provides information on

mental health expenditures and sources of funding specifically for behavioral health crisis response services. This includes funding from the 

MHBG, Medicaid, other federal funding sources, state, local, other, and supplemental MHBG funds including COVID-19, ARP, and BSCA.

MHBG Table 3 Set-aside for Children’s Mental Health Service: MHBG table 3 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 including COVID-19, ARP, and BSCA supplemental 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 Mental Health Authority: This 

table provides a report of 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 (FEP), early serious mental illness (ESMI) programs, and crisis services.
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MHBG Table 6 Maintenance of Effort for Statewide Expenditures for Mental Health Service: This table provides a report of expenditures 

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

This table provides information on mental health expenditures and sources of funding. This includes funding from the MHBG, Medicaid, 

other federal funding sources, state, local, other funds, and supplemental MHBG funds including COVID-19, ARP, and BSCA. 

MHBG Table 2a

Reporting Period From: To:

State Identifier:

Activity

Sources of Funds

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

G. COVID19 Relief 

Funds 

(MHBG)1

H. ARP 

Funds2

I. Bipartisan 

Safer 

Communities 

Funds3

J. 

Total

1. Mental Health 

Prevention4

$ $ $ $ $ $ $ $ $ $

2. Evidence-Based 

Practices for Early 

Serious Mental 

Illness including 

First Episode 

Psychosis (10 

percent of total 

award MHBG)5

$ $ $ $ $ $ $ $ $ $

3. State Hospital $ $ $ $ $ $ $ $ $

4. Other Psychiatric 

Inpatient Care

$ $ $ $ $ $ $ $ $

5. Other 24-Hour 

Care (Residential 

Care)

$ $ $ $ $ $ $ $ $ $

6. Ambulatory/ 

Community Non24-Hour Care

$ $ $ $ $ $ $ $ $ $

7. Crisis Services (5 

percent setaside)6

$ $ $ $ $ $ $ $ $ $
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MHBG Table 2a 

(Cont.)

Reporting Period From: To:

State Identifier:

Activity

Sources of Funds

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

G. COVID19 Relief 

Funds 

(MHBG)1

H. ARP 

Funds2

I. Bipartisan 

Safer 

Communities 

Funds3

J. 

Total

8. Administration 

(Excluding 

Program and 

Provider Level) 7

$ $ $ $ $ $ $ $ $ $

Total $ $ $ $ $ $ $ $ $ $

Comments on Data

1 The 24-month expenditure period for the COVID-19 Relief supplemental funding is March 15, 2021 – March 14, 2023, which is different from the expenditure 

period for the “standard” MHBG. Column G should reflect the COVID-19 Relief supplemental funding allotment portion used during the state reporting period. 

Note: If your state has an approved no cost extension, you have until March 14, 2024 to expend the COVID-19 Relief supplemental funds.

2 The expenditure period for The American Rescue Plan Act of 2021 (ARP) supplemental funding is September 1, 2021 – September 1, 2025, which is different 

from the expenditure period for the “standard” MHBG. Column H should reflect the ARP supplemental funding allotment portion used during the state 

reporting period.

3 The expenditure period for the 1st allocation of the Bipartisan Safer Communities Act (BSCA) supplemental funding is October 17, 2022 – October 16, 2024, 

and the 2nd allocation is September 30, 2023 – September 29, 2025 which is different from the expenditure period for the “standard” MHBG. Column I should 

reflect the BSCA allotment portion used during the state reporting period.

4 While the state may use state or other funding for prevention services, the MHBG funds must be directed toward adults with SMI or children with SED. 

5 Column A row 2 should include Early Serious Mental Illness including First Episode Psychosis programs funded through MHBG set aside. States may expend 

more than 10 percent of their MHBG allocation.

6 Row 7 should include Crisis Services programs funded through different funding sources, including the MHBG set aside. States may expend more than 5 

percent of their MHBG allocation.

7 Per statute, administrative expenditures cannot exceed 5% of the fiscal year award.
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MHBG Table 2B (URS Table 7B)- MHBG State Agency Early Serious Mental Illness including First Episode Psychosis Expenditure 

Report 

This table provides information on mental health expenditures and sources of funding specifically for the First Episode Psychosis (FEP) 

Programs as well as other Early Serious Mental Illness (ESMI) programs through the MHBG 10% set-aside.

MHBG Table 2b

Reporting Period: From: To:

State Identifier:

Activity

Sources of Funds

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

G.

COVID-19 

Funds 

(MHBG)1

H.

ARP 

Funds 

(MHBG)2

I.

BSCA 

Funds 

(MHBG)3

J.

Total

1. CSC-Evidence-Based 

Practices for First Episode 

Psychosis4

$ $ $ $ $ $ $ $ $ $

2. Training for CSC Practices $ $ $ $ $ $ $ $ $ $

3. Planning for CSC Practices $ $ $ $ $ $ $ $ $ $

4. Other Early Serious Mental 

Illnesses programs (other than 

FEP or partial CSC programs)

$ $ $ $ $ $ $ $ $ $

5. Training for ESMI $ $ $ $ $ $ $ $ $ $

6. Planning for ESMI $ $ $ $ $ $ $ $ $ $

7. Other5 $ $ $ $ $ $ $ $ $ $

Total $ $ $ $ $ $ $ $ $ $

Comments on Data:

1 The 24-month expenditure period for the COVID-19 Relief supplemental funding is March 15, 2021 – March 14, 2023, which is different from the expenditure period for the 

“standard” MHBG. Column G should reflect the COVID-19 Relief supplemental funding allotment portion used during the state reporting period. Note: If your state has an 

approved no cost extension, you have until March 14, 2024 to expend the COVID-19 Relief supplemental funds. 2 The expenditure period for The American Rescue Plan Act of 2021 (ARP) supplemental funding is September 1, 2021 – September 1, 2025, which is different from the 

expenditure period for the “standard” MHBG. Column H should reflect the ARP supplemental funding allotment portion used during the state reporting period. 3 The expenditure period for the 1st allocation of the Bipartisan Safer Communities Act (BSCA) supplemental funding is October 17, 2022 – October 16, 2024, and the 2nd

allocation is September 30, 2023 – September 29, 2025 which is different from the expenditure period for the “standard” MHBG. Column I should reflect the BSCA allotment 

portion used during the state reporting period. 4 Use row 1 to report only those programs that are providing all components of a CSC model. 5 Use row 7 if the state uses only certain components of a CSC model specifically for FEP.

Note, The Totals for this table should equal the amounts reported on Row 2 (Evidence-Based Practices for Early Serious Mental Illness including First Episode Psychoses) on 

MHBG Table 2A (URS Table 7A). 
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MHBG Table 2C (URS Table 7C) - MHBG State Agency Crisis Services Expenditures Report

This table describes expenditures for Crisis Response services provided or funded by the state mental health authority by source of funding. 

MHBG Table 2c

Reporting Period From: To:

State Identifier:

Sources of Funds

Services

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

H.

COVID19 Funds 

(MHBG)1

I. 

ARP 

Funds 

(MHBG)2

J.

BSCA 

Funds 

(MHBG)3

K.

Total

1. Call Centers $ $ $ $ $ $ $ $ $ $

2. 24/7 Mobile Crisis Teams $ $ $ $ $ $ $ $ $ $

3. Crisis Stabilization Programs $ $ $ $ $ $ $ $ $ $

4. Training and Technical 

Assistance $ $ $ $ $ $ $ $ $ $

5. Strategic Planning and 

Coordination $ $ $ $ $ $ $ $ $ $

Total $ $ $ $ $ $ $ $ $ $

Comments on Data:

1 The 24-month expenditure period for the COVID-19 Relief supplemental funding is March 15, 2021 – March 14, 2023, which is different from the expenditure period for the 

“standard” MHBG. Column H should reflect the COVID-19 Relief supplemental funding allotment portion used during the state reporting period. Note: If your state has an 

approved no cost extension, you have until March 14, 2024 to expend the COVID-19 Relief supplemental funds.

2 The expenditure period for The American Rescue Plan Act of 2021 (ARP) supplemental funding is September 1, 2021 – September 1, 2025, which is different from the 

expenditure period for the “standard” MHBG. Column I should reflect the ARP supplemental funding allotment portion used during the state reporting period. 

3 The expenditure period for the 1st allocation of the Bipartisan Safer Communities Act (BSCA) supplemental funding is October 17, 2022 – October 16, 2024, and the 2nd

allocation is September 30, 2023 – September 29, 2025 which is different from the expenditure period for the “standard” MHBG. Column J should reflect the BSCA allotment 

portion used during the state reporting period. 

Note, The Totals for this table should equal the amounts reported on Row 7 (Crisis Services (5 percent set-aside)) on MHBG Table 2a (URS Table 7a).

For definitions, please refer to the National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit (https://www.samhsa.gov/sites/default/files/nationalguidelines-for-behavioral-health-crisis-care-02242020.pdf).
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MHBG Table 3 Set-Aside for Children’s Mental Health Services

This table provides a report of statewide expenditures for children’s mental health services during the last completed SFY 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:

Reporting Period: From: To:

A 

Actual SFY 1994

B 

Actual SFY 2022

C 

Estimated/Actual SFY 2023

Please specify if expenditure amount 

reported in Column C is actual or 

estimated.

