Block Grant Reporting Section 

CFDA 93.958 

(Mental Health) 

U.S. Department of Health and Human Services 

Substance Abuse and Mental Health Services Administration 
 

 

 

 

 

Table of Contents 

A. Introduction

B. Implementation Report

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

C. State Agency Expenditure Reports

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

b. MHBG Table 2b - (URS Table 7a) - State Agency Early Serious Mental Illness (ESMI) Expenditures Report

c. MHBG Table 2c - (URS Table 7b) - MHBG State Agency Crisis Services Expenditures Report

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

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

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

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

D. Population and Services Reports

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

b. MHBG Table 8a and MHBG Table 8b - (URS Tables 2A and 2B) Profile of Persons Served, All Programs by Age,

Gender and Race/Ethnicity

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

Hospitals, and Other Settings

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

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

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

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

and Race/Ethnicity
 

 

 

 

 

 

 

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

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

Emotional Disturbance (SED)

E. Performance Indicators and Accomplishments

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

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

(Optional Table)

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

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

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

(Optional Table)

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

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

Emotional Disturbances Receiving Specific Services

h. MHBG Table 19a - (URS Table 16A) Adults with Serious Mental Illnesses and Children with Serious Emotional

Disturbances Receiving Evidence Based Services for First Episode Psychosis.

i. MHBG Table 19b – (URS Table 16B) Adults with Serious Mental Illness and Children with Serious Emotional

Disturbances Receiving Crisis Response Services.

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

the Year

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

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

m. 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

n. MHBG Table 23b - (URS Table 20B) Profile of Forensic Patients Readmission to Any State Psychiatric Inpatient

Hospital within 30/180 Days of Discharge

o. 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 Table)
 

 

 

 

 

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

sections: 

Section A. Introduction 

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

and Human Services, acting through the 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 E. 

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 funds are expended, the recipients of grant funds, and the 

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

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

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

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

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

includes specific due dates for annual reports: 

Due Dates for Mental Health and Combined Block Grant Components 

FY the state is 

applying for funds 

Application 

Due 

Plan 

Due 

Planning Period MHBG Report 

Due 

2022 9/1/2021 Yes 7/1/19 – 6/30/21 12/1/2021 

Report year is Last 

Completed SFY 

2023 9/1/2022 No Updates only 12/1/2022 

Report year is Last 

Completed SFY 
 

 

 

 

 

 

 

 

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

respective plans were implemented, the progress towards the priorities and goals identified in the Block Grant plan over 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 in 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 states and jurisdictions are required to complete the Performance 

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

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

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

B. Implementation Report

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

2022/2023 Behavioral Health Assessment and Plan will automatically populate cells 1 – 6 in the progress report tables below. States and

jurisdictions are required to indicate whether each year performance target/outcome measurement identified in the 2022/2023 Plan was

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

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

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

Priority Areas and Annual Performance Indicators 

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

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

4. Goal of the priority area:

5. Objective:

6. Strategies to attain the objective:

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

Indicator #1:

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

b) First-year target/outcome measurement (Progress – end of SFY 2022):

c) Second-year target/outcome measurement (Final – end of SFY 2023):

d) Data source:

e) Description of data:

f) Data issues/caveats that affect outcome measures:

8. Report of Progress toward Goal Attainment:

First-year Target: ____ Achieved _____ Not Achieved (If not achieved, explain why.)

Reason why target was not achieved, and changes proposed to meet target: 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. State Agency Expenditure Reports

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

expended for authorized activities to treat mental illness during the last completed SFY.

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

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

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

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

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

Mental Health Expenditures and Sources of Funding specifically for the First Episode Psychosis (FEP) Programs as well as other Early 

Serious Mental Illness (ESMI) programs through the required MHBG 10% set-aside. This includes funding from Medicaid, the MHBG and 

other federal funding sources, state, local and other funds. The inclusion of local funds is important but optional. 

MHBG Table 2c - MHBG State Agency Crisis Services Expenditures Report. MHBG Table 2c provides information on how different 

funding sources are being used to fund crisis response services in the state. 

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 is made. A waiver granted by the Secretary shall be applicable only for the 

fiscal year in question. 

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

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

Authority (SMHA) during the last completed SFY. 

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

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

provided mental health services during the last completed SFY, including services for those with a first episode psychosis (FEP) and early 

serious mental illness (ESMI) programs. 
 

 

 

 

 

 

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

statewide, non-Federal expenditures for authorized activities to treat mental illness during the last completed SFY. 

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

This table describes expenditures for public mental health services provided by mental health providers funded by the state mental health 

agency by source of funding. 

MHBG Table 2a 

State Agency Expenditures Report 

Report Period From: To: 

State Identifier: 

Source of Funds 

ACTIVITY 

(See instructions for using 

Row 1.) 

A. 

Substance 

Abuse 

Block Grant 

B. 

Mental 

Health 

Block Grant 

C. 

Medicaid 

(Federal, State, 

and Local) 

D. Other Federal

Funds (e.g., ACF

(TANF), CDC,

CMS (Medicare)

SAMHSA, etc.)

E. State

Funds

F. Local

Funds

(excluding

local

Medicaid)

G. Other H. 

COVID-19 

Relief 

Funds 

(MHBG) a 

I. ARP

Funds b 

1. Substance Abuse

Prevention and

Treatment

a. Pregnant Women and

Women with Dependent

Children

b. All Other

2. Primary Prevention

a. Substance Abuse

Primary Prevention

b. Mental Health Primary

Prevention c 

$ $ $ $ $ $ $ $ 
 

 

 

 

 

 

 

 

 

 

 

 

3. Evidence-Based Practices

for Early Serious Mental

Illness including First

Episode Psychosis (10

percent of total award

MHBG) d.

