1 

Block Grant Reporting Section 

CFDA 93.958 

(Mental Health)

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration
2 

Table of Contents

Section A. Introduction........................................................................................................................................ 4

B. Implementation Report ................................................................................................................................... 6

MHBG Table 1 - Priority Area and Annual Performance Indicators – Progress Report...................................... 6

C. State Agency Expenditure Reports................................................................................................................... 7

MHBG Table 2a State Agency Expenditures Report ......................................................................................... 9

MHBG Table 2b - MHBG State Agency First Episode Psychosis Expenditure Report....................................... 10

MHBG Table 3 Set-Aside for Children’s Mental Health Services..................................................................... 11

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 MHA

...................................................................................................................................................................... 13

MHBG Table 6 Maintenance of Effort for State Expenditures on Mental Health Services .............................. 14

D. Populations and Services Report ................................................................................................................... 17

MHBG Table 7 (URS Table 1). Profile of the State Population by Diagnosis................................................... 19

MHBG Table 8A (URS Table 2A). Profile of Persons Served, All Programs by Age, Gender, Race/Ethnicity .... 20

MHBG Table 8B (URS Table 2B). Profile of Persons Served, All Programs by Age, Gender and Race/Ethnicity22

MHBG Table 9 (URS Table 3). Profile of Persons served in the Community Mental Health Settings, State 

Psychiatric Hospitals and Other Settings........................................................................................................ 23

MHBG Table 10A. Profile of Clients by Type of Funding Support (URS Table 5A)............................................ 26

MHBG Table 10B. (URS Table 5B) Profile of Clients by Type of Funding Support............................................ 29

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/Ethnicity ............................................................................................................................................... 38

MHBG Table13B (URS Table 14B). Profile of Persons with SMI/SED served by Age, Gender and Ethnicity .... 41

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 ...................................... 42

E. Performance Data and Outcomes................................................................................................................ 45

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

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

Diagnosis Reported ....................................................................................................................................... 50

MHBG Table 16 (URS Table 9): SOCIAL CONNECTEDNESS AND IMPROVED FUNCTIONING............................. 51

MHBG Table 17A (URS Table 11): Summary Profile of Client Evaluation of Care ........................................... 53

MHBG Table 18 (URS Table 15). Living Situation Profile:................................................................................ 61

MHBG Table 18 (cont.) Living Situation Profile: ............................................................................................. 62

Table 19: Profile of Adults with Serious Mental Illnesses and Children with Serious Emotional Disturbances 

Receiving Specific Services: ........................................................................................................................... 63

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

Receiving Evidence-Based Services for First Episode Psychosis...................................................................... 64

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

During the Year: ............................................................................................................................................ 65

MHBG Table 21 (URS Table 19a) Profile of Criminal Justice or Juvenile Justice Involvement:........................ 67

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
3 

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 .................................................................................................................. 75
4 

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. 

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, and the authorized 

activities conducted, and services purchased with such funds. Particular attention should be 

given to the progress made toward accomplishing the goals and performance indicators identified 

in the states and jurisdictions’ plans. 

All states and jurisdictions are required to prepare and submit their respective reports utilizing 

SAMHSA’s Web Block Grant Application System (BGAS). This report must be received by 

SAMHSA no later than December 1, in order for the state or jurisdiction to receive its next grant. 

If the due date falls on a weekend or federal holiday, the report will be due on the next business 

day. The following schedule includes specific due dates for annual reports: 

Due Dates for MH and Combined BG Components

FY the state is 

applying for funds

Application

Due

Plan

Due Planning Period MHBG Report Due

2020 9/2/2019 Yes 7/1/19 – 6/30/21 12/1/2019

Report year is Last 

Completed SFY

2021 9/1/2020 No Updates only 12/1/2020

Report year is Last 

Completed SFY

Section B: Implementation Report - In this section, states, and jurisdictions are required to provide a 

brief review of the extent to which their respective plans were implemented, the progress towards the 

priorities and goals identified in the Block Grant plan, covering the last completed fiscal year. The 

report should also include a brief review of areas the state or jurisdiction identified in that Block 

Grant Plan, as needing improvement and changes the state or jurisdiction would propose to achieve 

the goals established for the priorities. 

Section C: State Agency Expenditure Reports - In this section, states and jurisdictions should 

provide information regarding expenditures for authorized activities and services for mental health. 
5

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 jurisdictionselected performance indicators.
6 

B. Implementation Report

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

in the planning section of the 2020/2021 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 2020/2021 

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. 