Actual Estimated

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

mm/dd/yyyy
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MHBG Table 4 (URS Table 8) Profile of Community Mental Health Block Grant Expenditures for Non-Direct Service Activities

This table describes the use of MHBG funds including COVID-19, ARP, and BSCA supplemental funds for non-direct service activities that are 

funded or conducted by the State Mental Health Authority during the last completed SFY for non-direct service activities that are sponsored, or 

conducted, by the State Mental Health Authority. Please enter the total amount of the block grant expended for each activity. 

MHBG Table 4

Reporting Period: From: To:

State Identifier

Non-Direct-Services/System Development

Activity A. 

MHBG

B. 

COVID Funds1

C.

ARP2

D.

BSCA3

E.

Total

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 $ $ $ $ $

Total $ $ $ $ $

Comments on Data

1 The 24-month expenditure period for the COVID-19 Relief supplemental funding is March 15, 2021 – March 14, 2023, which is different from the expenditure period for the 

“standard” MHBG. Column B should reflect the COVID-19 Relief supplemental funding allotment portion used during the state reporting period. Note: If your state has an 

approved no cost extension, you have until March 14, 2024 to expend the COVID-19 Relief supplemental funds.

2 The expenditure period for The American Rescue Plan Act of 2021 (ARP) supplemental funding is September 1, 2021 – September 1, 2025, which is different from the 

expenditure period for the “standard” MHBG. Column C should reflect the ARP supplemental funding allotment portion used during the state reporting period. 

3 The expenditure period for the 1st allocation of the Bipartisan Safer Communities Act (BSCA) supplemental funding is October 17, 2022 – October 16, 2024, and the 2nd

allocation is September 30, 2023 – September 29, 2025 which is different from the expenditure period for the “standard” MHBG. Column D should reflect the BSCA allotment 

portion used during the state reporting period. 
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MHBG Table 5 (URS Table 10) Profiles of Agencies Receiving Block Grant Funds Directly from the State Mental Health Authority

This table provides a report of 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 (FEP), early serious mental illness (ESMI) programs, and crisis services. 

This table is to be used to provide an inventory of providers/agencies who directly receive Block Grant allocations. Only report those programs that receive MHBG funds to provide 

services. Do not report planning council members reimbursements or other administrative reimbursements related to running the MHBG Program. 

State Identifier:

Reporting Period: From: To:

State Identifier:

Entity

Number 

Area Served (Statewide or 

Sub-State Planning Area)

Provider/ 

Program Name

Street 

Address

City State Zip Total Block Grant 

Funds

Adults with serious 

mental illness

Children with serious 

emotional disturbance

Set-aside for 

FEP programs

Set-aside for 

ESMI programs

Set-aside for 

crisis services

$ $ $ $ $ $

$ $ $ $ $ $

$ $ $ $ $ $

$ $ $ $ $ $

$ $ $ $ $ $

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

This table provides a report of expenditures of all statewide, non-Federal expenditures for authorized activities to treat mental illness 

during the last completed SFY.

MHBG Table 6:

State Identifier:

Report Period: From: To:

Total Expenditures for State:

A

Period 

B

Expenditures 

C

B1 (2021) + B2 (2022) 

2

Please specify if expenditure amounts 

reported in Column B are actual or 

estimated.

SFY 2021

(1) Actual Estimated

SFY 2022

(2) Actual Estimated

SFY 2023

(3) Actual Estimated

If 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 for adults and SED for 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

1

Section 1915(b)(1) of the PHS Act (42 USC 300x-4). 2

Section 1915(b)(2) of the PHS Act (42 USC 300x-4).
Page | 14

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. 

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.
Page | 15

D. Populations and Services Report

States and jurisdictions are required 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 estimates of adults with serious 

mental illness (SMI) and children with serious emotional disturbance (SED) residing within the state in the current reporting year and three 

years forward. Data for this table is prepared for the States by SAMHSA.

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

MHBG Tables 8A and 8B provide an unduplicated aggregate profile of persons served 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, and ethnicity.

MHBG Tables 8C and 8D (URS Tables 2C and 2D) [optional reporting table] Profile of Persons Served in All Programs by sexual 

orientation, Race, and Ethnicity: MHBG Tables 8C and 8D provide an unduplicated aggregate profile of persons served 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 sexual orientation , race, and 

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 the number of persons that received public mental health services in community

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

under the justice system. The reporting year should be the latest SFY for which data are available. States and jurisdictions are to provide 

this information on all programs by age and gender. States and jurisdictions are to provide this information on all programs by age and 

gender.

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

an unduplicated aggregate profile of number of persons served in the reporting period by type of funding support (Medicaid Only, NonMedicaid Sources Only, Both Medicaid and Non-Medicaid, and Status Not Available). The reporting period should be the latest SFY for 

which data are available. 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 gender, race, and ethnicity.

MHBG Table 11 (URS Table 6) Profile of Client Turnover: MHBG Table 11 provides 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 in

this table includes admissions and discharges during the year as well as length of stay.
Page | 16 

MHBG Table 12 (URS Table 12) State Mental Health Agency Profile: MHBG Table 12 provides context for the data reported in the 

MHBG tables. This profile includes the populations served by age groups, services for which the state mental health agency is responsible, 

data reporting capacities, percentage of children and adults that meet the federal definition of SED and SMI, respectively, the percentage of 

children and adults with co-occurring mental and substance use disorders (M/SUD), as well as other summary administrative information. 

MHBG Tables 13A and 13B (URS Tables 14A and 14B) Profile of Persons with SMI/SED Served by Age, Gender, Race, and Ethnicity: 

MHBG Tables 13A and 13B provides an unduplicated aggregate profile of number of persons with SMI or SED served in the reporting 

year. The profile is based on a client receiving services in programs provided or funded by the state mental health agency. States and 

jurisdictions should report data using the Federal Definitions of SMI and SED if they can, if not, please report using the state’s definitions of 

SMI and SED and provide information in these tables describing your state’s definitions. 

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

Other Settings for Adults with SMI and Children with SED: MHBG Table 15A provides an unduplicated aggregate profile of number of 

adults with SMI and children with SED served in the reporting year in each service setting. The reporting year should be the latest SFY for 

which data are available. This profile takes into account all institutional and community services for all such programs. State and 

jurisdictions are to provide this information on all programs by age and gender.
Page | 17 

MHBG Table 7 (URS Table 1) Profile of 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 disturbance (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 to estimate the state level of adults with SMI and children with SED. 

MHBG Table 7

Reporting 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.
Page | 18 

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

This table provides an unduplicated 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 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 such programs. States and jurisdictions are to provide this information on all programs 

by age, gender, and race.

MHBG Table 8A

Reporting

Period: From: To:

State Identifier:

Total American Indian or Alaska Native Asian

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

0-5 years 0 0 0 0

6-12 years 0 0 0 0 0 0 0 0

13-17 years 0 0 0 0 0 0 0 0

18-20 years 0 0 0 0 0 0 0 0

21-24 years 0 0 0 0 0 0 0 0

25-44 years 0 0 0 0 0 0 0 0

45-64 years 0 0 0 0 0 0 0 0

65-74 years 0 0 0 0 0 0 0 0

75+ years 0 0 0 0 0 0 0 0

Not Available 0 0 0 0 0 0 0 0

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

Pregnant Women 0 0 0 0 0 0 0

Are these measures unduplicated? ☐ Unduplicated ☐ Duplicated between hospitals and community ☐ Duplicated among community programs ☐ Duplicated between children and adults ☐ Other, please describe: ___________________________________________

Comments on 

Data (Age):

Comments on 

Data (Gender):

Comments on 

Data (Race):

Comments on 

Data (Overall):

(Continued on next page) 
Page | 19 

MHBG Table 8A

(Cont.)

Reporting

Period: From: To: 

State Identifier:

Total Black or African American Native Hawaiian or Other Pacific Islander

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

0-5 years 0 0 0 0

6-12 years 0 0 0 0 0 0 0 0

13-17 years 0 0 0 0 0 0 0 0

18-20 years 0 0 0 0 0 0 0 0

21-24 years 0 0 0 0 0 0 0 0

25-44 years 0 0 0 0 0 0 0 0

45-64 years 0 0 0 0 0 0 0 0

65-74 years 0 0 0 0 0 0 0 0

75+ years 0 0 0 0 0 0 0 0

Not Available 0 0 0 0 0 0 0 0

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

Pregnant 

Women 0 0 0 0 0 0 0

(Continued below) 

MHBG Table 8A 

(Cont.)

Reporting

Period: From: To:

State Identifier:

Total White Some Other Race

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

0-5 years 0 0 0 0

6-12 years 0 0 0 0 0 0 0 0

13-17 years 0 0 0 0 0 0 0 0

18-20 years 0 0 0 0 0 0 0 0

21-24 years 0 0 0 0 0 0 0 0

25-44 years 0 0 0 0 0 0 0 0

45-64 years 0 0 0 0 0 0 0 0

65-74 years 0 0 0 0 0 0 0 0

75+ years 0 0 0 0 0 0 0 0

Not Available 0 0 0 0 0 0 0 0

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

Pregnant 

Women 0 0 0 0 0 0 0

(Continued on next page) 
Page | 20 

MHBG Table 8A 

(Cont.)