$ $ $ $ $ $ $ $ 

4. Tuberculosis Services

5. Early Intervention

Services for HIV

6. State Hospital $ $ $ $ $ $ $ 

7. Other Psychiatric

Inpatient Care

$ $ $ $ $ $ $ $ 

8. Other 24-Hour Care

(Residential Care)

$ $ $ $ $ $ $ $ 

9. Ambulatory/Community

Non-24-Hour Care

$ $ $ $ $ $ $ $ 

10. Administration

(Excluding Program and

Provider Level) MHBG

and SABG must be

reported separately e 

$ $ $ $ $ $ $ $ 

11. Crisis Services (5 percent

set-aside) f 

$ $ $ $ $ $ $ $ 

12. Subtotal (Rows 1, 2, 4, 5

and 9)

$ $ $ $ $ $ $ $ 

13. Subtotal (Rows 3, 6, 7

and 8)

$ $ $ $ $ $ $ $ 

14. Total $ $ $ $ $ $ $ $ 

a 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. Per the instructions, the standard MHBG expenditures captured in Columns A – G are for the state expenditure period of July 1, 2022 – 

June 30, 2024, for most states. Column H should reflect the spending for the state reporting period. The total may reflect the COVID-19 Relief allotment portion used 

during the state reporting period.

b 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. The standard MHBG expenditures captured in Columns A – G are for the state expenditure period of July 1, 2022 – 
 

 

June 30, 2024, for most states.” Column I should reflect the spending for the state reporting period. The total may reflect the ARP allotment portion used during the state 

reporting period. 

c While the state may use state or other funding for these services, the MHBG funds must be directed toward adults with SMI or children with SED d Column 3B should include Early Serious Mental Illness programs funded through MHBG set aside 

e Per statute Administrative expenditures cannot exceed 5% of the fiscal year award. 

f Row 10 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. 
 

 

 

 

-

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

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

MHBG Table 2b 

Report Period From: To: 

State Identifier: 

Source of Funds 

Activity 

(See instructions for using Row 1) 

A. 

Mental Health 

Block Grant 

B. 

Medicaid 

(Federal, 

State, and 

Local) 

C. 

Other Federal 

Funds (e.g., 

ACF (TANF), 

CDC, CMS 

(Medicare), 

SAMHSA, 

etc.) 

D. 

State Funds 

E. 

Local funds 

(excluding 

local Medicaid) 

F. 

Other 

1. CSC Evidence-Based Practices for 

First Episode Psychosis* 

$ $ $ $ $ $ 

2. Training for CSC Practices 

3. Planning for CSC Practices 

4. Other Early Serious Mental Illnesses 

programs (other than FEP or partial 

CSC programs) 

3.. Training for ESMI $ $ $ $ $ $ 

4.. Planning for ESMI 

Total $ $ $ $ $ $ 

Comments on Data: 

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

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

Note, the totals for this table should equal the amounts reported on Row 3 (Evidence-Based Practices for Early Serious Mental Illness) on MHBG Table 2a (URS

Table 7a)

MHBG Table 2c - MHBG State Agency Crisis Services Expenditures Report 

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

 

-

MHBG State Agency Crisis Services Expenditures Report 

MHBG Table 2c 

Report Period From: To: 

State Identifier: 

Source 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 G. 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: 

* Mental Health Block Grant funding includes one-time funding i.e.: 5% Crisis Set-Aside, COVID-19, and ARP sources. If the funding source

is not captured in the table, please report the name of 'Other' funding per service under the comments section.
 

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

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

Statewide Expenditures for Children’s Mental Health Services 

MHBG Table 3: 

State Identifier: 

Report Period: From: To: 

Actual SFY 1994 Actual SFY 2021 
 

 

 

 

 

 

 

 

 

 

 

-

-

--

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 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. 

Non Direct Services/System Development 

MHBG Table 4 

State Identifier: 

Report Period From: To: 

Activity A. MHBG B. COVID 19

Funds a 

C. ARP Funds b 

1. Information Systems $ $ $ 

2. Infrastructure Support $ $ $ 

3. Partnerships, community outreach, and needs 

assessment 

$ $ $ 

4. Planning Council Activities (MHBG required,

SABG optional) 

$ $ $ 

5. Quality assurance and improvement $ $ $ 

6. Research and Evaluation $ $ $ 

7. Training and Education $ $ $ 

8. Total $ $ $ 

Comments on Data a 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. Per the instructions, the standard MHBG expenditures captured in Columns A - C are for the state expenditure period of July 1 – June 30 of the same year 

for most states. Column B should reflect the spending for the state reporting period. The total may reflect the COVID-19 Relief allotment portion used during the state budget 

reporting period.

b 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. Per the instructions, the standard MHBG expenditures captured in Columns A – C are for the state expenditure period of July 1 – 

June 30 of the same year, for most states. Column C should reflect the spending for the state reporting period. The total may reflect the ARP allotment portion used during the 

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

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

MHBG Table 5 

State Identifier: 

Report Period- From: To: 

Source of Funds 

SA Block Grant MH Block Grant 

A B B D E F G H I J 

Entity 

Number 

I-SATS

ID (for

SABG)

Area Served 

(Statewide 

or Sub-State 

Planning 

Area) 

Provider/Program 

Name 

Street 

Address 

City State Zip Total 

Block 

Grant 

Funds 

Preventio 

n (other 

than 

primary 

preventio 

n) and

Treatment

Services

Pregnant 

Women 

and 

Women 

with 

Dependent 

Children 

Primary 

Prevention 

Early 

Intervention 

Services for 

HIV 

Total 

MH 

Block 

Grant 

Funds 

Adults 

with 

serious 

mental 

illness 

Children 

with a 

serious 

emotional 

disturbance 

Set-aside 

for FEP 

programs 

Set-aside 

for 

ESMI 

programs 

$ $ $ $ $ $ $ $ $ $ 

$ $ $ $ $ $ $ $ $ $ 

Total $ $ $ $ $ $ $ $ $ $ 
 

 

 

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

Maintenance of Effort for State Expenditures on Mental Health Services 

MHBG Table 6: 

State Identifier: 

Report Period- From: To: 

Total Expenditures for State: 

Period 

A 

Expenditures 

B 

B1 (2018) + B2 (2019) 

2 

C 

SFY 2019 

(1) 

SFY 2020 

(2) 

SFY 2021 

(3) 

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

Yes No 

SFY 2019 

SFY 2020 

SFY 2021 

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

mm/dd/yyyy 
 

 

 

 

 

 

States are required to submit sufficient information for the Secretary to make a determination of compliance with the statutory Maintenance of Effort (MOE) requirements.1 MOE 

information is necessary to document that the state maintained expenditures for community mental health services at a level that is not less than the average level of such 

expenditures for the 2-year period preceding the fiscal year for which the state applies for the grant. The state shall only include community mental health services expenditures 

for individuals that meet the federal or state definition of SMI adults and SED children. States that received approval to exclude funds from the maintenance of effort calculation 

should include the appropriate MOE approval documents. 

A. MOE Exclusion

The Secretary may exclude from the aggregate amount any state funds appropriated to the principal agency for authorized activities of a non-recurring nature and for a specific 

purpose.2

A request for MOE exclusion should meet the following requirements: 

The state shall request the exclusion separately from the application. 

The request shall be signed by the state’s Chief Executive Officer or by an individual authorized to apply for the 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 MOE requirement for the year in 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

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). 
 