3. 

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

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

4.

5. 

Goal of the priority area:

Objective:

6. Strategies to attain the objective:

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

Indicator #1:

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

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

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

d) Data source: 

e) Description of data:

f) Data issues/caveats that affect outcome measures:

8. Report of Progress toward Goal Attainment:

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

Reason why target was not achieved, and changes proposed to meet target:
7 

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. 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 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 is optional. 

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

statewide expenditures for children’s mental health services during the last completed SFY. States 

are required to provide systems of integrated services for children with SED. Each year the State 

shall expend not less than the amount expended in FY 1994. If there is a shortfall in funding 

available for children’s mental health services, the state may request a waiver. A waiver may be 

granted if the Secretary determines that the State is providing an adequate level of comprehensive 

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

children in need of such services with the services actually available within the State. The Secretary 

shall approve or deny the request for a waiver no later than 120 days after the request has been made. 

A waiver granted by the Secretary shall be applicable only for the fiscal year in question. 

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

Service Activities. MHBG Table 4 is used to report expenditures of MHBG funds for non-direct 

service activities that are funded or conducted by the State Mental Health Authority during the last 

completed SFY.

MHBG Table 5 (URS Table 10) - Profiles of Agencies Receiving Block Grant Funds Directly from 

the state MHA. This table, reports payments to recipients of MHBG funds including intermediaries, 

(e.g., administrative service organizations, and other organizations), which provided mental health 

services during the last completed SFY, including services for those with a first episode psychosis

(FEP) and early serious mental illness (ESMI) programs. 
8 

MHBG Table 6 - Maintenance of Effort for Statewide Expenditures for Mental Health Service: This 

table reports expenditures of all statewide, non-Federal expenditures for authorized activities to 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. 
9 

MHBG Table 2a State Agency Expenditures Report

Report Period From: To:

State Identifier:

ACTIVITY

(See instructions for using 

Row 1.)

Source of Funds

A.

Substance 

Abuse 

Block 

Grant

B. 

Mental 

Health 

Block 

Grant

C. 

Medicaid

(Federal, 

State, and 

local)

D. 

Other Federal 

Funds (e.g., 

ACF (TANF), 

CDC, CMS 

(Medicare) 

SAMHSA, 

etc.)

E.

State 

funds

F.

Local funds

(excluding 

local

Medicaid)

G.

Other

1. Substance Abuse 

Prevention and 

Treatment

a. Pregnant Women 

and Women with 

Dependent 

Children

b. All Other 

2. Primary Prevention* $ $ $ $ $ $

3. Evidence-Based Practices 

for Early Serious Mental 

Illness.**

$ $ $ $ $ $ $ 

4. Tuberculosis Services

5. HIV Early Intervention 

Services

6. State Hospital

7. Other Psychiatric 

Inpatient Care

8. Other 24-Hour 

(residential Care)

$ $ $ $ $ $ 

9. Ambulatory/Community 

Non-24-Hour Care

$ $ $ $ $ $ 

10. Administration 

(excluding program/ 

provider level

$ $ $ $ $ $ 

11. Total $ $ $ $ $ $

Comments on Data:
10 

*States may only use MHBG funds to provide primary prevention services to the priority populations of adults with 

serious mental illness and children with severe emotional disturbance.

**Column 3B is for expenditures related to ESMI including Frist Episode Psychosis programs funded through MHBG setaside. These funds are not to be also counted in #8 Ambulatory/Community Non-24-Hour Care. 

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

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

MHBG Table 2b

Report Period From: To:

State Identifier:

Source of Funds

Activity

(See instructions for using Row 1

A.

Mental 

Health 

Block 

Grant

B. 

Medicaid 

(Federal, 

State, and 

local)

C.

Other Federal 

Funds (e.g., 

ACF (TANF), 

CDC, CMS 

(Medicare), 

SAMHSA, etc.)

D.

State 

Funds

E.

Local funds 

(excluding 

local 

Medicaid)

F.

Other

1. CSC-Evidence-Based 

Practices for First Episode 

Psychosis*

$ $ $ $ $ $ 

2. 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)
11 

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

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

Statewide Expenditures for Children’s Mental Health Services

MHBG Table 3:

State Identifier:

Report Period: From: To:

Actual SFY 1994 Actual SFY 2019

MHBG Table 4 (URS Table 8) Profile of Community Mental Health Block Grant Expenditures 

for Non-Direct Service Activities

This table is used to describe the use of MHBG funds for non-direct service activities that are 

sponsored, or conducted, by the State Mental Health Authority. 