Reporting

Period: From: To:

State Identifier:

Total More than One Race Reported Not Available

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

0-5 years 0 0 0 0

6-12 years 0 0 0 0 0 0 0 0

13-17 years 0 0 0 0 0 0 0 0

18-20 years 0 0 0 0 0 0 0 0

21-24 years 0 0 0 0 0 0 0 0

25-44 years 0 0 0 0 0 0 0 0

45-64 years 0 0 0 0 0 0 0 0

65-74 years 0 0 0 0 0 0 0 0

75+ years 0 0 0 0 0 0 0 0

Not Available 0 0 0 0 0 0 0 0

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

Pregnant 

Women 0 0 0 0 0 0 0
Page | 21 

MHBG Table 8B (URS Table 2B) Profile of Persons Served, All Programs by Age, Gender, and Ethnicity

This table provides an unduplicated 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 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 such programs. States and jurisdictions are to provide this information on all programs 

by age, gender, and ethnicity. Total persons served would be the same as the total indicated in MHBG Table 8A. 

MHBG Table 

8B.

Reporting

Period: From: To:

State Identifier:

Not Hispanic or Latino Hispanic or Latino

Hispanic or Latino Origin 

Not Available

Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender 

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender 

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender 

NonConforming Other

Not

Available

0-5 years

6-12 years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75+ years

Not Available

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

Pregnant 

Women

Comments on 

Data (Age):

Comments on 

Data (Gender):

Comments on 

Data (Ethnicity):

Comments on 

Data (Overall):

(Continued on next page) 
Page | 22 

MHBG Table 8B 

(Cont.)

Reporting Period: From: To:

State Identifier:

Total

Female Male

Transgender 

(Trans Woman)

Transgender

(Trans Man)

Gender NonConforming Other Not Available Total

0-5 years 0 0 0 0

6-12 years 0 0 0 0 0 0 0 0

13-17 years 0 0 0 0 0 0 0 0

18-20 years 0 0 0 0 0 0 0 0

21-24 years 0 0 0 0 0 0 0 0

25-44 years 0 0 0 0 0 0 0 0

45-64 years 0 0 0 0 0 0 0 0

65-74 years 0 0 0 0 0 0 0 0

75+ years 0 0 0 0 0 0 0 0

Not Available 0 0 0 0 0 0 0 0

Total 0 0 0 0 0 0 0 0

Pregnant Women 0 0 0 0 0 0 0
Page | 23 

MHBG Table 8C (URS Table 2C) Profile of Persons Served, All Programs by Sexual Orientation and Race (Optional Reporting Table) 

This table provides an unduplicated 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 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 such programs. States and jurisdictions are to provide this information on all programs 

by sexual orientation and race. Total persons served would be the same as the total indicated in MHBG Table 8A.

MHBG Table 8C

Reporting Period: From: To:

State Identifier:

American Indian 

or Alaska Native Asian

Black or African 

American

Native Hawaiian 

or Other Pacific 

Islander White

More Than One 

Race Reported Some Other Race

Race Not

Available Total

Straight or Heterosexual 0

Homosexual (Gay or Lesbian) 0

Bisexual 0

Queer 0

Pansexual 0

Questioning 0

Asexual 0

Other 0

Not Available 0

Total 0 0 0 0 0 0 0 0 0

Comments on Data (Sexual Orientation):

Comments on Data Race):

Comments on Data (Overall):
Page | 24 

MHBG Table 8D (URS Table 2D) Profile of Persons Served, All Programs by Sexual Orientation and Ethnicity (Optional Reporting 

Table) 

This table provides an unduplicated aggregate profile of persons served in the reporting year. The reporting year should be the latest state 

fiscal year for which data are available. The 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 such programs. States and 

jurisdictions are to provide this information on all programs by sexual orientation and ethnicity. Total persons served would be the same as 

the total indicated in MHBG Table 8B. 

MHBG Table 8D

Reporting Period: From: To:

State Identifier:

Not Hispanic or Latino

Hispanic or 

Latino

Hispanic or Latino Origin 

Not Available Total

Straight or Heterosexual 0

Homosexual (Gay or Lesbian) 0

Bisexual 0

Queer 0

Pansexual 0

Questioning 0

Asexual 0

Other 0

Not Available

Total 0 0 0 0

Comments on Data (Sexual Orientation):

Comments on Data (Ethnicity):

Comments on Data (Overall):
Page | 25 

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

This provides an aggregate profile of the number of persons that received public mental health services in community mental health settings, in state psychiatric hospitals, in other psychiatric inpatient settings, residential treatment 

centers, and institutions under the justice system. The reporting year should be the latest SFY for which data are available. States and jurisdictions are to provide this information on all programs by age and gender. 

MHBG Table 9

Reporting Period: From: To:

State Identifier:

Age 0-5 Age 6-12 Age 13-17

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

Community Mental Health

Programs

State Psychiatric Hospitals

Other Psychiatric Inpatient

Residential Treatment Centers

Institutions under the Justice

System

Comments on Data (Age):

Comments on Data (Gender):

Comments on Data (Race):

Comments on Data (Overall):

(Continued below) 

MHBG Table 9 (Cont.)

Reporting Period: From: To:

State Identifier:

Age 18-20 Age 21-24 Age 25-44

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

Community Mental Health

Programs

State Psychiatric Hospitals

Other Psychiatric Inpatient

Residential Treatment Centers

Institutions under the Justice

System

(Continued on next page) 
Page | 26 

MHBG Table 9 (Cont.)

Reporting Period: From: To:

State Identifier:

Age 45-64 Age 65-74 Age 75+

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

Community Mental Health

Programs

State Psychiatric Hospitals

Other Psychiatric Inpatient

Residential Treatment Centers

Institutions under the Justice

System

(Continued below) 

MHBG Table 9 (Cont.)

Reporting Period: From: To:

State Identifier:

Age Not Available Total

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total

Community Mental Health

Programs 0 0 0 0 0 0 0 0

State Psychiatric Hospitals 0 0 0 0 0 0 0 0

Other Psychiatric Inpatient 0 0 0 0 0 0 0 0

Residential Treatment Centers 0 0 0 0 0 0 0 0

Institutions under the Justice

System 0 0 0 0 0 0 0 0

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 both rows.
Page | 27 

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

This table provide an aggregate profile of the unduplicated number of persons served in the reporting period by type of funding support (Medicaid Only, Non-Medicaid Sources Only, Both Medicaid and Non-Medicaid, and Status Not 

Available). The reporting period should be the latest SFY for which data are available. 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 gender and race. Persons are to be counted in the Medicaid row if they received a service reimbursable through Medicaid. 

MHBG Table 10A

Reporting Period: From: To:

State Identifier:

Total American Indian or Alaska Native Asian

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

Medicaid Only 0 0 0 0 0 0 0 0

Non-Medicaid 

Sources Only 0 0 0 0 0 0 0 0

People Served by 

Both Medicaid 

and Non-Medicaid 0 0 0 0 0 0 0 0

Medicaid Status 

Not Available 0 0 0 0 0 0 0 0

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

☐ 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 (Race):

Comments on 

Data (Gender):

Comments on 

Data (Overall):

Each row should have a unique (deduplicated) 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 deduplicate counts of 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’ 

checkbox should be checked.

(Continued on next page) 
Page | 28 

MHBG Table 10A

(Cont.)

Reporting Period: From: To:

State Identifier:

Total Black or African American Native Hawaiian or Other Pacific Islander

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

Medicaid Only 0 0 0 0 0 0 0 0

Non-Medicaid 

Sources Only 0 0 0 0 0 0 0 0

People Served by 

Both Medicaid 

and Non-Medicaid 0 0 0 0 0 0 0 0

Medicaid Status 

Not Available 0 0 0 0 0 0 0 0

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

(Continued below) 

MHBG Table 10A

(Cont.)

Reporting Period: From: To:

State Identifier:

Total White Some Other Race

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

Medicaid Only 0 0 0 0 0 0 0 0

Non-Medicaid 

Sources Only 0 0 0 0 0 0 0 0

People Served by 

Both Medicaid 

and Non-Medicaid 0 0 0 0 0 0 0 0

Medicaid Status 

Not Available 0 0 0 0 0 0 0 0

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

(Continued on next page) 
Page | 29

MHBG Table 10A

(Cont.)

Reporting Period: From: To:

State Identifier:

Total More than One Race Reported Race Not Available

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

Medicaid Only 0 0 0 0 0 0 0 0

Non-Medicaid 

Sources Only 0 0 0 0 0 0 0 0

People Served by 

Both Medicaid 

and Non-Medicaid 0 0 0 0 0 0 0 0

Medicaid Status 

Not Available 0 0 0 0 0 0 0 0

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Page | 30 

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

This table provide an aggregate profile of the unduplicated number of persons served in the reporting period by type of funding support (Medicaid Only, Non-Medicaid Sources Only, Both Medicaid and Non-Medicaid, and Status Not 

Available). The reporting period should be the latest SFY for which data are available. 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 gender and ethnicity. Persons are to be counted in the Medicaid row if they received a service reimbursable through Medicaid. Total persons served would be the same as the total indicated in MHBG 

Table 10A. 