 

 

 

 

 

 

 

 

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

the State Fiscal Year in question. An extraordinary economic condition is defined as a financial crisis in which the total tax revenues declined at least one and one-half percent, 

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

2. Material Compliance

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

circumstances, to make a finding that even though there was a shortfall on the MOE, the state maintained material compliance with the MOE requirement for the fiscal year in 

question. Therefore, the state is given an opportunity to submit information that might lead to a finding of material compliance. The relevant factors that SAMHSA considers in 

making a recommendation to the Secretary include: (1) whether the state maintained service levels; (2) the state’s mental health expenditure history; and (3) the state’s future 

commitment to funding mental health services. 

D. Populations and Services Report

States and jurisdictions are 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 number of Adults with serious mental illness (SMI) and Children with 

serious emotional disturbance (SED) in the reporting year and in 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, All Programs by Age, Gender and Race/Ethnicity. MHBG Tables 8a and 8b provide an aggregate 

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

in programs provided or funded by the state mental health agency. The client profile takes into account institutional and community services for all such programs. States and 

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

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

aggregate profile of unduplicated persons in the reporting year for services provided or funded through the MHBG. The reporting year should be the latest SFY for which data are 

available. The client profile considers institutional and community services for all such programs. States and jurisdictions are to provide this information on all programs by age, 

gender, and race/ethnicity. 

MHBG Table 10a and 10b (URS Tables 5A and 5B) Profile of Clients by Type of Funding Support. MHBG Tables 10a and 10b provide the number of female and male clients 

by race and ethnicity that have Medicaid Only, Non-Medicaid Sources, Both Medicaid and Non-Medicaid, and Status Not Available. 

MHBG Table 11 (URS Table 6) Profile of Client Turnover. MHBG Table 11 requests information regarding the profile of client turnover in various out-of-home settings (e.g. 

state hospitals, inpatient psychiatric hospitals, and residential treatment centers). Information collected by this table requests admissions, discharges, and length of stay. 
 

 

 

 

 

 

 

MHBG Table 12 (URS Table 12) State Mental Health Agency Profile. MHBG Table 12 provides the populations covered in state hospitals and community program in age 

categories 0-3, 4-17, and 18 and above. 

MHBG Tables 13a and 13b (URS Tables 14A and 14B) Profile of Persons with SMI/SED Served By Age, Gender and Race/Ethnicity. MHBG Tables 13a and 13b request counts 

for persons with SMI or SED using the definitions provided by CMHS. These tables include individuals receiving services in programs provided or funded by the state mental 

health agency. States and jurisdictions should report 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 definition. 

MHBG Table 14 (URS Table 15A) Profile of Persons Served in the Community Mental Health Settings, State Psychiatric Hospitals, and Other Settings for Adults with SMI and 

Children with SED. MHBG Table 14 provides a profile for Adults with Serious Mental Illnesses (SMI) and Children With Serious Emotional Disturbances (SED) that received 

public funded mental health services in community mental health settings, in state psychiatric hospitals, in other psychiatric inpatient programs, and in residential treatment centers 

for children. 

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

This table summarizes the estimates of adults residing within the state with serious mental illness (SMI) and children residing 

within the state with serious emotional disturbances (SED). The table calls for estimates for two time periods, one for the 

report year and one for three years into the future. CMHS will provide this data to states based on the standardized 

methodology developed and published in the Federal Register and the state level estimates for both adults with SMI and 

children with SED. 

MHBG Table 7 

Report Period- From: To: 

State Identifier: 

Current Report 

Year 

Three Years Forward 

Adults with SMI 

Children with SED 

Note: CMHS will complete this table for the states. 
MHBG Table 8a (URS Table 2A) Profile of Persons Served, All Programs by Age, Gender, Race/Ethnicity 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This table provides an aggregate profile of persons in the reporting year. The reporting year should be the latest state fiscal year for which data are available. This profile is based on a client receiving services 

in programs provided or funded by the state mental health agency. The client profile takes into account all institutional and community services for all such programs. Please provide unduplicated counts if 

possible. 

MHBG Table 8a 

Report Period- From: To: 

State Identifier: 

Total 

American Indian or Alaska Native Asian Black or African American 

Female Male Other N/A Total Female Male Other N/A Female Male Other N/A Female Male Other N/A 

0-12 years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older 

Age not 

Available 

Total 

Pregnant 

Women 

Are these numbers unduplicated? 

Comments on Data (for Age): 

Comments on Data (for Gender): 

Comments on Data (for Race/Ethnicity): 

Comments on Data (Overall): 

(Continued on next page) 
- 

MHBG Table 8a (Cont.) 

Report Year From: To: 

State Identifier: 

Native Hawaiian or 

Other Pacific Islander 

White More Than One Race Reported Race Not Available 

Female Male Other N/A Female Male Other N/A Female Male Other N/A Female Male Other N/A 

0-12 years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older 

Age not 

Available 

Total 

Pregnant 

Women 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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

total as indicated in MHBG Table 8a. 

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

MHBG Table 8b 

Report Year- From: To: 

State Identifier: 

0-12 years

Not Hispanic Hispanic or Latino Hispanic or Latino Origin Not 

Available Total 

Female Male Other N/A Female Male Other N/A Female Male Other N/A Female Male Other N/A Total 

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older 

Age not available 

Total 

Pregnant Women 

Comments on Data (for Age): 

Comments on Data (for Gender): 

Comments on Data (for Ethnicity): 

Comments on Data (Overall): 

Are these unduplicated? 

_ 
 

 

 

 

 

 

 

 

 

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 

Report Year- From: To: 

State Identifier: 

Service Setting 

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

Female Male Other N/A Female Male Other N/A Female Male Other N/A Female Male Other N/A 

Community Mental 

Health Programs 

State Psychiatric 

Hospitals 

Other Psychiatric 

Inpatient 

Residential Treatment 

Centers 

Institutions in the 

Justice System 

(Continued on next page) 
 

MHBG Table 9 (cont.) 

Report Year- From: To: 

State Identifier: 

Service Setting 

Age Not Available Total 

Female Male Other N/A Female Male Other N/A Total 

Community Mental Health Programs 

State Psychiatric Hospitals 

Other Psychiatric Inpatient 

Residential Treatment Centers 

Institutions in the Justice System 

Comments on Data (for Age): 

Comments on Data (for Gender): 

Comment on Data (Overall): 
 

 

 

 

 

 

 

State Identifier:

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

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

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

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

MHBG Table 10a 

Report Period- From: To: 

Total American Indian or Alaska Native Asian Black or African American 

Female Male Other N/A Total Female Male Other N/A Female Male Other N/A Female Male N/A Other 

Medicaid (only Medicaid) 

Non-Medicaid Sources (only) 

People Served by Both Medicaid and Non-Medicaid 

Sources 

Medicaid Status Not Available 

Total Served 

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

Comments on Data (for Race): 

Comments on Data (for Gender): 

Comments on Data (Overall): 

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

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

Both includes people with any Medicaid' check box should be checked. 