Please 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

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 $ 
12 

Activity A. MHBG

6. Research and Evaluation $ 

7. Training and Education $ 

8. Total $ 

Comments on Data
13 

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 

ISATS 

ID 

(for 

SAB

G)

Area 

Served 

(Statewide 

or SubState 

Planning 

Area)

Provider/Pro

gram Name

Street 

Addres

s 

Cit

y 

Sta

te

Zi

p 

Tot

al 

Blo

ck 

Gra

nt 

Fun

ds

Preventi

on 

(other 

than 

primary 

preventi

on) and 

Treatme

nt 

Service

s 

Pregna

nt 

Wome

n and 

Wome

n with 

Depend

ent 

Childre

n 

Primar

y 

Prevent

ion

Early 

Interven

tion 

Services 

for HIV

Tota

l 

MH 

Bloc

k 

Gran

t 

Fun

ds

Adul

ts 

with 

serio

us 

ment

al 

illne

ss

Childre

n with a 

serious 

emotion

al 

disturba

nce

Setaside 

for 

FEP 

progra

ms

Setaside 

for 

ESMI

progra

ms

$ $ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $ $

Total $ $ $ $ $ $ $ $ $ $
14 

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 2018

(1)

SFY 2019

(2)

SFY 2020

(3)
15 

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

Yes No

SFY 2018

SFY 2019

SFY2020

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

 mm/dd/yyyy

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

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

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

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

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

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

documents. 

A. MOE Exclusion

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

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

A request for MOE exclusion should meet the following requirements: 

The State shall request the exclusion separately from the application.

 

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

2Section 1915(b)(2) of the PHS Act (42 USC 300x-4). 
16 

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. 
17

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 all institutional and community services for all such programs. States 

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

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

Other Settings: MHBG Table 9 provides an aggregate profile of unduplicated persons in the reporting year for services provided or 

funded through the MHBG. The reporting year 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 age, gender, and race/ethnicity.

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

provide the number of female and male clients by race and ethnicity that have Medicaid Only, Non-Medicaid Sources, Both Medicaid 

and 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, residential treatment centers). 

Information collected by this table requests admissions, discharges, and length of stay.

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

hospitals and community program in age categories 0-3, 4-17 and 18 and above. 

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

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

CMHS. MHBG Tables 13A and 13B included individuals receiving services in programs provided or funded by the state mental 
18 

health agency. These tables count only clients who meet the CMHS definition of SMI or SED. States and jurisdictions should report 

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

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

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

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

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

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

children. 
19 

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

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

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

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

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

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

both adults with SMI and children with SED. 

MHBG Table 7

Report Period: From: To:

State Identifier:

Current Report 

Year

Three Years 

Forward

Adults with Serious Mental Illness (SMI)

Children with Serious Emotional Disturbances 

(SED)

Note: CMHS will complete this table for the states.
20 

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

(Continued on next page) 

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 Not 

Available 

Total Female Male Not 

Available 

Female Male Not 

Available 

Female Male Not 

Availa

ble

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): 
21 

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 Not 

Available

Female Male Not 

Available

Female Male Not 

Available

Female Male Not 

Available

0-12 years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older

Age not 

Available

Total

Pregnant 

Women
22 

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" are calculated automatically

MHBG Table 8B

Report Year: From: To: 

State Identifier:

Not Hispanic or Latino Hispanic or Latino

Hispanic or Latino Origin 

Not Available Total

Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Female Male Not Available Total

0-12 years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older

Age not available

Total

Pregnant Women

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (for Ethnicity):

Comments on Data (Overall):
23 

Are these numbers unduplicated? 

 Unduplicated

 Duplicated between Hospital and Community

 Duplicated Among Community Programs 

 Duplicated between children and adults

 Other: describe: 

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

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

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

 

MHBG Table 9

Report Year: From: To:

State Identifier: 

MHBG Table 9 

Service Setting

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

Female Male

Not 

Available Female Male Not Available Female Male

Not 

Available Female Male

Not 

Available

Community Mental 

Health Programs

State Psychiatric 

Hospitals

Other Psychiatric 

Inpatient

Residential 

Treatment Centers

Institutions in the 

Justice System

 (Continued on next page) 
24 

MHBG Table 9 (cont.)