MHBG Table 

10B

Reporting 

Period: From: To:

State Identifier:

Not Hispanic or Latino Hispanic or Latino

Hispanic or Latino Origin 

Not Available

Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender 

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender 

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender 

NonConforming Other

Not

Available

Medicaid Only

Non-Medicaid 

Sources Only

People Served 

by Both Medicaid and NonMedicaid

Medicaid Status 

Not Available

Comments on 

Data (Ethnicity):

Comments on 

Data (Gender):

Comments on 

Data (Overall):

(Continued below)

MHBG Table 10B 

(Cont.)

Reporting Period: From: To:

State Identifier: 

Total

Female Male

Transgender 

(Trans Woman)

Transgender

(Trans Man)

Gender NonConforming Other Not Available Total

Medicaid Only 0 0 0 0 0 0 0 0

Non-Medicaid 

Sources Only 0 0 0 0 0 0 0 0

People Served by 

Both Medicaid and 

Non-Medicaid 0 0 0 0 0 0 0 0

Medicaid Status Not 

Available 0 0 0 0 0 0 0 0

Total 0 0 0 0 0 0 0 0

Each row should have a unique (deduplicated) 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 deduplicate counts of 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’ 

checkbox should be checked.
Page | 31 

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

This table provides 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 includes total served at the beginning of year, admissions and discharge during the year, and lengths of stay. The reporting year should be the latest 

SFY for which data are available. States and jurisdictions are to provide this information on all programs by age. 

MHBG Table 11

Reporting Period: 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 1 Year 

or Less: 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 0 0 0

Age 0-5

Age 6-12

Age 13-17

Age 18-20

Age 21-24

Age 25-44

Age 45-64

Age 65-74

Age 75+

Age NA

Other Psychiatric Inpatient 0 0 0

Age 0-5

Age 6-12

Age 13-17

Age 18-20

Age 21-24

Age 25-44

Age 45-64

Age 65-74

Age75+

Age NA

(Continued on next page)
Page | 32

MHBG Table 11 (cont.)

Reporting Period: 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 1 Year 

or Less: 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

Residential Treatment Centers 0 0 0

Age 0-5

Age 6-12

Age 13-17

Age 18-20

Age 21-24

Age 25-44

Age 45-64

Age 65-74

Age 75+ 

Age NA

Community Programs 0 0

Age 0-5

Age 6-12

Age 13-17

Age 18-20

Age 21-24

Age 25-44

Age 45-64

Age 65-74

Age 75+ 

Age NA

Comments on Data (State Hospital):

Comments on Data (Other Inpatient):

Comments on Data (Residential

Treatment Centers):

Comments on Data (Community

Programs):

Comments on Data (Overall):
Page | 33 

MHBG Table 12 (URS Table 12) State Mental health Agency Profile

This table provides context for the data reported in the MHBG tables. This profile includes the populations that receive services operated or 

funded by the state mental health agency, data reporting capacities, percentage of children and adults that meet the federal definition of 

SED and SMI, respectively, the percentage of children and adults with co-occurring mental and substance use disorders (M/SUD), as well 

as other summary administrative information. 

MHBG Table 12

Reporting Period: 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. Age 0 to 5 ☐ Yes ☐ Yes ☐ Yes ☐ Yes

2. Age 6 to 12 ☐ Yes ☐ Yes ☐ Yes ☐ Yes

3. Age 13 to 17 ☐ Yes ☐ Yes ☐ Yes ☐ Yes

4. Age 18 to 20 ☐ Yes ☐ Yes ☐ Yes ☐ Yes

5. Age 21 to 24 ☐ Yes ☐ Yes ☐ Yes ☐ Yes

6. Age 25 to 44 ☐ Yes ☐ Yes ☐ Yes ☐ Yes

7. Age 45 to 64 ☐ Yes ☐ Yes ☐ Yes ☐ Yes

8. Age 65 to 74 ☐ Yes ☐ Yes ☐ Yes ☐ Yes

9. Age 75+ ☐ Yes ☐ Yes ☐ Yes ☐ Yes

4. Forensics ☐ Yes ☐ Yes ☐ Yes ☐ Yes

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?

☐ 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 Percentage 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 Use

3.a.

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

illness and substance use?

(Continued on next page) 
Page | 34 

MHBG Table 12 (cont.)

Reporting Period: From: To:

State Identifier:

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

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

substance use:

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

use?

3.b.1 Percentage of adults meeting federal definition of SMI who also have a diagnosis of substance use:

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

diagnosis of substance use:

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 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 

(Continued on next page) 
Page | 35

MHBG Table 12 (cont.)

Reporting Period: From: To:

State Identifier:

If yes, please check the responsibilities the SMHA has:

4.b.3 Direct contractual responsibility and oversight of the Managed Care Organizations

(MOCs) or specialty Behavioral Health Organizations (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 allow the generation of 

unduplicated client counts between different parts of your mental health system. Please respond in particular for MHBG Table 8, which requires unduplicated counts of clients served across your entire mental 

health system.

The data reported in the tables are:

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 reporting unduplicated data: If you are not currently able to provide unduplicated client counts across all

parts of your mental health system, please describe your plans to report unduplicated client counts.

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:
Page | 36 

MHBG Table 13A (URS Table 14A) Profile of Persons with SMI/SED Served by Age, Gender, and Race

This table provides an unduplicated aggregate profile of the number of persons with SMI or SED served in the reporting year. The profile is based on a client receiving services in programs provided or funded by the state mental 

health agency. States and jurisdictions should report data using the Federal Definitions of SMI and SED if they can, if not, please report using the state’s definition of SMI and SED and provide information below describing your 

state’s definition. The reporting period should be the latest SFY for your which data are available. States and jurisdictions are to provide this information on all programs by age, gender, and race. 

MHBG Table 13A

Reporting

Period: From: To:

State Identifier:

Total American Indian or Alaska Native Asian

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

0-5 years 0 0 0 0

6-12 years 0 0 0 0 0 0 0 0

13-17 years 0 0 0 0 0 0 0 0

18-20 years 0 0 0 0 0 0 0 0

21-24 years 0 0 0 0 0 0 0 0

25-44 years 0 0 0 0 0 0 0 0

45-64 years 0 0 0 0 0 0 0 0

65-74 years 0 0 0 0 0 0 0 0

75+ years 0 0 0 0 0 0 0 0

Not Available 0 0 0 0 0 0 0 0

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

Comments on 

Data (Age):

Comments on 

Data (Gender):

Comments on 

Data (Race):

Comments on 

Data (Overall):

Do the State definitions of SMI/SED match the Federal definition? 

Adults with SMI, If no, describe or attach state definition: __________________________________________________________________________________________________________________________

 Diagnoses included in state SMI definition: __________________________________________________________________________________________________________________________

Children with SED, if no, describe or attach state definition: __________________________________________________________________________________________________________________________ 

 Diagnoses included in state SED definition: __________________________________________________________________________________________________________________________

(Continued on next page) 
Page | 37 

MHBG Table 

13A (Cont.)

Reporting

Period: From: To:

State Identifier:

Total Black or African American Native Hawaiian or Other Pacific Islander

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

0-5 years 0 0 0 0

6-12 years 0 0 0 0 0 0 0 0

13-17 years 0 0 0 0 0 0 0 0

18-20 years 0 0 0 0 0 0 0 0

21-24 years 0 0 0 0 0 0 0 0

25-44 years 0 0 0 0 0 0 0 0

45-64 years 0 0 0 0 0 0 0 0

65-74 years 0 0 0 0 0 0 0 0

75+ years 0 0 0 0 0 0 0 0

Not Available 0 0 0 0 0 0 0 0

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

(Continued below) 

MHBG Table 

13A (Cont.)

Reporting

Period: From: To:

State Identifier:

Total White Some Other Race

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

0-5 years 0 0 0 0

6-12 years 0 0 0 0 0 0 0 0

13-17 years 0 0 0 0 0 0 0 0

18-20 years 0 0 0 0 0 0 0 0

21-24 years 0 0 0 0 0 0 0 0

25-44 years 0 0 0 0 0 0 0 0

45-64 years 0 0 0 0 0 0 0 0

65-74 years 0 0 0 0 0 0 0 0

75+ years 0 0 0 0 0 0 0 0

Not Available 0 0 0 0 0 0 0 0

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

(Continued on next page) 
Page | 38 

MHBG Table 

13A (Cont.)