(Continued on next page) 

25 
 

MHBG Table 10a 

(Cont.) 

Report PeriodFrom: To: 

State Identifier: 

Native Hawaiian or 

Other Pacific Islander 

White More Than One Race Reported Race Not Available 

Female Male Other N/A Female Male Other N/A Female Male Other N/A Female Male Other N/A 

Medicaid (only Medicaid) 

Non-Medicaid Sources (only) 

People Served by Both 

Medicaid and 

Non-Medicaid Sources 

Medicaid Status Not 

Available 

Total Served 
 

 

 

 

 

 

 

 

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

Of the total persons covered by Medicaid, please indicate the gender and number of persons who are Hispanic/Latino or not Hispanic/Latino. Total persons covered by Medicaid would be the total indicated in MHBG Table 10a. 

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

MHBG Table 10b. 

Report Period- From: To: 

State Identifier: 

Not Hispanic or Latino 

Hispanic or Latino Hispanic or Latino Origin 

Unknown Total 

Female Male Other N/A Female Male Other N/A Female Male Other N/A Female Male Other N/A Total 

Medicaid Only 

Non-Medicaid Only 

People Served by Both Medicaid and Non-Medicaid Sources 

Medicaid Status Unknown 

Total Served 

Comments on Data (for Ethnicity): 

Comments on Data (for Gender): 

Comments on Data (Overall): 

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

 

 

 

 

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

MHBG Table 

11 

Report Year- From: To: 

State Identifier: 

Profile of Service Utilization 

Total Served at 

Beginning of Year 

(unduplicated) 

Admissions 

During the year 

(duplicated) 

Discharges 

During the year 

(duplicated) 

Length of Stay (in Days): 

Discharged Patients 

For Clients in Facility for 

Less Than 1 Year: Length 

of Stay (in Days): Residents 

at end of year 

For Clients in Facility More 

Than 1 Year: Length of Stay 

(in Days): Residents at end 

of year 

Average 

(Mean) Median 

Average 

(Mean) Median 

Average 

(Mean) Median 

State Hospitals 

Children (0 to 17 years) 

Adults (18 years and over) 

Age Not Available 

Other Psychiatric Inpatient 

Children (0 to 17 years) 

Adults (18 years and over) 

Age Not Available 

Residential Treatment Centers 

Children (0 to 17 years) 

Adults (18 years and over) 

Age Not Available 

Community Programs 

Children (0 to 17 years) 
 

 

Adults (18 years and over) 

Age Not Available 

Comments on Data (State Hospital): 

Comments on Data (Other Inpatient): 

Comments on Data (Residential 

Treatment): 

Comments on Data (Community 

Programs): 

Comments on Data (Overall): 
 

 

 

 

 

 

 

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

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

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

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

MHBG Table 12 

Report Year- From: To: 

State Identifier: 

Populations Served 

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

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

Populations Covered Included in Data 

State Hospitals Community Programs State Hospitals Community 

Programs 

1. Aged 0 to 3

☐Yes ☐Yes ☐Yes ☐Yes

2. Aged 4 to 17

☐Yes ☐Yes ☐Yes ☐Yes

3. Adults Aged 18 and

over ☐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 Percent of adults meeting federal definition of SMI: 

2.a.2 Percentage of children/adolescents meeting federal definition of SED: 

3 Co-Occurring Mental Health and Substance Abuse: 

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

mental illness and substance abuse? 

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

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

problem: 

3.b. Percentage of persons served for the reporting period who met the federal definitions of adults with SMI 

and children with SED have a dual diagnosis of mental illness and substance abuse: 

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

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

substance abuse problem: 

3b.3 Please describe how you calculate and count the number of persons with co-occurring disorders: 

4 State Mental Health Agency Responsibilities 

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

provided through Medicaid? (Check All that Apply)

1. State Medicaid Operating Agency ☐Yes

2. Setting Standards ☐Yes

3. Quality Improvement/Program Compliance ☐Yes

4. Resolving Consumer Complaints ☐Yes

5. Licensing ☐Yes

6. Sanctions ☐Yes

7. Other

 

Are Data for these 

programs reported on 

URS Tables? 

b. Managed Care (Mental Health Managed

Care

4.b.1

Does the state have a Medicaid Managed Care initiative? ☐Yes ☐Yes

4.b.2

Does the State Mental Health Agency have any 

responsibilities for mental health services provided through 

Medicaid Managed Care? ☐Yes ☐Yes

 

4.b.3 Direct contractual responsibility and oversight of the

MCOs or BHOs ☐Yes

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

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

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

4.b.7 Input in contract development ☐Yes

4.b.8 Performance monitoring ☐Yes

4.b.9 Other

If yes, please check the responsibilities the SMHA has: 

 
 

 

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

5 counts between different parts of your mental health system. Please respond in particular for MHBG Table 13a and MHBG 

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

Are data reporting in the tables? 

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

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

responsible for different geographic or programmatic areas. 

☐

5.b.

Duplicated: across state hospital and community programs ☐

5.c. Duplicated: within community programs ☐

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

5.e.

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

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

Data Infrastructure Grant. 

6 Summary Administrative Data 

6.a. Report Year 

6.b. State Identifier 

Summary Information on Data Submitted by SMHA: 

6.c.

Year being reported: 

From: To 

6.d. Person Responsible for Submission: 

6.e. Contact Phone Number: 

6.f. Contact Address: 

6.g. E-mail:
 

 

 

 

 

 

 

 

 

 

 

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

This table requests counts for persons with SMI or SED using the definitions provided by SAMHSA. MHBG Table 8a and 8b (URS Table 2A and 2B) included all clients served by publicly operated 

or funded programs. This table counts only clients who meet the federal definition of SMI or SED. For many states, this table may be the same as MHBG Tables 8a and 8b (URS Table 2A and 2B). 

States should report using the federal definitions of SMI and SED if they can, if not, please report using your state’s definitions of SMI and SED and provide information below describing your state’s 

definition. 

