Providing Mental Health Services to TANF Recipients

Appendix B:
Program Forms for Screening and Assessment

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Note:  All forms are in PDF format.


  1. Screening and Assessment Tools
  2. Referral Forms
  3. Confidentiality and Consent Forms
  4. Service Delivery Pathways
  5. Service Planning and Tracking Forms

Screening/Assessment Instrument

Utah's Mental Health Services Clinical Evaluation

Utah's Department of Workforce Services (DWS) uses the Mental Health Services Clinical Evaluation as the basis for making a clinical diagnosis and recommendations for mental health treatment and other types of services. However, social workers at DWS are given discretion to use their own inventories. Most social workers incorporate components of the clinical evaluation with a variety of other tools in their clinical assessment. Two assessment tools used in Utah are presented in this appendix. The first is the standard DWS form, which is used by some social workers around the state, and the second is an example of a modified assessment tool used by a social worker in Salt Lake County.

Purpose of the screening/assessment tool: The purpose of the assessment tool is to provide a clinical diagnosis and recommendation for mental health treatment and other types of services.

Target population: The clinical evaluation/assessment instrument is administered to TANF recipients referred to mental health services, clients in sanction status, clients reaching their time limit on cash assistance, and clients who screen positive on the CAGE substance abuse questionnaire.(1)

Who administers the assessment: The assessment is administered by licensed clinical social workers (LSCWs) who have extensive experience providing clinical treatment and by certified social workers, under the supervision of an LCSW, who have earned an M.S.W.

Time required to complete the assessment: The assessments can take anywhere from two to fours hours to complete and may be done in one or more sessions.

Information collected/issues addressed: The following information is collected through the assessment: basic demographic characteristics, current situation, social and family history, alcohol and drug history, legal issues, physical and mental health, and family violence. A recommended treatment plan is also included in the assessment.

Utah's Screening/Assessment Instrument [in PDF format]

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Tennessee's Family Services Counseling Assessment Form

The Family Services Counseling (FSC) Assessment Form is a standard tool used statewide by all family services counselors. The assessment was developed by the program director with input from welfare and FSC program staff. Family services counselors may use additional inventories but are required to complete the basic assessment form for all clients referred to the FSC program. Copies of completed assessment forms are sent to the College of Social Work, Office of Research and Public Service at the University of Tennessee for use in the FSC program evaluation.

Purpose of the screening/assessment tool: The purpose of the assessment is to determine the service needs of TANF recipients participating in the FSC program. Results from the assessment are used to design the types and volume of activities included in the client's employment plan. This assessment is also used in a statewide evaluation of the FSC program.

Target population: The FSC Assessment Form is administered to TANF recipients referred to the FSC program, which includes those with mental health and substance abuse problems, victions of domestic violence, individuals with learning disabilities, and/or children with behavioral problems. Clients in sanction status are automatically referred to FSC (participation in services is voluntary).

Who administers the assessment: The assessment is administered by family services counselors, who are either licensed mental health professionals or individuals supervised by a licensed mental health professional.

Time required to complete the assessment: On average, assessments take about two hours to complete.

Information collected/issues addressed: The FSC Assessment Form collects information on demographics, family situation, sources of stress, problems the client is struggling with, school/work history, physical health, counseling history, drug and alcohol use, current functioning, and on issues covered in the Adult Strength Scale.(2) Counselors also recorded their impressions and recommendations on the form. In addition, the form includes four supplemental screenings: (1) learning needs screening, (2) drug and alcohol screening, (3) family violence screening, and (4) functional assessment.(3) These screenings are only used if certain "red flag" questions on the assessment are answered positively or if the counselor believes that additional questions may help the client open up and disclose more information.

Tennessee's Screening/Assessment Instrument [in PDF format]

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Florida's TANF SAMH Program Survey

The Florida TANF SAMH (Substance Abuse/Mental Health) Program Screening is a standard 32-item screening tool used statewide by TANF SAMH outreach workers. The TANF SAMH program director developed the screening tool with input from TANF SAMH district specialists, and mental health and substance abuse contracted service providers. Questions can be added to the basic screening tool, but the 32 core questions may not be modified.

Purpose of the screening/assessment tool: The purpose of the screening is to identify clients at risk for mental health and/or substance abuse issues.

Target population: The screening/assessment tool is administered to TANF clients and other low-income families with an income less than 200 percent of the federal poverty level. Clients are screened in one-stop employment centers, public health centers, public schools, county courthouses, WIC offices, Head Start offices, and other locations that serve TANF recipients and other low-income families.

Who administers the assessment: Bachelor's level outreach workers administer the assessment to TANF recipients and other low-income families. The outreach workers, staff from the contracted mental health and substance abuse service providers, have a background in psychology, social work, or other social service-related fields.

Time required to complete the screening: The screening can be completed in 45 minutes to an hour.

Information collected/issues addressed: The screening tool begins with two open-ended questions: (1) "How is your life going for you right now?" and (2) "How is life going for your children?" The tool also includes the CAGE to detect drug and alcohol abuse, and a DSM IV-based mental health screening tool that addresses 10 disorders including, among others, depression; suicidal ideations; anxiety; history of sexual, physical, or emotional abuse; and domestic violence. A scoring system for the screening tools allows outreach workers to determine whether a client should be referred to treatment. A "yes" response to any one of seven specified questions indicates an automatic referral.

Florida's Screening/Assessment Instrument [in PDF format]

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Referral Forms

Utah's Department of Workforce Services Referral for Services Form. Employment counselors use the Referral for Services form to link clients with mental health and other services such as medical, housing, transportation, and legal services. Employment counselors send the forms to the Department of Workforce Services social worker assigned to the local welfare office. Social workers may also use this form to access mental health treatment for the client. The form takes approximately 10 to 15 minutes to complete.

Tennessee's Family Services Counseling (FSC) Referral Form. Tennessee's FSC Referral Form was developed exclusively for the FSC program. Employment case manager complete this two-page form to refer a client to the FSC program. The form includes basic demographic information, reason for referral, referral source, TABE test results, the employment case manager's name, and potential barriers to employment. The form takes between 20 and 25 minutes to complete.

Florida's TANF SAMH Program Certification (Referral) Form. Contracted service providers use this form to obtain authorization to provide mental health and substance abuse services to TANF recipients and other low-income families. Clients may be identified by outreach workers or referred directly to contracted service providers for mental health and substance abuse treatment. Contracted service providers complete this referral form and fax it to the TANF SAMH district specialist for approval. The form takes 10 to 15 minutes to complete.

Florida's TANF SAMH Services and One-Time Payment, Purchase of Service, Request/Approval Form. Florida's TANF SAMH specialists monitor and approve the services provided through the contracted TANF SAMH treatment agencies. Every six months, a TANF SAMH specialist reviews each case. These specialists are given wide latitude in deciding which services should be provided and for how long.

Referral forms for all sites [in PDF format]

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Confidentiality and Consent Forms

Although the layout of the confidentiality forms are unique to each state, there is little variation across the states with regard to content and use. Every state requires a client to sign a release of information allowing mental health staff to share information with the welfare agency and other service providers. Clients are also notified about the types of information that are kept confidential. In some states, clients are required to sign a statement declaring that they are voluntarily participating in mental health services. In each state, licensed mental health professional (or mental health staff under the supervision of a licensed mental health professional) complete the forms. The forms used in the study states include:

Confidentiality and Consent forms for all sites [in PDF format]

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Service Delivery Pathways

Florida, Tennessee, and Utah have developed service delivery pathways to illustrate the process for accessing mental health services. The service delivery pathways also provide a basic overview of the mental health services from the point of referral to the completion of services.

Service Delivery Pathways for all sites [in PDF format]

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Service Planning/Tracking Forms

Tennessee's Family Services Counseling Forms

Tennessee has separate service planning forms for its Family Services Counseling (FSC) program (mental health services) and its Families First program (welfare). Counselors in the FSC program complete the following series of forms for each client:

Initial Feedback and Change Feedback Forms. Both the Initial Feedback Form and the Change Feedback Form are used to indicate a client's current status in the FSC program and to document any modifications in a client's work plan (such as time limit interruptions).

Service Plan. The Service Plan Form is used to identify the types of services or treatment and amount of time spent in each activity.

Progress Notes and Contact Log. The Progress Note and Contact Log are used to record client contacts with the family services counselor and the client's progress in the FSC program.

All family services counselors are required to use these forms. FSC district coordinators periodically review case files to ensure that the forms are completed accurately and in a timely manner.

Tennessee's service plan/tracking form [in PDF format]

Florida's TANF SAMH Program

Florida has developed a set of forms to track outreach activities, the number of screenings and referrals, and the number of clients accessing treatment. These forms, listed below, are completed by the TANF SAMH contracted service providers and submitted to the TANF SAMH specialist:

TANF SAMH Screening and Referral Analysis Form. This form, submitted by contracted service providers to the TANF SAMH specialist at the end of each month, reports on the number of clients referred for different reasons (e.g., substance abuse referrals, domestic violence referrals, outreach contacts made that month, etc.).

Log of Outreach Activities Form. This form is a monthly reporting form completed by the contracted service provider. Types of services, total units of services, and number of persons served are some of the data reported on this form.

SAMH Treatment Verification Form. This form was developed to approve time limit extensions for clients successfully completing treatment. TANF SAMH treatment providers indicate the amount of time a participant has spent in treatment. This information is used to determine whether a time limit extension should be granted for the number of months spent in treatment.

TANF SAMH Client Log. The client log is used to track individual client information such as name, social security number, TANF participant status, and status date.

Florida's service plan/tracking form [in PDF format]

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1.  Employment counselors are required to refer clients to mental health services if they respond, "yes" to two or more of the four CAGE questions asked during the general employment assessment.

2.  The Adult Strength Scale includes questions on home, work/school/training, emotional, and social resources and strengths.

3.  Sections in the functional assessment are understanding and memory, sustained concentration and persistence, social interaction, and adaptation.

Where to?

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Home Pages:
Human Services Policy (HSP)
Assistant Secretary for Planning and Evaluation (ASPE)
U.S. Department of Health and Human Services (HHS)

Updated: 10/04/01