Reporting

Period: From: To:

State Identifier:

Total More than One Race Reported Not Available

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

0-5 years 0 0 0 0

6-12 years 0 0 0 0 0 0 0 0

13-17 years 0 0 0 0 0 0 0 0

18-20 years 0 0 0 0 0 0 0 0

21-24 years 0 0 0 0 0 0 0 0

25-44 years 0 0 0 0 0 0 0 0

45-64 years 0 0 0 0 0 0 0 0

65-74 years 0 0 0 0 0 0 0 0

75+ years 0 0 0 0 0 0 0 0

Not Available 0 0 0 0 0 0 0 0

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Page | 39 

MHBG Table 13B (URS Table 14B) Profile of Persons with SMI/SED Served by Age, Gender, and Ethnicity

This provides an aggregate profile of unduplicated number of persons with SMI or SED served in the reporting year. The profile is based on a client receiving services in programs provided or funded by the state mental health 

agency. States and jurisdictions should report data using the Federal Definitions of SMI and SED if they can, if not, please report using the state’s definition of SMI and SED and provide information below describing your state’s 

definition. The reporting period should be the latest SFY for your which data are available. States and jurisdictions are to provide this information on all programs by age, gender, and ethnicity. The total persons served who meet the 

Federal definition of SMI or SED would be the same as the total in MHBG Table 13A.

MHBG Table 

13B.

Reporting

Period: From: To:

State Identifier: 

Not Hispanic or Latino Hispanic or Latino

Hispanic or Latino Origin 

Not Available

Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender 

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender 

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender 

NonConforming Other

Not

Available

0-5 years

6-12 years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75+ years

Not Available

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

Comments on 

Data (Age):

Comments on 

Data (Gender):

Comments on 

Data (Ethnicity):

Comments on 

Data (Overall):

(Continued on next page) 
Page | 40 

MHBG Table 13B 

(Cont.)

Reporting Period: From: To:

State Identifier:

Total

Female Male

Transgender 

(Trans Woman)

Transgender

(Trans Man)

Gender NonConforming Other Not Available Total

0-5 years 0 0 0 0

6-12 years 0 0 0 0 0 0 0 0

13-17 years 0 0 0 0 0 0 0 0

18-20 years 0 0 0 0 0 0 0 0

21-24 years 0 0 0 0 0 0 0 0

25-44 years 0 0 0 0 0 0 0 0

45-64 years 0 0 0 0 0 0 0 0

65-74 years 0 0 0 0 0 0 0 0

75+ years 0 0 0 0 0 0 0 0

Not Available 0 0 0 0 0 0 0 0

Total 0 0 0 0 0 0 0 0
Page | 41 

MHBG Table 14 (URS Table 14C) Profile of Persons Served in Community Mental Health Setting, State Psychiatric Hospitals, and Other Settings for Adults with SMI and Children with SED

This table provides an aggregate profile of the number of adults with serious mental illness (SMI) and children with serious emotional disturbance (SED) that received publicly funded mental health services in community mental 

health settings, in state psychiatric hospitals, in other psychiatric inpatient programs, in residential treatment centers, and institutions under the justice system. The reporting year should be the latest SFY for which data are available. 

States and jurisdictions are to provide this information on all programs by age and gender. 

MHBG Table 14

Reporting Period: From: To:

State Identifier:

Age 0-5 Age 6-12 Age 13-17

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

Community Mental Health

Programs

State Psychiatric Hospitals

Other Psychiatric Inpatient

Residential Treatment Centers

Institutions under the Justice

System

Comments on Data (Age):

Comments on Data (Gender):

Comments on Data (Race):

Comments on Data (Overall):

(Continued below) 

MHBG Table 14 (Cont.)

Reporting Period: From: To:

State Identifier:

Age 18-20 Age 21-24 Age 25-44

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

Community Mental Health

Programs

State Psychiatric Hospitals

Other Psychiatric Inpatient

Residential Treatment Centers

Institutions under the Justice

System

(Continued on next page) 
Page | 42 

MHBG Table 14 (Cont.)

Reporting Period: From: To:

State Identifier:

Age 45-64 Age 65-74 Age 75+

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

Community Mental Health

Programs

State Psychiatric Hospitals

Other Psychiatric Inpatient

Residential Treatment Centers

Institutions under the Justice

System

(Continued below) 

MHBG Table 14 (Cont.)

Reporting Period: From: To:

State Identifier:

Age Not Available Total

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total

Community Mental Health

Programs 0 0 0 0 0 0 0 0

State Psychiatric Hospitals 0 0 0 0 0 0 0 0

Other Psychiatric Inpatient 0 0 0 0 0 0 0 0

Residential Treatment Centers 0 0 0 0 0 0 0 0

Institutions under the Justice

System 0 0 0 0 0 0 0 0

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.
Page | 43 

E. Performance Indicators and Accomplishments

MHBG Table 15A (URS Table 4) Profile of Adult Clients by Employment Status: MHBG Table 15A provides an unduplicated aggregate 

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

for adults, recognizing, however, that there are clients who are disabled, retired or who are homemakers, caregivers, etc., and not a part of 

the labor force. These persons should be reported under the “Not in Labor Force” category. 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. The reporting year is the latest SFY for which data are available.

MHBG Table 15B (URS Table 4A) Profile of Adult Clients by Employment Status and Primary Diagnosis: MHBG Table 15B provides 

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

is the latest SFY for which data are available.

MHBG Table 16 (URS Table 9) Social Connectedness and Improved Functioning: MHBG Table 16 provides information for 

children/adolescents and adults regarding improved social connectedness. In addition, states are required 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 provides 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, outcomes, participation in treatment planning, cultural sensitivity of 

staff, and general satisfaction with services. 

MHBG Table 17B (URS Table 11A) [optional reporting table]: Consumer Evaluation of Care by Race and 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 provides an unduplicated aggregate profile of persons served 

in the reporting year by the public mental health system in terms of living situation. Living situation categories include, but are not limited 

to, private residence, foster care, residential care, jail/correctional facility, homeless shelter, etc. Data should be based on the most recent 

assessment in the reporting period. Specifically, information is collected on the individual’s last known living situation. The reporting year 

should be the latest SFY for which data are available.

MHBG Table 19A (URS Table 16A) Profile of Adults with Serious Mental Illness and Children with Serious Emotional Disturbances 

Receiving Specific Services: MHBG Table 19A provides a profile of adults with SMI and children with SED receiving specific evidencebased practices in the reporting year. In addition, the table captures information on if and how States and Jurisdictions monitor the fidelity 

for the evidence-based services. The reporting year should be the latest SFY for which data are available. 

MHBG Table 19B (URS Table 16B) Profile of Adults with Serious Mental Illnesses Receiving Specific Services during the Year: MHBG 

Table 19B provides a profile of adults with SMI receiving family psycho education, integrated treatment for co-occurring disorders, illness 
Page | 44 

self-management and recovery, and medication management. In addition, this table provides information on if, and how, states and 

jurisdictions monitor the fidelity for the evidence-based services. The reporting year should eb the latest SFY for which data are available. 

MHBG Table 19C (URS Table 16C) Adults with Serious Mental Illnesses and Children with Serious Emotion Disturbances receiving 

Evidence Based Services for First Episode Psychosis: MHBG Table 19C provides information on the number of adults with SMI and 

children with SED that were admitted into and received Coordinated Specialty Care (CSC) evidence-based first episode psychosis (FEP) 

services. In addition, the table provides information on if, and how, states and jurisdictions monitor the fidelity for the CSC FEP services.

The reporting year should be the latest SFY for which data are available.

MHBG Table 19D (URS Table 16D) Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances Receiving 

Evidence-Based Services for First Episode Psychosis who have Experienced No Psychiatric Hospitalization or Arrest: MHBG Table 19D 

provides information on the percentage of individuals enrolled in Coordinated Specialty Care (CSC) First Episode Psychosis (FEP) services 

who experienced no psychiatric hospitalization in the current fiscal year and the percentage of adults with SMI and children with SED 

enrolled in CSC FEP services who experienced no arrest in the current fiscal year. The reporting year should be the latest SFY for which 

data are available.

MHBG Table 20 (URS Table 17) Profile of Persons Receiving Crisis Response Services: MHBG Table 20 provides the number of persons 

that received crisis response services. In addition, this table also provides the estimated percentage of persons with access to crisis response 

services. The reporting year should be the latest SFY for which data are available. 

MHBG Table 21 (URS Table 19A) Profile of Criminal Justice or Juvenile Justice Involvement: MHBG Table 21 provides information on 

the number of children/youth and adults with an arrest in T1 (prior 12 months) and T2 (most recent 12 months) to measure the change in 

arrests over time. Information required includes information on arrests and impact of services. 

MHBG Table 22 (URS Table 19B), Profile of Change in School Attendance: MHBG Table 22 provides information on the number of 

children with suspension and expulsion from school in T1 (prior 12 months) and T2 (most recent 12 months) to measures the change in 

school attended over time. Information required includes information on suspensions/expulsions, and impact of 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 civil discharges within the 

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

year should be the latest SFY for which data are 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 provides the total number of forensic discharges within the year, the number of readmissions within 

30-days and 180-days, and the percent readmitted by age, gender, race, and ethnicity. The reporting year should be the latest SFY for which 

data are available.