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

MHBG Table 13a 

Report Year- From: To: 

State Identifier: 

Total American Indian or Alaska 

Native 

Asian Black or African American Native Hawaiian or Other Pacific 

Islander 

Femal 

e 

Male Other N/A Total Femal 

e 

Male Other N/A Femal 

e 

Male Other N/A Femal 

e 

Male Other N/A Femal 

e 

Male Other N/A 

0-12 years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older 

Age Not 

Available 

Total 

Comments on Data (for Age): 

Comments on Data (for Gender): 

Comments on Data (for 

Race/Ethnicity): 

Comments on Data (Overall): 

(Continued on next page) 
 

MHBG Table 13a. 

Report Year: 

State Identifier: 

White More Than One Race Reported Race Not Available 

Female Male Other N/A Female Male Other N/A Female Male Other N/A 

0-12 years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older 

Age Not 

Available 

Total 

1. State Definitions Match the Federal Definitions:

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

☐Yes ☐No

Diagnoses included in state SMI definition: 

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

☐Yes ☐No Diagnoses included in State SED definition: 
 

 

 

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

Gender and Ethnicity 

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

Hispanic/Latino. The total persons served who meet the federal definition of SMI or SED should be the total as indicated in MHBG Table 13b. 

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

MHBG Table 13b 

Report Year- From: To: 

State Identifier: 

Not Hispanic or Latino 

Hispanic or Latino Hispanic or Latino Origin 

Not Available Total 

Female Male Other N/A Female Male Other N/A Female Male Other N/A Female Male Other N/A Total 

0-12 years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older 

Age Not 

Available 

Total 

Comments on Data (for Age): 

Comments on Data (for Gender): 

Comments on Data (for Race/Ethnicity): 

Comments on Data (Overall): 
MHBG Table 14 (URS Table 15A) 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 a profile for adults with Serious Mental Illness (SMI) and children with serious emotional disturbance (SED) that received public funded mental health services in community m 

services in hospitals, other psychiatric inpatient programs, residential treatment centers and Institutions under Justice System. 

MHBG Table 14 

Report Year- From: To: 

State Identifier: 

Service 

Setting 

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

Female Male Other N/A Female Male Other N/A Female Male Other N/A 

Community 

Mental 

Health 

Programs 

State 

Psychiatric 

Hospitals 

Other 

Psychiatric 

Inpatient 

Residential 

Treatment 

Centers 

Institutions 

under 

Justice 

Systems 

(Continued on next page) 
MHBG Table 14 

Report Year- From: To: 

State Identifier: 

Service 

Setting 

Age 65+ Age Not Available Total 

Female Male Other N/A Female Male Other N/A Female Male Other N/A Total 

Community 

Mental Health 

Programs 

State 

Psychiatric 

Hospitals 

Other 

Psychiatric 

Inpatient 

Residential 

Treatment 

Centers 

Institutions 

under Justice 

Systems 

Comments on 

Data (for 

Age): 

Comments on 

Data (for 

Gender): 

Comments on 

Data 

(Overall): 

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

 

 

Instructions: 

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

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

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

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

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

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

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

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

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

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E. Performance Data and Outcomes

MHBG Table 15a (URS Table 4) Profile of Adult Clients by Employment Status. MHBG Table 15a describes the status of adult clients served in the report year by the public mental health system in terms of employment status. The 

focus is on employment for the working age population, recognizing, however, that there are clients who are disabled, retired or who are homemakers, caregivers, etc., and not a part of the workforce. These persons should be reported 

under the “Not in Labor Force” category. This category has two subcategories: retired and other (the totals of these two categories should equal the number listed in the "Not in Labor Force" column). Unemployed refers to persons 

who are looking for work but have not found employment. Data should be reported for clients in non-institutional settings at time of discharge or last evaluation. 

MHBG Table 15b (URS Table 4A) Optional Table: Profile of Adult Clients by Employment Status, by Primary Diagnosis Reported. MHBG Table 15b requests information on the status of adult clients served in the report year by the 

public mental health system in terms of employment status by primary diagnosis reported. 

MHBG Table 16 (URS Table 9) Social Connectedness and Improved Functioning. MHBG Table 16 requests states and jurisdictions to provide information for youth and adults regarding social connectedness. In addition, states are 

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 develop a sense of community belonging. 

MHBG Table 17a (URS Table 11) Summary Profile of Client Evaluation of Care. MHBG Table 17a requests information that evaluates the “experience” of care for individuals that participate in the public mental health system. 

Specifically, the evaluation focuses on several areas including access, quality and the appropriateness of services, participation in treatment planning, and general satisfaction with services. Please provide unduplicated counts, if 

possible. This table provides an aggregate profile of persons served in the reporting year. The reporting year should be the latest state fiscal year for which data are available. This profile is based on a client's last known living 

situation. 

MHBG Table 17b (URS Table 11A) Optional Table: Consumer Evaluation of Care by Consumer Characteristics: Race/Ethnicity. MHBG Table 17b requests information that evaluates the “experience” of care for individuals that 

participate in the public mental health system, broken down by race, ethnicity, and age category (adult or child/adolescent). 

MHBG Table 18 (URS Table 15), Living Situation Profile. MHBG Table 18 requests information regarding the number of Individuals in Each Living Situation as collected by the most recent assessment in the reporting period. 

Specifically, information is collected on the individual’s last known living situation. Living situations include, but are not limited to, private residence, foster care, residential care, jail/correctional facility, homeless shelter and other. 

MHBG Table 19 (URS Table 11) Profile of Adults with Serious Mental Illness and Children with Serious Emotional Disturbances Receiving Specific Services. MHBG Table 19 requests information regarding the number and 

demographics of individuals that are receiving specific evidence-based services. In addition, the table requests information on if and how states and jurisdictions monitor the fidelity for the evidence-based services. 

MHBG Table 19a (URS Table 16a) Adults with Serious Mental Illness and Children with Serious Emotion Disturbances receiving Evidence Based Services for First Episode Psychosis. Table 19a requests information regarding the 

number of individuals that are receiving evidence-based services for First Episode Psychosis (FEP). In addition, the table requests information on if, and how, states and jurisdictions monitor the fidelity for the FEP evidence-based 

services. 

MHBG Table 19b Adults with Serious Mental Illness and Children with Serious Emotional Disturbances Receiving Crisis Response Services. Table 19b requests information to assess the usage of crisis response services by adults and 

children in the state. 

MHBG Table 20a (URS Table 16) Profile of Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances Receiving Specific Services. MHBG Table 20a requests information regarding the number and 

demographics of individuals that are receiving specific evidence-based services. In addition, the table requests information on if, and how, states and jurisdictions monitor the fidelity for the evidence-based services. 