Report Year: From: To:

State Identifier:

Table 9

Service Setting

Age Not Available Total

Female Male Not Available Female Male Not Available 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):
25 

Table 9

Service Setting

Age Not Available Total

Female Male Not Available Female Male Not Available Total

Comment on Data (Overall):
26 

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

This table provides a summary of clients by Medicaid coverage. Since the focus of the reporting is on clients of the public mental 

health service delivery system, this table focuses on the clientele serviced by public programs that are funded or operated by the State 

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

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

MHBG Table 10A

Report Period From: To:

State Identifier:

Total

American Indian or 

Alaska Native Asian

Black or African 

American

Female Male

Not 

Available Total Female Male

Not 

Availabl

e Female Male

Not 

Available

Female Male Not 

Available

Medicaid (only Medicaid)

Non-Medicaid Sources (only)

People Served by Both Medicaid 

and Non-Medicaid Sources

Medicaid Status Not Available

Total Served

Data Based on Medicaid Services

Data Based on Medicaid Eligibility, not Medicaid Paid Services

People Served by Both includes people with any Medicaid
27 

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 un-duplicate between people whose care is paid for by Medicaid only or Medicaid and other funds, then all data 

should be reported into the 'People Served by Both Medicaid and Non-Medicaid Sources' and the 'People Served by Both includes 

people with any Medicaid' check box should be checked. 

(Continued on next page)
28 

MHBG Table 10A (Cont.) 

 

Report Period- From: To: 

 

State Identifier:

Native Hawaiian or Other 

Pacific Islander

White More Than One Race Reported Race Not Available

Female Male Not 

Available

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

Medicaid (only Medicaid)

Non-Medicaid Sources (only)

People Served by Both Medicaid and 

Non-Medicaid Sources

Medicaid Status Not Available

Total Served
29 

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

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

would be the total indicated in MHBG Table 10A. 

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

MHBG Table 10B.

Report Period- From To:

State Identifier:

Not Hispanic or Latino Hispanic or Latino

Hispanic or Latino 

Origin Unknown Total

Female Male Not Available Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Total

Medicaid Only 

Non-Medicaid Only 

People Served by Both Medicaid and Non-Medicaid Sources

Medicaid Status Unknown 

Total Served

Comments on Data (for Ethnicity):
30 

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. 
31 

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 Tx Centers

Children (0 to 17 years)

Adults (18 years and over)

Age Not Available

Community Programs

Children (0 to 17 years)

Adults (18 years and over)

Age Not Available

Comments on Data (State Hospital):

Comments on Data (Other Inpatient): 
32 

Comments on Data (Residential Treatment):

Comments on Data (Community Programs): 

Comments on Data (Overall):
33 

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

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

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

duplication of numbers served as well as certain summary administrative information

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

2. Aged 4 to 17 ☐Yes ☐Yes ☐Yes

3. Adults Aged 18 and 

over

☐Yes ☐Yes ☐Yes

4. Forensics ☐Yes ☐Yes ☐Yes

Comments on Data:
34 

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
35 

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

Question Check if answer is Yes

Are Data for these programs 

reported on URS Tables?

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

☐Yes ☐Yes

4.b.2 Does the State Mental Health Agency have any responsibilities

for mental health services provided through Medicaid Managed Care?

☐Yes ☐Yes

If yes, please check the responsibilities the SMHA has: Check if 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
36 

If yes, please check the responsibilities the SMHA has: Check if yes

4.b.7 Input in contract development ☐Yes

4.b.8 Performance monitoring ☐Yes

4.b.9 Other

5 

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

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

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

Are the data reporting in the tables?

5.a.

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

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

responsible for different geographic or programmatic areas.

☐

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

5.c. Duplicated: within community programs ☐

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

5.e.

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

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

Infrastructure Grant.
37 

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:
38 

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 8 A and 8B (URS Table 

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

below describing your state’s definition.

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

MHBG Table 13A

Report Year: From: To:

State Identifier:

Total American Indian or Alaska 

Native

Asian Black or African American Native Hawaiian or Other Pacific Islander

Female Male Not 

Available

Total Female Male Not 

Available

Female Male Not 

Available

Female Male Not 

Available

Female Male Not Available

0-12 Years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older

Age Not 

Available

Total

Comments on Data (for Age): 

Comments on Data (for Gender): 
39 

Comments on Data (for Race/Ethnicity):

Comments on Data (Overall):
40 

MHBG Table 13A.