MHBG Table 24 (URS Table 21), Optional Reporting Table: 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 civil discharges from inpatient care units within the year, the number of readmissions within 
Page | 45

30-days and 180-days, and the percent readmitted by age, gender, race, and ethnicity. The reporting year should be the latest SFY for which 

data are available.
Page | 46 

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

This table provides an unduplicated aggregate profile of adults served in the report year by the public mental health system in terms of employment status. The focus is on employment for adults, recognizing, however, that there are 

clients who are disabled, retired or who are homemakers, caregivers, etc., and not a part of the labor force. These persons should be reported under the “Not in Labor Force” category. 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. The reporting year is the latest SFY for which data are available.

MHBG Table 15A

Reporting Period: From: To:

State Identifier:

Age 18-20 Age 21-24 Age 25-44

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

Competitively Employed Full- or 

Part-Time (including Supported 

Employment)

Unemployed

Not in Labor Force (retired, 

sheltered employment, sheltered workshops, homemaker, 

student, volunteer, disabled, 

etc.)

Not Available

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

How often does your state measure employment status? ☐ At Admission ☐ At Discharge ☐ Monthly ☐ Quarterly ☐ Other, please describe: ________________________________________________________________________

What populations are included in reported data? All clients Only selected groups. Please describe: __________________________________________________________

Comments on Data (Age):

Comments on Data (Gender):

Comments on Data (Overall):

(Continued on next page)
Page | 47 

MHBG Table 15A (Cont.)

Reporting Period: From: To:

State Identifier:

Age 45-64 Age 65-74 Age 75+

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available

Competitively Employed Full- or 

Part-Time (including Supported 

Employment)

Unemployed

Not in Labor Force (retired, 

sheltered employment, sheltered workshops, homemaker, 

student, volunteer, disabled, 

etc.)

Not Available

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

(Continued below) 

MHBG Table 15A (Cont.)

Reporting Period: From: To:

State Identifier:

Age Not Available Total

Female Male

Transgender

(Trans

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Female Male

Transgender 

(Trans 

Woman)

Transgender

(Trans

Man)

Gender

NonConforming OtherNot

Available Total

Competitively Employed Full- or 

Part-Time (including Supported 

Employment) 0 0 0 0 0 0 0 0

Unemployed 0 0 0 0 0 0 0 0

Not in Labor Force (retired, 

sheltered employment, sheltered workshops, homemaker, 

student, volunteer, disabled, 

etc.) 0 0 0 0 0 0 0 0

Not Available 0 0 0 0 0 0 0 0

Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Page | 48 

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

This table provides 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. Data should be reported for clients in non-institutional settings at time of discharge or last 

evaluation. The reporting year is the latest SFY for which data are available. Total persons reported on this table would be the same as the 

total indicated in MHBG Table 15A. 

MHBG Table 15B

Reporting Year From: To:

State Identifier:

Clients

Primary Diagnosis

Competitively Employed 

Full- or Part-Time 

(including Supported 

Employment) Unemployed

Not in Labor Force (retired, 

sheltered employment, 

sheltered workshops, 

homemaker, student, 

volunteer, disabled, etc.)

Employment Status 

Not Available Total

Schizophrenia & Related 

Disorders (F20, F25) 0

Bipolar and Mood Disorders (F30,

F31, F32, F32.9, F33, F34.0, 

F34.1) 0

Other Psychoses (F22, F23, F24,

F28, F29) 0

All Other Diagnoses 0

No Diagnosis and Deferred 

Diagnosis (R69, R99, Z03.89) 0

Total 0 0 0 0 0

Comments on Data:
Page | 49 

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

This table provides information for children/adolescents and adults regarding improved social connectedness. In addition, states are 

required 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 16

Reporting Period (Year Survey was Conducted): From: To:

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 Social Connectedness Questions? Measure used

2: Did you use the recommended Functioning Domain Questions?

Measure used

3. Did you collect these as part of your MHSIP Adult Consumer 

Survey?

If no, what source did you use?

Child/Family Social Connectedness and Functioning Measures

4. Did you use the recommended Social Connectedness Questions? Measure used

5: Did you use the recommended Functioning Domain Questions?

Measure used

6. Did you collect these as part of your YSS-F Survey?

If no, what source did you use?
Page | 50 

Recommended Scoring Rules

Please use the same rules for reporting Social Connectedness and Functioning Domain scores as for calculating other Consumer Survey Domain sores for Table 

11: i.e.: 

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 Items

1. I do thinks 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 a 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 taking 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.
Page | 51 

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

This table provides 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, outcomes, participation in treatment planning, cultural sensitivity of staff, and general satisfaction with services. 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 17A

Reporting Period (Year Survey was Conducted): From: To:

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

Comments on Data:

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

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.

1c. Did you use any translation of MHSIP into another language? 1. Spanish

 2. Other Language: __________________________________

Adult Survey Approach

2. Population covered in survey (note: all survey should covered all 

regions of the state)

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

 4. Other sample: ___________________________________________

(Continued on next page)
Page | 52 

MHBG Table 17A (Cont.)

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

 1. Persons currently receiving services

 2. Persons no longer receiving services

 2.c. If yes, please describe how you survey persons no longer receiving services: 

_____________________________________________________________________________________________________________________

3. Please describe the populations inlucded in your sample (e,g,all adults, only adults with SMI, etc.)

 1. All adult consumers in state

 2. Adults with serious mental illness

 3. Adults who were Medicaid eligible or in Medicaid Managed Care

 4. Other, describe (for example, if you survey anyone served in the last 3 months, descibe that here:

 __________________________________________________________________________________________

4. Methdology of collecting data (check all that apply):

Self-Administered Interview

Phone Yes Yes

Mail Yes

Face-to-face Yes Yes

Web-based Yes Yes

4.a. Who administered the survey (check all that apply)?

 1. MH consumers

 2. Family members

 3. Professional interviewers

 4. MH clinicians

 5. Non-direct treatment staff

 6. Other: describe: __________________________________________________________________

5. Are responses anonymous, confidential and/or linked to other patient databases?

 1. Responses are anonymous

 2. Responses are confidential

 3. Responses are matched to client databases

6. Sample Sice and Response Rate

6a. How many surveys were attempted (sent our ro calls initiatied?

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

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

6d. What was your response rate (number of completed surveys dividied by number of contacts)?

6e. 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?

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

7b. Local mental health providers/county mental health providers conducted or contracted for the survey (survey 

was done at the local or regional level)

7c. Other: describe: ____________________________________________________________________________________________________

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)

(Continued on next page) 
Page | 53 

MHBG Table 17A (Cont.)

Child/Family Consumer Surveys

1. Was the MHSIP Youth Services Survey for Families (YSS-F) used? Yes

 If no, what survey was used? ________________________________________________

If no, please attached instrument used.

1.a Did you use any translations of the YSS-F into another language? 1. Spanish

 2. Other Language: __________________________________

Child Survey Approach:

2. Population covered in survey (note: all surveys should cover all regions of the 

state)

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

 4. Other sample: ___________________________________________

2.b. Do you survey only people currently in servics, or do you also survey persons no longer in service?

 1. Persons currently receiving services

 2. Persons no longer receiving services

 2.c. If yes, please describe how you survey persons no longer receiving services: 

_____________________________________________________________________________________________________________________

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

 1. All child consumers in state

 2. Children with serious emotional disturbances

 3. Children who were Medicaid eligible or in Medicaid Managed Care

 4. Other, describe (for example, if you survey anyone served in the last 3 months, descibe that here:

____________________________________________________________________________________________________________________

4. Methodology of collecting data (check all that apply):

Self-Administered Interview

Phone Yes Yes

Mail Yes

Face-to-face Yes Yes

Web-based Yes Yes

4.a. Who administered the survey (check all that apply)?

 1. MH consumers

 2. Family members

 3. Professional interviewers

 4. MH clinicians

 5. Non direct treatment staff

 6. Other: describe: __________________________________________________________________

5. Are responses anonymous, confidential and/or linked to other patient databases?

 1. Responses are anonymous

 2. Responses are confidential

 3. Responses are matched to client databases

6. Sample Sice and Response Rate

6a. How many surveys were attempted (sent our ro calls initiatied?

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

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

6d. What was your response rate (number of completed surveys dividied by number of contacts)?

6e. 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?

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

7b. Local mental health providers/county mental health providers conducted or contracted for the survey (survey 

was done at the local or regional level)

7c. Other: describe: ____________________________________________________________________________________________________
Page | 54 

MHBG Table 17B (URS Table 11A) Consumer Evaluation of Care by race and Ethnicity (Optional Reporting Table) 

This table 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). 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. 