MHBG Table 20b (URS Table 17) Profile of Adults with Serious Mental Illnesses Receiving Specific Services during the Year. MHBG Table 20b provides the number of unduplicated Adults with SMI receiving family psycho 

education, integrated treatment for co-occurring disorders, illness self-management and medication management. 

MHBG Table 21 (URS Table 19A) Profile of Criminal Justice or Juvenile Justice Involvement. MHBG Table 21 requests information to measure the change in arrests over time. 

MHBG Table 22 (URS Table 19B) Profile of Change in School Attendance. MHBG Table 22 measures the change in days attended over time. Information required includes information on suspensions, expulsions, and changes in the 

school attendance. 

MHBG Table 23a (URS Table 20A) Profile of Non-Forensic (Voluntary and Civil-Involuntary) Patients Readmission to Any State Psychiatric Inpatient Hospital Within 30/180 Days of Discharge. MHBG Table 23a provides the total 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

MHBG Table 23b (URS Table 20B) Profile of Forensic Patients Readmission to Any State Psychiatric Inpatient Hospital within 30/180 Days of Discharge. MHBG Table 23 provides the total number of discharges within the year, the 

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

MHBG Table 24 (URS Table 21) Optional 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 discharges from inpatient care units within the year, the number of readmissions within 30-days and 180-days and the percent readmitted by age, gender, race, 

and ethnicity. 

MHBG Table 15a (URS Table 4) Profile of Adult Clients by 

Employment Status 

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

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

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

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

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

MHBG Table 15a 

Report Year- From: To: 

State Identifier: 

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

Female Male Other N/A Female Male Other N/A Female Male Other N/A Female Male Other N/A Female Male Other N/A Total 

Employed: 

Competitively 

Employed Full or Part 

Time (includes 

Supported Employment) 

Unemployed 

Not in Labor Force: 

Retired, Sheltered 

Employment, Sheltered 

Workshops, Other 

(homemaker, student, 

volunteer, disabled, etc.) 

Not Available 

Total 

How Often Does your State Measure Employment Status? 

What populations are included: 

Comments on Data (for 

Age): 

Comments on Data (for 

Gender): 

Comments on Data 

(Overall): 

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

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

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

 

 

 

 

 

 

 

 

MHBG Table 15b 

Report Year- From: To: 

State Identifier: 

Clients 

Primary Diagnosis

Employed: 

Competitively 

Employed Full or Part 

Time (includes 

Supported 

Employment) Unemployed 

Not In Labor Force: Retired, 

Sheltered Employment, 

Sheltered Workshops, Other 

(homemaker, student, 

volunteer, disabled, etc.) 

Employment Status 

Not Available Total 

Schizophrenia & Related Disorders (F20, F25) 

Bipolar and Mood Disorders (F30, F31, F32, F33, 

F34.1, F60.89, F34.0, F32.9) 

Other Psychoses (F22, F23, F24, F29) 

All Other Diagnoses 

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

Diagnosis Total 

Comments on Data (for Diagnosis): 

MHBG Table 16 (URS Table 9): SOCIAL CONNECTEDNESS AND IMPROVED FUNCTIONING 

MHBG Table 16: NOMS Social Connectedness & Functioning 

Report Year (Year Survey was Conducted): 

State Identifier: 

Adult Consumer Survey Results: Number of Positive 

Responses 

Responses Percent Positive (calculated) 

1. Social Connectedness

2. Functioning 

Child/Adolescent Consumer Survey Results: Number of Positive 

Responses 

Responses Percent Positive (calculated) 

3. Social Connectedness

4. Functioning 

Comments on Data: 

Adult Social Connectedness and Functioning Measures 

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

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

If no, what source did you use? 

Child/Family Social Connectedness and Functioning Measures 

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

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

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

If No, what source did you use? 

Recommended Scoring Rules 

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

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

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

2. Exclude respondents with more than 1/3 of the items in that domain missing. 

3. Calculate the mean of the items for each respondent. 

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

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

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

MHBG Table 17a 

Report Year (Year Survey was Conducted): 

State Identifier: 

Adult Consumer Survey Results: 

1. Reporting Positively About Access 

2. Reporting Positively About Quality and Appropriateness for Adults 

Number of Positive 

Responses 

Responses Confidence Interval* 

3. Reporting Positively About Outcomes 

4. Adults Reporting on Participation in Treatment Planning 

5. Adults Positively about General Satisfaction with Services 

Child/Adolescent Consumer Survey Results: Number of Positive 

Responses 

Responses Confidence Interval* 

1. Reporting Positively About Access 

2. Reporting Positively about General Satisfaction for Children 

3. Reporting Positively about Outcomes for Children 

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

5. Family Members Reporting High Cultural Sensitivity of Staff 

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

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

Comments on Data: 

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

Adult Consumer Surveys 

1. a. If no, which version: 

1. Original 40 Item Version 

2. 21-Item Version 

3. State Variation of MHSIP 

4. Other Consumer Survey 
 

 

 

 

 

 

 

 

 

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

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

2. Other Language: 

Adult Survey Approach: 

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

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

4. Other Sample: 

Adult Consumer Surveys (Continued) 

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

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

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

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

Self-Administered Interview 

Phone 

Mail 

Face-to-face 

Web-Based 

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

6. Other: describe: 

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

6. Sample Size and Response Rate: 

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

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

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

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

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

calculation of response rates? 

7. Who Conducted the Survey? 

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

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

(survey was done at the local or regional level) 

7.c Other: Describe: 

* Report Confidence Intervals at the 95 percent confidence level 

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

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

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

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

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

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

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

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

 

 

 

 

 

 

 

 

 

 

 

Child/Family Consumer Surveys 

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

If No, what survey did you use? 

If no, please attach instrument used. 

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

2. Other Language: 

Child Survey Approach: 

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

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

4. Other Sample: 

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

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

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

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

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

Self-Administered Interview 

Phone 

Mail 

Face-to-face 

Web-based 

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

6. Other: describe: 

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

6. Sample Size and Response Rate: 

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

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

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

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

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

these surveys as "completed" for the calculation of response rates? 

7. Who Conducted the Survey? 

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

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

(survey was done at the local or regional level) 

7.c. Other: Describe: 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Table 17b. 

Report Year: From: To: 

State Identifier: 

Adult Consumer Survey Results: 

*State used the 2 question version for 

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

about Hispanic Origin/Status 

Indicators Total 

American Indian or 

Alaska Native Asian Black or African American 

Native Hawaiian or Other 

Pacific Islander White 

More than One Race 

Reported Other/ Not Available Hispanic Origin* 

Adult Consumer 

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

1. Reporting Positively 

About Access. 