Report Year:

State Identifier:

White More Than One Race Reported Race Not Available

Female Male Not 

Available

Female Male Not 

Available

Female Male Not Available

0-12 Years

13-17 years

18-20 years

21-24 years

25-44 years

45-64 years

65-74 years

75 and older

Age Not 

Available

Total

1. State Definitions Match the Federal Definitions:

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

☐Yes ☐No

Diagnoses included in state SMI definition:

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

☐Yes ☐No Diagnoses included in State SED definition:
41 

MHBG Table13B (URS Table 14B). Profile of Persons with SMI/SED served by Age, Gender and Ethnicity

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

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

13b. 

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

MHBG Table 13B

Report Year: From: To:

State Identifier:

Not Hispanic or Latino Hispanic or Latino

Hispanic or Latino Origin 

Not Available Total

Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Total

0 - 12 Years

13 - 17 years

18 - 20 years

21-24 years

25-44 years

45-64 years

65-74 years

75and older

Age Not Available

Total

Comments on Data (for Age): 

Comments on Data (for Gender): 

Comments on Data (for Race/Ethnicity):

Comments on Data (Overall):
42 

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 mental health settings, in state psychiatric hospitals, in other psychiatric inpatient programs, residential treatment centers and Institutions under Justice 

System.

MHBG Table 14

Report Year: From: To:

State Identifier:

MHBG Table 13A Age 0-17 Age 18-20 Age 21-64

Service Setting Female Male Not Available Female Male Not Available Female Male Not Available

Community Mental 

Health Programs

State Psychiatric 

Hospitals

Other Psychiatric 

Inpatient

Residential 

Treatment Centers

Institutions under 

Justice Systems
43 

MHBG Table 14

Report Year: From: To:

State Identifier:

MHBG Table 14 

Service Setting

Age 65+ Age Not Available Total

Female Male

Not 

Available Female Male

Not 

Available Female Male

Not 

Available Total

Community Mental Health Programs

State Psychiatric Hospitals

Other Psychiatric Inpatient

Residential Treatment Centers

Institutions under Justice Systems

Comments on Data (for Age):

Comments on Data (for Gender):

Comments on Data (Overall):

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).
44 

Instructions:

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

services in state hospitals.

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

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

4

Persons, who receive inpatient psychiatric care through a private provider or medical provider licensed, or contracted through the SMHA, should be 

counted in the "Other Psychiatric Inpatient" row. Persons who receive Medicaid funded inpatient services through a provider that is not licensed or 

contracted by the SMHA should not be counted here.

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

6

RTC: CMHS has a standardized definition of RTC for Children: “An organization, not licensed as a psychiatric hospital, whose primary purpose is 

the provision of individually planned programs of mental health treatment services in conjunction with residential care for children and youth 

primarily 17 years old and younger. It has a clinical program that is directed by a psychiatrist, psychologist, social worker, or psychiatric nurse who 

has a master’s degree or doctorate. The primary reason for the admission of the clients is mental illness that can be classified by either DSM-V or 

ICD-10 codes other than the codes for mental retardation, developmental disorders, and substance-related disorders such as drug abuse and 

alcoholism (unless these are co-occurring with a mental illness).”
45

E. Performance Data and Outcomes

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

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

the working age population, recognizing, however, that there are clients who are disabled, retired or who are homemakers, care-givers, 

etc., and not a part of the workforce. These persons should be reported under the, “Not in Labor Force” category. This category has 

two subcategories: retired and other (The total of these two categories should equal the number listed in the "Not in Labor Force" 

column). Unemployed refers to persons who are looking for work but have not found employment. Data should be reported for 

clients in non-institutional settings, at time of discharge or last evaluation.

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

MHBG Table 15B request information on the status of adult clients served in the report year by the public mental health system in 

terms of employment status by primary diagnosis reported.

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

to provide information for youth and adults regarding Social Connectedness. In addition, states are 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 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 
46 

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

care, jail/correctional facility, homeless shelter and other.

MHBG Table 19 (URS Table 11), Summary Profile of Client Evaluation of Care, MHBG Table 19 Profile of Adults with Serious 

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

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

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

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

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

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

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

individuals that are receiving specific evidenced-based services. In addition, the table requests information on if, and how states and 

Jurisdictions monitor the fidelity for the evidenced based services.