Table 17B

Reporting Year: From: To:

State Identifier:

Adult Consumer Survey Results:

Indicators Total

American Indian or

Alaska Native Asian

Black or African

American

Native Hawaiian or

Other Pacific Islander White Some Other Race

More than One Race

Reported 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 # Positive Responses

1. Reporting Positively About Access 0 0

2. Reporting Positively About Quality 

and Appropriateness 0 0

3. Reporting positively About Outcomes 0 0

4. Reporting Positively About 

Participation in Treatment Planning 0 0

5. Reporting Positively About General 

Satisfaction 0 0

6. Social Connectedness 0 0

7. Functioning 0 0

Child/Adolescent Family Survey Results:

Indicators Total

American Indian or

Alaska Native Asian

Black or African

American

Native Hawaiian or

Other Pacific Islander White

Some Other 

Race

More than One Race

Reported 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 # Positive Responses

1. Reporting Positively About Access

0 0

2. Reporting Positively About General 

Satisfaction

0 0

3. Reporting Positively About Outcomes

0 0

4. Reporting Positively About 

Participation in Treatment Planning for 

their Children

0 0

5. Reporting Positively About Cultural 

Sensitivity of Staff

0 0

6. Social Connectedness

0 0

7. Functioning 0 0

Comments on Data:
Page | 55 

MHBG Table 18 (URS Table 15) Living Situation Profile

This table provides an unduplicated aggregate profile of persons served in the reporting year by the public mental health system in terms of living situation. Living situation categories 

include, but are not limited to, private residence, foster care, residential care, jail/correctional facility, homeless shelter, etc. Data should be based on the most recent assessment in the 

reporting period. Specifically, information is collected on the individual’s last known living situation. The reporting year should be the latest SFY for which data are available. 

MHBG Table 18

Reporting Year: From: To:

State Identifier:

Private 

Residence Foster Home

Residential 

Care Crisis Residence

Residential 

Treatment

Institutional 

Setting

Jail/ 

Correctional 

Facility

Homeless/ 

Shelter Other

Not 

Available Total

0-5 0

6-12 0

13-17 0

18-20 0

21-24 0

25-44 0

45-64 0

65-74 0

75 and Older 0

Not Available 0

TOTAL 0 0 0 0 0 0 0 0 0 0 0

Female 0

Male 0

Transgender (Trans Woman) 0

Transgender (Trans Man) 0

Gender Non-Conforming 0

Other 0

Not Available 0

TOTAL 0 0 0 0 0 0 0 0 0 0 0

American Indian/Alaska Native 0

Asian 0

Black/African American 0

Hawaiian/Pacific Islander 0

White 0

Some Other Race 0

More than One Race Reported 0

Race/Ethnicity Not Available 0

TOTAL 0 0 0 0 0 0 0 0 0 0 0

(Continued on next page) 
Page | 56 

MHBG Table 18 (cont.)

Reporting Year: From: To:

State Identifier:

Private 

Residence Foster Home

Residential 

Care Crisis Residence

Residential 

Treatment

Institutional 

Setting

Jail/ 

Correctional 

Facility

Homeless/ 

Shelter Other

Not 

Available Total

Hispanic or Latino Origin 0

Non-Hispanic or Latino Origin 0

Hispanic or Latino Origin Not Available 0

TOTAL 0 0 0 0 0 0 0 0 0 0 0

Comments on Data:

How often does your state measure living situation? ☐ At Admission ☐ At Discharge ☐ Monthly ☐ Quarterly ☐ Other, please describe: _____________________________________________________
Page | 57 

MHBG Table 19A (URS Table 16A) Profile of Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances Receiving Specific Services

This table provides a profile of adults with SMI and children with SED receiving specific evidence-based practices in the reporting year. In addition, the table captures information on if and how States and Jurisdictions monitor the 

fidelity for the evidence-based services. The reporting year should be the latest SFY for which data are available. 

MHBG Table 19A

Reporting Period: From: To:

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 

Multisystemic 

Therapy

N Receiving Family 

Functional Therapy

Total unduplicated 

N - Children with 

SED

Age

0-5

6-12

13-17

18-20

21-24

25-44

45-64

65-74

75+

Not Available

TOTAL 0 0 0 0 0 0 0 0

Gender

Female

Male

Transgender (Trans Woman)

Transgender (Trans Man)

Gender Non-Conforming

Other

Not Available

Race

American Indian/Alaska Native

Asian

Black/African American

Hawaiian/Other Pacific Islander

White

Some Other Race

More than one race

Not Available

Ethnicity

Hispanic/Latino Origin

Non-Hispanic/Latino Origin

Not Available

 (Continued on next page) 
Page | 58 

MHBG Table 19A (cont.)

Reporting Period: From: To: 

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

Do You monitor fidelity Yes / No Yes / No 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 Yes / No Yes / No

Is the SAMHSA EBP Toolkit used to 

guide EBP Implementation?

Have staff been specifically trained 

to implement the EBP?

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 (Multisystemic 

Therapy):

Comments on Data (Family

Functional Therapy):
Page | 59 

MHBG Table 19B (URS Table 16B) Profile of Adults with Serious Mental Illness Receiving Specific Services During the Year

This table provides a profile of adults with SMI receiving family psychoeducation, integrated treatment for co-occurring disorders, illness 

self-management and recovery, and medication management. In addition, this table provides information on if, and how, states and 

jurisdictions monitor the fidelity for the evidence-based services. The reporting year should eb the latest SFY for which data are available.

MHBG Table 19B

Reporting Year From: To:

State Identifier:

ADULTS WITH SERIOUS MENTAL ILLNESS:

Receiving Family 

Psychoeducation

Receiving Integrated Treatment for 

Co-occurring Disorders (M/SUD)

Receiving Illness Self-Management 

and Recovery

Receiving Medication 

Management

Age

18-20

21-24

25-44

45-64

65-74

75+

Not Available

TOTAL

Gender

Female

Male

Transgender (Trans Woman)

Transgender (Trans Man)

Gender Non-Conforming

Other

Not Available

Race

American Indian/Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Some Other Race

More than One Race

Not Available

Ethnicity

Hispanic/Latino Origin

Non-Hispanic/Latino

Not Available

(Continued on next page)
Page | 60 

MHBG Table 19B (cont.)

Reporting Year From: To:

State Identifier:

ADULTS WITH SERIOUS MENTAL ILLNESS

Receiving Family 

Psychoeducation

Receiving Integrated Treatment for 

Co-occurring Disorders (M/SUD) Receiving Illness Self-Management Receiving Medication Management

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?

 Yes No Yes No Yes No Yes No

Is the SAMHSA EBP Toolkit 

used to guide EBP 

implementation?

Have staff been specifically 

trained to implement the EBP?

Comments on Data (overall):

Comments on Data (Family 

Psychoeducation):

Comments on Data 

(Integrated Treatment for Cooccurring Disorders):

Comments on Data (Illness 

Self-Management):

Comments on Data 

(Medication Management):
Page | 61

MHBG Table 19C (URS Table 16C) Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances Receiving Evidence-Based Services for First Episode Psychosis

This table provides information on the number of adults with SMI and children with SED that were admitted into and received Coordinated Specialty Care (CSC) evidence-based first episode psychosis (FEP) services as well as the 

number of individuals that were successfully discharged from CSC programs, and the number of individuals who discontinued FEP services prior to discharge. In addition, the table provides information on if, and how, states and 

jurisdictions monitor the fidelity for the CSC FEP services. The reporting year should be the latest state fiscal year for which data are available. 

MHBG Table 19C

State Identifier:

Reporting Period: From: To:

Program Name

Number of Admissions into CSC Services During FY Number of Clients with FEP Successfully Discharged from CSC Services During the FY

Age 0-5 Age 6-17 Age 18-20 Age 21-24 Age 25-44 Age 45-64 Age 65-74 Age 75+

Age Not 

Available Age 0-5 Age 6-17 Age 18-20 Age 21-24 Age 25-44 Age 45-64 Age 65-74 Age 75+

Age Not 

Available

(Continued on next page)
Page | 62

MHBG Table 19C

(Cont.)

State Identifier:

Reporting Period: From: To:

Program Name

Number of Clients with FEP who Discontinued Services Prior to Discharge During the FY Current Number of Clients with FEP Receiving CSC FEP Services

Age 0-5 Age 6-17 Age 18-20 Age 21-24 Age 25-44 Age 45-64 Age 65-74 Age 75+

Age Not 

Available Age 0-5 Age 6-17 Age 18-20 Age 21-24 Age 25-44 Age 45-64 Age 65-74 Age 75+

Age Not 

Available

(Continued on next page)
Page | 63

MHBG Table 19C (cont.)

State Identifier:

Reporting Period: From: To:

Program Name

Do you monitor fidelity 

for this service?

What fidelity measure do 

you use? Who measures fidelity?

How often is fidelity measured?

Has staff been specifically 

trained to implement the 

CSC EBP?
Page | 64

MHBG Table 19D (URS Table 16D) Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances Receiving Evidence-Based Services for First Episode Psychosis who have Experienced No 

Psychiatric Hospitalization or Arrest.

This table provides information on the percentage of individuals enrolled in Coordinated Specialty Care (CSC) First Episode Psychosis (FEP) services who experienced no psychiatric hospitalization in the current fiscal year and the 

percentage of adults with SMI and children with SED enrolled in CSC FEP services who experienced no arrest in the current fiscal year. The reporting year should be the latest state fiscal year for which data are available.