2. Reporting Positively 

About Quality and 

Appropriateness. 

3. Reporting Positively 

About Outcomes. 

4. Reporting Positively 

about Participation in 

Treatment Planning 

5. Reporting Positively 

about General 

Satisfaction 

6. Social Connectedness 

7. Functioning 

Child/Adolescent Family Survey Results: 

*State used the 2 question version for 

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

about Hispanic Origin/Status 

Indicators Total 

American Indian or 

Alaska Native Asian Black or African American 

Native Hawaiian or Other 

Pacific Islander White 

More than One Race 

Reported Other/ Not Available Hispanic Origin* 

Child/Adolescent 

Family Survey Results: 

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

Reporting Positively 

About Access. 

Reporting Positively 

About General 

Satisfaction 

Reporting Positively 

About Outcomes. 

Reporting Positively 

Participation in Treatment 

Planning for their 

Children. 

Reporting Positively 

About Cultural Sensitivity 

of Staff. 

6. Social Connectedness 

7. Functioning 

Comments on Data: 

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

Percent positive will be calculated from these data. 
 

 

 

 

 

MHBG Table 18 (URS Table 15). Living 

Situation Profile: 

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

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

Please provide unduplicated counts, if possible. This table provides an aggregate profile of persons served in the reporting year. The reporting year should be the latest state fiscal year for which data are available. This profile is based on a 

client's last known Living Situation. 

MHBG Table 18 

Report Year- From: To: 

State Identifier: 

Private 

Residence 

Foster 

Home Residential Care 

Crisis 

Residence 

Children's 

Residential 

Treatment 

Institutional 

Setting 

Jail/Correctional 

Facility 

Homeless/

Shelter Other NA Total 

0-17

18-64

65 + 

Not Available 

TOTAL 

Female 

Male 

Other 

Not Available 

TOTAL 

American Indian/Alaska Native 

Asian 

Black/African American 

Hawaiian/Pacific Islander 

White/Caucasian 

More than One Race Reported 

Race/Ethnicity Not Available 

TOTAL 

(Continued on next page) 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MHBG Table 18 (cont.) Living 

Situation Profile: 

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

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

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

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

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

MHBG Table 18 

Report Year- From: To: 

State Identifier: 

Private 

Residence 

Foster 

Home 

Residential 

Care 

Crisis 

Residence 

Children's 

Residential 

Treatment 

Institutional 

Setting 

Jail/ 

Correctional 

Facility 

Homeless/

Shelter Other NA Total 

Hispanic or Latino Origin 

Non-Hispanic or Latino Origin 

Hispanic or Latino Origin Not Available 

TOTAL 

Comments on Data: 

How Often Does your State Measure Living 

Situation? 

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as an Ethnic Origin are not available
Table 19 - (URS Table 16): Profile of Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances Receiving Specific 

Services: 

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

Table 19: 

Report Year: 

State Identifier: 

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

N Receiving 

Supported 

Housing 

N Receiving 

Supported 

Employment 

N Receiving 

Assertive 

Community 

Treatment 

Total 

unduplicated N - 

Adults with 

SMI served 

N Receiving 

Therapeutic 

Foster Care 

N Receiving 

Multi-Systemic 

Therapy 

N Receiving 

Family 

Functional 

Therapy 

Total 

unduplicated N - 

Children with 

SED 

Age

0-12 

13-17 

18-20 

21-64 

65-74 

75+ 

Not Available 

TOTAL 0 0 0 0 0 0 0 0 

Gender 

Female 

Male 

Other 

Not Available 

Race/Ethnicity 

American Indian/Alaska Native 

Asian 

Black/African American 

Hawaiian/Pacific Islander 

White 

Hispanic* 

More than one race 

Not Available 

Hispanic/Latino Origin 

Hispanic/Latino Origin 

Non Hispanic/Latino 

Not Available 

Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No 

Do You monitor fidelity 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? 

p y 

implement the EBP? 

* Hispanic is part of the total served. 

Comments on Data (overall): 

Comments on Data (Supported Housing): 

Comments on Data (Supported 

Employment): 

Comments on Data (Assertive Community 

Treatment): 

Comments on Data (Therapeutic Foster 

Care): 

Comments on Data (Multi-Systemic 

Therapy): 

Comments on Data (Family Functional 

Yes No 
 

 

 

 

MHBG Table 19a Adults with Serious Mental illness and Children with Serious Emotional Disturbances 

Receiving Evidence-Based Services for First Episode Psychosis. 

This table provides the number of Adults with SMI and Children with SED, who were admitted into and received 

Coordinated Specialty Care (CSC) evidence based First Episode Psychosis Services (FEP). The reporting year 

should be the latest fiscal year for which data are available. 
 

 

 

MHBG Table 19b (URS Table 16B) Adults with Serious Mental Illness and Children with Serious Emotional 

Disturbances Receiving Crisis Response Services. 

This table provides the number and percentage of the respective population of adults with serious mental illness 

and children with serious emotional disturbances that are receiving Crisis Response services. The reporting year 

should be the latest state fiscal year for which data are available. 

Table 16b 

State Identifier: 

Report Period From: To: 

Service 

Actual Number of 

Adults Served via 

Service 

Estimated 

Percentage of Adult 

Population with 

Access to Service 

Actual Number of 

Children Served via 

Service 

Estimated 

Percentage of Child 

Population with 

Access to Service 

Call Centers 

24/7 Mobile Crisis 

Teams 

Crisis Stabilization 

Programs 
 

 

 

 

 

 

 

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

the Year. 

MHBG Table 20 

Report Year- From To: 

State Identifier: 

ADULTS WITH SERIOUS MENTAL 

ILLNESS 

Receiving Family 

Psychoeducation 

Receiving Integrated 

Treatment for Co-occurring 

Disorders (MH/SA) 

Receiving 

Illness SelfManagement 

Receiving Medication 

Management 

Age 

18-20

21-64

65-74

75+ 

Not Available 

TOTAL 

Gender 

Female 

Male 

Other 

Not Available 

Race 

American Indian/ Alaska Native 

Asian 

Black/African American 

Hawaiian/Pacific Islander 

White 

More than one race 

Unknown 

Ethnicity

Hispanic/Latino Origin

Non-Hispanic/Latino 

Hispanic origin not available 

Do you monitor fidelity for 

this service? 

☐Yes ☐No ☐Yes ☐No Yes ☐No Yes ☐No 

IF YES, 

What fidelity measure do you use? 

Who measures fidelity? 