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

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

co-occurring disorders, illness self-management and medication management.

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

to measure the change in Arrests over time. 

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

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

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

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

year, the number of readmissions within 30-days and 180-days and the percent readmitted by age, gender, race, and ethnicity.
47 

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

30/180 Days of Discharge, MHBG Table 23B provides the total number of discharges within the year, the number of readmissions 

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

MHBG Table 24 (URS Table 21), 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.
48 

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

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

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

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

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

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

MHBG Table 15 A

Report Year: From: To:

State Identifier:

Adults Served

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

Femal

e

Mal

e

Not 

Availabl

e

Femal

e

Mal

e

Not 

Availabl

e

Femal

e

Mal

e

Not 

Availabl

e

Femal

e

Mal

e

Not 

Availabl

e

Femal

e

Mal

e

Not 

Availabl

e

Tota

l

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
49 

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): 
50 

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): 
51 

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:
52 

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.
53 

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: 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
54 

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

Percent positive will be calculated from these data.

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

Comments on Data:

Adult Consumer Surveys

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

1. a. If no, which version: 

1. Original 40 Item Version 

2. 21-Item Version 

3. State Variation of MHSIP 

4. Other Consumer Survey 

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

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

2. Other Language:

Adult Survey Approach:

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

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

4. Other Sample:

Adult Consumer Surveys (Continued)

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

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

3.4 Other: describe: (for example, if you survey anyone served in the last 3 months, describe that here):
55 

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

Self-Administered Interview

Phone

Mail

Face-to-face

Web-Based

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

 6. Other: describe:

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

6. Sample Size and Response Rate

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

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

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

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

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

the calculation of response rates?

7. Who Conducted the Survey
56 

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?
57 

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
58 

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

6. Other: describe:

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

6. Sample Size and Response Rate

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

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

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

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

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

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

7. Who Conducted the Survey

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

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

 (survey was done at the local or regional level)

7.c. Other: Describe:
59 

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 

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 Applicable 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
60 

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

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 Applicable 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

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.
61 

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

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: 

 At Admission  At Discharge  Monthly  Quarterly  Other: Describe 

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 

62 
 / / / / /

Table 19: Profile of Adults with Serious Mental Illnesses and Children with Serious 

Emotional Disturbances Receiving Specific Services:

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

Table 19:

Report Year:

State Identifier:

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

N Receiving 

Supported 

Housing

N Receiving 

Supported 

Employment

N Receiving 

Assertive 

Community 

Treatment

Total 

unduplicated N - 

Adults with 

SMI served

N Receiving 

Therapeutic 

Foster Care

N Receiving 

Multi-Systemic 

Therapy

N Receiving 

Family 

Functional 

Therapy

Total 

unduplicated N - 

Children with 

SED

Age

 0-12

13-17

18-20

21-64

65-74

75+

Not Available

TOTAL 0 0 0 0 0 0 0 0

Gender

Female

Male

Not Available

Race/Ethnicity

American Indian/Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

Hispanic*

More than one race

Not Available

Hispanic/Latino Origin

Hispanic/Latino Origin

Non Hispanic/Latino

Not Available

Do You monitor fidelity

 for this service?

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

IF YES,

What fidelity measure do you use?

Who measures fidelity?

How often is fidelity measured?

Is the SAMHSA EBP Toolkit used to 

guide EBP Implementation?

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

Have staff been specifically trained to 

implement the EBP?

* Hispanic is part of the total served. Yes No

Comments on Data (overall):

Comments on Data (Supported Housing):

Comments on Data (Supported 

Employment):

Comments on Data (Assertive Community 

Treatment):

Comments on Data (Therapeutic Foster 

Care):

Comments on Data (Multi-Systemic 

Therapy):

Comments on Data (Family Functional 

Therapy):

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

63
64 

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 19A

State Identifier:

Report Period: From: To:

Program Name

Number of 

Adult 

Admissions 

into CSC 

Services 

During FY

Current 

Number 

of Adults 

with FEP 

Receiving 

CSC FEP 

Services

Number of 

Child/

Adolescents 

Admissions 

with FEP 

Receiving CSC 

FEP Services

Current 

number of 

Child/

Adolescents 

with FEP 

Receiving CSC 

FEP Services

Did you 

monitor 

fidelity 

for this 

service

What 

fidelity 

measure 

did you 

use?