MHBG Table 19D

State Identifier:

Reporting Period: From: To:

Program Name

Percentage of Clients with FEP Enrolled in CSC Services who Experienced No Psychiatric Hospitalization in the FY1 Percentage of Clients with FEP Enrolled in CSC Services who Experienced No Arrest in the FY2

Age 0-5 Age 6-17 Age 18-20 Age 21-24 Age 25-44 Age 45-64 Age 65-74 Age 75+

Age

Not Available Age 0-5 Age 6-17 Age 18-20 Age 21-24 Age 25-44 Age 45-64 Age 65-74 Age 75+

Age 

Not Available

1 Report the percentage of individuals who experienced no psychiatric hospitalization while enrolled in the CSC program during the fiscal year.

2 Report the percentage of individuals who experienced no arrest while enrolled in the CSC program during the fiscal year.
Page | 65

MHBG Table 20 (URS Table 17) Profile of Persons Receiving Crisis Response Services

This table provides the number of persons that received crisis response services. In addition, this table also provides the estimated 

percentage of persons with access to crisis response services. The reporting year should be the latest SFY for which data are available. 

Crisis services should not be viewed as stand-alone resources operating independent of the local community mental health and hospital systems 

but rather an integrated part of a coordinated continuum of care. Crisis services include centrally deployed 24/7 mobile crisis units, short-term 

residential crisis stabilization beds, evidence-based protocols for delivering services to individuals with suicide risk, and regional or State-wide 

crisis call centers coordinating in real time (please see page 39 of the National Guidelines for Behavioral Health Crisis Care – A Best Practice 

Toolkit). The crisis services are for anyone who is in a mental health crisis regardless of their SMI or SED status.

MHBG Table 20

State Identifier:

Reporting Period: From: To:

Service

Actual Number of Persons Served Via Service

Age 0-5 Age 6-12 Age 13-17 Age 18-20 Age 21-24 Age 25-44 Age 45-64 Age 65-74 Age 75+

Age

Not Available

Call Centers

24/7 Mobile Crisis 

Team

Crisis Stabilization 

Programs 

Comments on Data:

(Continued on next page)
Page | 66 

Table 20 (cont.)

State Identifier:

Reporting Period: From: To:

Service

Estimated Percentage of Population with Access to Service

Age 0-5 Age 6-12 Age 13-17 Age 18-20 Age 21-24 Age 25-44 Age 45-64 Age 65-74 Age 75+

Age Not

Available

Call Centers 

24/7 Mobile Crisis 

Team 

Crisis Stabilization 

Programs 
Page | 67 

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

This table provides information on the number of children/youth and adults with an arrest in T1 (prior 12 months) and T2 (most recent 12 months) to measure the change in arrests over 

time. Information required includes information on arrests and impact of services. 

1. The SAMHSA National Outcome Measure for Criminal Justice or Juvenile Justice measures change in arrests over time.

2. If your SMHA has data on arrest records from alternative 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 column. If you 

can calculate the change in arrests from T1 to T2, please use all those columns.

3. Please complete the checkboxes at the bottom of the table to help explain the data sources that you have used to complete the table.

4. Please tell us anything else that would help us to understand your indicator (e.g., list surveys or MIS questions; describe linking methodology and data sources; specify time period for criminal or juvenile 

justice involvement; explain whether treatment data are collected).

State: Reporting Period: From: to:

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 Arrested

Not

Arrested

No

Response

# with an 

Arrest in 

T2

# with No 

Arrest at 

T2

No

Response

# with an 

Arrest in T2

# with No 

Arrest at T2

No

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

Female 0

Male 0

Transgender (Trans 

Woman) 0

Transgender (Trans 

Man)

Gender

Non-Conforming 0

Other 0

Gender Not Available 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

Female 0

Male 0

Transgender (Trans 

Woman)

Transgender (Trans 

Man) 0

Gender

Non-Conforming 0

Other 0

Gender Not Available 0

(Continued on next page)
Page | 68 

MHBG Table 21 (cont.)

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 Arrested

Not

Arrested

No

Response

# with an 

Arrest in 

T2

# with No 

Arrest at 

T2

No

Response

# with an 

Arrest in T2

# with No 

Arrest at T2

No

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

Female 0

Male 0

Transgender (Trans 

Woman) 0

Transgender (Trans 

Man)

Gender

Non-Conforming 0

Other 0

Gender Not Available 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

Female 0

Male 0

Transgender (Trans 

Woman) 0

Transgender (Trans 

Man)

Gender

Non-Conforming 0

Other 0

Gender Not Available 0

(Continued on next page) 
Page | 69 

MHBG Table 21 (cont.)

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

 ☐ ☐ ☐6) Other (specify): _______________________________

Measure of adult criminal

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

Measure of children/youth criminal justice 

Involvement: 

 4) State criminal/juvenile justice agency 

 

 5) Local criminal/juvenile justice agency 

Mental health programs included: ☐1) Adults with SMI only 

 ☐1) Arrests 

 2) Other adults (specify) ☐ : ____________________________________ ☐3) Both (all adults)

 ☐1) Children with SED only ☐2) Other Children (specify): 

 ☐2) Other (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/juvenile 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 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 CJ data available for?

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

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).
Page | 70

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

This table provides information on the number of children with suspension and expulsion from school in T1 (prior 12 months) and T2 (most recent 12 months) to measures the change in 

school attended over time. Information required includes information on suspensions/expulsions, and impact of services. 

1. The SAMHSA National Outcome Measure for School Attendance measures the change in days attended over time.

2. If your SMHA has data on school attendance from alternative 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

column, if you can calculate the change in attendance from T1 to T2, please use all these columns.

3. Please complete the checkboxes 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 surveys or MIS questions; describe linking methodology and data sources; specify time period for school attendance;

explain whether treatment data are collected).

State: Reporting Period: From: to:

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 

Expulsion or 

Suspension 

in T2

# with no 

Expulsion or 

Suspension 

in T2

No

Response

# with an 

Expulsion or 

Suspension 

in T2

# with no 

Expulsion or 

Suspension 

in 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

Female 0

Male 0

Transgender 

(Trans Woman) 0

Transgender 

(Trans Man)

Gender

Non-Conforming 0

Other 0

Gender Not 

Available 0

Age

Under 18 0

(Continued on next page) 
Page | 71 

MHBG Table 22 (Cont.)

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

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

Female 0

Male 0

Transgender 

(Trans 

Woman)

Transgender 

(Trans Man) 0

Gender NonConforming 0

Other 0

Gender Not 

Available 0

Age

Under 18 0

(Continued on next page)
Page | 72 

MHBG Table 22 (cont.)

Sources of School Attendance Information ☐ 1) Consumer survey (recommended questions) 2) Other Survey: Please send copy of questions ☐ ☐ 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 (all Children)

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 criminal justice/juvenile justice data are reported?

 Child/Adolescents

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 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)? 

State Comments/Notes:
Page | 73 

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

This table provides the total number of civil discharges within the year, the number of readmissions 

within 30-days and 180-days, and the percent readmitted by age, gender, race, and ethnicity. The 

reporting year should be the latest SFY for which data are available. 

MHBG Table 23A.

Reporting 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

0-5

6-12

13-17

18-20

21-24

25-44

45-64

65-74

75+

Not Available

Gender

Female

Male

Transgender (Trans Woman)

Transgender (Trans Man)

Gender Non-Conforming

Other

Not Available

Race

American Indian/ Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Some Other Race

More than one race

Not Available

Ethnicity

Hispanic/Latino Origin

Non-Hispanic/Latino

Not Available

Are Forensic Patients Included?

Comments on Data:
Page | 74 

MHBG Table 23B (URS Table 20B) Profile of Forensic Patients Readmission to any State 

Psychiatric Inpatient Hospital within 30/180 Days of Discharge 

This table provides the total number of forensic discharges within the year, the number of 

readmissions within 30-days and 180-days, and the percent readmitted by age, gender, race, and 

ethnicity. The reporting year should be the latest SFY for which data are available. 

MHBG Table 23B.

Reporting 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

0-5

6-12

13-17

18-20

21-24

25-44

45-64

65-74

75+

Not Available

Gender

Female

Male

Transgender (Trans Woman)

Transgender (Trans Man)

Gender Non-Conforming

Other

Not Available

Race

American Indian/ Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Some Other Race

More than one race

Not Available

Hispanic/Latino Origin

Hispanic/Latino Origin

Non-Hispanic/Latino

Not Available

Comments on Data:
Page | 75

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 (Optional Reporting Table)

This table 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. The reporting year should be the latest SFY for which data are available.

MHBG Table 24. 

Reporting 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

0-5

6-12

13-17

18-20

21-24

25-44

45-64

65-74

75+

Not Available

Gender

Female

Male

Transgender (Trans Woman)

Transgender (Trans Man)

Gender Non-Conforming

Other

Not Available

Race

American Indian/ Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Some Other Race

More than one race

Not Available

Ethnicity

Hispanic/Latino Origin

Non-Hispanic/Latino

Not Available

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

2. Are forensic patients included?

Comments on Data:
Page | 76 

F. State General Data Notes 

States may utilize this table to provide additional data notes deemed necessary to provide context for 

the data reported. 

MHBG Table Number General Data Note