How often is fidelity measured? 

Have staff been specifically trained to 

implement the EBP? 

☐Yes ☐No ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No
 

 

 

* Hispanic is part of the total served.

Comments on Data (overall): 

Comments on Data (Family Psycho-education): 

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

Comments on Data (Illness Self-Management): 

Comments on Data (Medication Management): 

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

 

 

 

 

 

 

 

 

 

 

 

 

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

1. The SAMHSA National Outcome Measure for Criminal Justice measures the change in Arrests over time. 

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

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

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

State: Time period in which services were received: ______________________________ 

For Consumers in Service for at least 12 months

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

"T1" Prior 12 months 

(more than 1 year ago) 

"T2" Most Recent 12 months 

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

Arrested 

Not 

Arrested 

No 

Response 

Not No 

Arrested Arrested Response 

# with an # with No No 

Arrest in T2 Arrest at T2 Response 

# with an # with No No 

Arrest in T2 Arrest at T2 Response 

# Reduced 

(fewer 

encounters 

# Stayed 

the Same 

# 

Increased 

# Not 

Applicable 

No 

Response 

Total 

Responses 

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

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

Female 0 

Male 0 

Other 

Gender NA 0 

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

Female 0 

Male 0 

Other 

Gender NA 0 

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

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

"T1" 12 months prior to beginning 

services 

"T2" Since Beginning Services 

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

Arrested 

Not 

Arrested 

No 

Response 

Not No 

Arrested Arrested Response 

# with an # with No No 

Arrest in T2 Arrest at T2 Response 

# with an # with No No 

Arrest in T2 Arrest at T2 Response 

# Reduced 

(fewer 

encounters) 

# Stayed 

the Same 

# 

Increased 

# Not 

Applicable 

No 

Response 

Total 

Responses 

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

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

Female 

Male 

Other 

Gender NA 

Total Adults (age 18 and over) 

Female 

Male 

Other 

Gender NA 

0 0 0 0 0 0 0 0 0 0 

0 

0 

0 

0 

0 

0 

0 0 0 0 0 0 0 0 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please Describe the Sources of your Criminal Justice Data 

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

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

Sources of children/youth criminal justice 

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

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

Measure of adult criminal 

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

Measure of children/youth criminal justice 

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

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

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

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

Region for which children/youth data 

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

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

Child/Adolescents Adults 

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

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

3. How many survey 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). 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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

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

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

use all these columns. 

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

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

Table22. Profile of Change in School Attendance 

State: Time period in which services were received: 

For Consumers in Service for at least 12 months

T1 T2 T1 to T2 Change Impact of Services "T1" Prior 12 months (more than 1 year 

ago) 

"T2" Most Recent 12 months (this 

year) 

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

# Suspended 

or Expelled 

# Not 

Suspended or 

Expelled 

No 

Response 

# Suspended 

or Expelled 

# Not 

Suspended or 

Expelled 

No 

Response 

# with an 

Expelled or 

Suspended in 

T2 

# with No 

Suspension 

or Expulsion 

at T2 

No Response 

# with an 

Expelled or 

Suspended in 

T2 

# with No 

Suspension 

or Expulsion 

at T2 

No 

Response 

# Greater 

(Improved) 

# Stayed 

the Same 

# Fewer days 

(gotten 

worse) 

# Not 

Applicable 

No 

response 

Total 

Responses 

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

Gender 

Female 0 

Male 0 

Other 

Gender NA 0 

Age 

Under 18 0 

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 # Not 

S d d No # Suspended # Not 

S d d No 

# with an 

Expelled or 

# with No 

Suspension 

# with an 

Expelled or 

# with No 

Suspension No # Greater # Stayed # Fewer days 

( # Not No Total 

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

Gender 

Female 0 

Male 0 

Other 

Gender NA 0 

Age 

Under 18 0 

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

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

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

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

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

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

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

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

 

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

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

State Psychiatric Inpatient Hospital Within 30/180 Days of Discharge 

MHBG Table 23a. 

Report Year- From: To: 

State Identifier: 

Total number of 

Discharges in 

Year 

Number of Readmissions to 

ANY STATE Hospital within 

Percent Readmitted 

30 days 180 days 30 days 180 days 

TOTAL 0 0 0 

Age 

0-12

13-17

18-20

21-64

65-74

75+ 

Not Available 

Gender 

Female 

Male 

Other 

Gender Not Available 

Race 

American Indian/ Alaska Native 

Asian 

Black/African American 

Hawaiian/Pacific Islander 

White 

More than one race 

Race Not Available 

Hispanic/Latino Origin 

Hispanic/Latino Origin 

Non-Hispanic/Latino 

Hispanic/Latino Origin Not Available 

Are Forensic Patients Included? 

Comments on Data: 

MHBG Table 23b (URS Table 20B) Profile of Forensic Patients Readmission to Any State Psychiatric Inpatient 

Hospital Within 30/180 Days of Discharge 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MHBG Table 23b. 

Report Year- From: To: 

State Identifier: 

Total number of 

Discharges in 

Year 

Number of Readmissions to 

ANY STATE Hospital within 

Percent Readmitted 

30 days 180 days 30 days 180 days 

TOTAL 0 0 0 

Age 

0-12 

13-17 

18-20 

21-64 

65-74 

75+ 

Not Available 

Gender 

Female 

Male 

Other 

Gender Not Available 

Race 

American Indian/ Alaska Native 

Asian 

Black/African American 

Hawaiian/Pacific Islander 

White 

More than one race 

Race Not Available 

Hispanic/Latino Origin 

Hispanic/Latino Origin 

Non-Hispanic/Latino 

Hispanic/Latino Origin Not Available 

Comments on Data: 
 

 

 

 

 

 

 

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

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

Discharge 

MHBG Table 24 

Report Year- From: To: 

State Identifier: 

Total number of 

Discharges in Year 

Number of Readmissions to ANY 

Psychiatric Inpatient Care Unit Hospital 

within the state 

Percent Readmitted 

30 days 180 days 30 days 180 days 

TOTAL 0 0 0 

Age 

0-12 

13-17 

18-20 

21-64 

65-74 

75+ 

Not Available 

Gender 

Female 

Male 

Other 

Gender Not Available 

Race 

American Indian/ 

Alaska Native 

Asian 

Black/African American 

Hawaiian/Pacific Islander 

White 

More than one race 

Race Not Available 

Hispanic/Latino Origin 

Hispanic/Latino Origin 

Non-Hispanic/Latino 

Hispanic/Latino Origin 

Not Available 

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

2. Are Forensic Patients Included? 

Comments on Data: