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Clients who were referred from an Other Psychiatric Inpatient Unit FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      E. Clients who were referred from a Designated Screening Center (DSC) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      F. Clients who were referred from an Affiliated Emergency Services (AES) or other Emergency Room based Program FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      G. Clients who were referred from a DMHS contracted Crisis Residential Program FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      H. Clients who were referred from an Partial Care/Hospital (PC/PH) Program FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      I. Clients who were referred from an Early Intervention and Support Services (EISS) Program FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      J. Clients who were referred from a DMHS funded Jail Diversion or Re-Entry Program FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      K. Clients who were referred from other DMHS Specialized Pilot Diversionary Programs FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Clients referred from Other sources: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       TOTAL FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Service Modality Outputs 4. The following is a breakdown by MODALITY of the number of Face-to-Face client contacts with outpatient staff (both on-site and off-site): A. Individual Therapy  FORMTEXT       B. Group Therapy  FORMTEXT       C. Family Therapy  FORMTEXT       D. Medication Monitoring  FORMTEXT       E. Intake/Clinical Assessment/Treatment Planning  FORMTEXT       F. Outreach  FORMTEXT       G. 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On-Site:  FORMTEXT       B.Off-Site:  FORMTEXT       Service Intensity Outputs 6. Total Face to Face Hours of Service to be provided:  FORMTEXT       7. Total Number of Collateral Contacts to be provided on Behalf of the Client:  FORMTEXT       8. Average Length of Stay in IOTSS program:  FORMTEXT       Additional Outputs 9. Total number of Wellness and Recovery Action Plans (WRAPs) to be developed:  FORMTEXT       10. Total Number of Consumers to receive Illness Management and Recovery (SAMHSA EBP):  FORMTEXT       11. Total Number of Physical Health Care Referrals:  FORMTEXT       12. Total Number of consumers to be educated about Psychiatric Advanced Directives?  FORMTEXT       13. Total Psychiatric Advanced Directives to be completed?:  FORMTEXT       14.. Staffing Total # of FTE s # of FTE s Directly Employed by the Provider # of FTE s Hired as Consultants by the Provider # of FTE Vacancies % Bi-Lingual Bi-Cultural Staff Currently Employed Psychiatrist FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Advanced Practice Nurse (APN) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Licensed Practical Nurse (LPN) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Psychologist FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Registered Nurse (RN) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Masters Level Clinicians FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Other (i.e. case managers) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Total FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       15. 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