Who 

measures 

fidelity?

How often 

is fidelity 

measured?

Has staff 

been 

specifically 

trained to 

implement 

the CSC?

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No
65 

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 Cooccurring Disorders 

(MH/SA)

Receiving 

Illness SelfManagement

Receiving Medication 

Management

Age

18-20

21-64

65-74

75+

Not Available

TOTAL

Gender

Female

Male

Not Available

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):
66 

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
67 

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: ______________________________ 

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 

Arrests 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

Male 0

Female 0

Gender NA 0

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

Male 0

Female 0

Gender NA 0
68 

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

Male 0

Female 0

Gender NA 0

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

Male 0

Female 0

Gender NA 0

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):
69 

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 Child/Adolescents Adults

Data are Reported

1. If data is from survey, what is the total number of 

was drawn?

people from which the sample 

2. What was your sample size (How many individuals were 

sample)?

selected for the 

3. How many 

addresses)?

survey Contracts were made (surveys to valid phone numbers or 

4. How many surveys were completed 

if data source was not a Survey.

for?

(survey forms returned, or calls completed), 

 How many persons were CJ data available 

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

of Contracts):

State Comments/Notes:

Instructions: 

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

responds to the Adult MHSIP survey, please include their responses in the Adult categories, since that was the survey they used).
70 

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).

State: ______________ Time period in which services were received: _________________________ 

Table 22. Profile of Change in School Attendance

T1 T2 T1 to T2 Change Impact of Services

# 

Suspended 

or

Expelled

# Not 

Suspended 

or 

Expelled

No

Response

# 

Suspended 

or

Expelled

# Not 

Suspended 

or 

Expelled

No

Response

# with an 

Expelled 

or 

Suspended 

in T2

# with No 

Suspension 

or

Expulsion at

T2

No

Response

# with an 

Expelled 

or 

Suspended 

in T2

# with No 

Suspension 

or

Expulsion at

T2

No

Response

# Greater

(Improved)

# Stayed 

the

Same

# Fewer 

days

(gotten 

worse)

# Not

Applicable

No 

response

Total

Responses

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

Gender

Male 0

Female 0

Gender NA 0

Age

Under 18 0
71 

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

Male 0

Female 0

Gender NA 0

Age

Under 18 0

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

Source of School Attendance Information 

1) Consumer survey (recommended items)

2) Other Survey: Please send us items 

3) Mental health MIS

4) State Education Department

5) Local Schools/Education Agencies

6) Other (specify) 

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

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

Region for which data are reported: 1) The whole state 2) Less than the whole state (please describe)
72 

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

What is the Total Number of Persons Surveyed or for 

whom School Attendance Data Are Reported Child/Adolescents Adults

1. If data is from a survey, what is the total Number of 

people from which the sample was drawn? 

2. What was your sample size? (How many individuals 

were selected for the sample)?

3. How many survey Contacts were made? (surveys to 

valid phone numbers or addresses) 

4. How many surveys were completed? (survey forms 

returned, or calls completed) If data source was not a 

Survey, how many persons were data available for? 

5. What was your response rate? (number of Completed 

surveys divided by number of Contacts): 
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

Total number of 

Discharges in 

Year

Number of Readmissions to 

ANY STATE Hospital within

Percent Readmitted

30 days 180 days 30 days 180 days

TOTAL 0 0 0

Age

0-12

13-17

18-20

21-64

65-74

75+

Not Available

Gender

Female

Male

Gender Not Available

Race

American Indian/ Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

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?

MHBG Table 23A.

Report Year: From: To:

State Identifier:
74 

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

Psychiatric Inpatient Hospital Within 30/180 Days of Discharge 

MHBG Table 23B.

Report Year: From: To:

State Identifier:

Total number of 

Discharges in 

Year

Number of Readmissions to 

ANY STATE Hospital within

Percent Readmitted

30 days 180 days 30 days 180 days

TOTAL 0 0 0

Age

0-12

13-17

18-20

21-64

65-74

75+

Not Available

Gender

Female

Male

Gender Not Available

Race

American Indian/ Alaska Native

Asian

Black/African American

Hawaiian/Pacific Islander

White

More than one race

Race Not Available

Hispanic/Latino Origin

Hispanic/Latino Origin

Non-Hispanic/Latino

Hispanic/Latino Origin Not Available

Comments on Data:
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

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

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: