ࡱ> %` Pbjbj |̟̟w&:::::::N6060608n0 1tNzU$2d5(666684-:QTSTSTSTSTSTST$WhZwT:<66<<wT::664UBBB<X:6:6QTB<QTBBreJT::AK6~2 `FE605=J%N,JU0zUJzZ=HZAKZ:AK:L;6BK;,w;f:::wTwT)Bj:::zU<<<<NNN$(r-NNNr-NNN:::::: QUARTERLY CONTRACT MONITORING REPORT (QCMR) LEVEL OF SERVICE REPORT INTENSIVE FAMILY SUPPORT SERVICES USTF PROJECT CODE:  FORMTEXT      REPORTING QUARTER: (CHECK ONE): NAME OF AGENCY:  FORMTEXT       JULY 1 TO SEPTEMBER 30  1  FORMTEXT      NAME OF PROGRAM:  FORMTEXT       OCTOBER 1 TO DECEMBER 30  2  FORMTEXT      PERSON COMPLETING FORM/PHONE#:  FORMTEXT       JANUARY 1 TO MARCH 31  3  FORMTEXT      DATE SUBMITTED:  FORMTEXT       APRIL 1 TO JUNE 30  4  FORMTEXT       CHECK AGENCY REPORTING QUARTER: 1  FORMTEXT       2  FORMTEXT       3  FORMTEXT        4  FORMTEXT       A.  FORMTEXT      B.  FORMTEXT      C.  FORMTEXT      D.  FORMTEXT      E.  FORMTEXT      Beginning Number of Active Individuals (First Day of Qtr.)New Individuals Enrolled into Program During QuarterNumber of Individuals Re-Enrolled this QuarterNumber of Individuals Terminated During QuarterEnding Number of Enrolled Individuals (Last Day of Qtr.)Aa.  FORMTEXT      Bb.  FORMTEXT      Cc.  FORMTEXT      Dd.  FORMTEXT      Ee.  FORMTEXT      Beginning Number of Active Families (First Day of Qtr.)New Families Enrolled into Program During QuarterNumber of Families Re-Enrolled this QuarterNumber of Families Terminated During QuarterEnding Number of Enrolled Families (Last Day of Qtr.) 3.Number of on-site face-to-face single family consultation contacts.3. FORMTEXT      4.Number of off-site face-to-face single family consultation contacts.4. FORMTEXT      5.Number of collateral contacts made on behalf of families.5. FORMTEXT      6.Number of multiple family support group sessions provided.6. FORMTEXT      7.Unduplicated number of participants in multiple family support groups.7. FORMTEXT      8.Number of psychoeducational program sessions provided.8. FORMTEXT      9.Unduplicated number of participants in psychoeducational program sessions.9. FORMTEXT       QUARTERLY CONTRACT MONITORING REPORT (QCMR) LEVEL OF SERVICE REPORT INTENSIVE FAMILY SUPPORT SERVICES USTF PROJECT CODE:  REF Text1  REPORTING QUARTER: (CHECK ONE): NAME OF AGENCY:  REF Text2   JULY 1 TO SEPTEMBER 30  1  REF Text6  NAME OF PROGRAM:  REF Text3   OCTOBER 1 TO DECEMBER 30  2  REF Text7   PERSON COMPLETING FORM/PHONE#:  REF Text4   JANUARY 1 TO MARCH 31  3  REF Text8  DATE SUBMITTED:  REF Text5   APRIL 1 TO JUNE 30  4  REF Text9   CHECK AGENCY REPORTING QUARTER: 1  REF Text10   2  REF Text11    3  REF Text12    4  REF Text13   10.Number of supportive telephone contacts made to family members.10. FORMTEXT      11.Number of staff face-to-face hours providing in-home respite care provided.11. FORMTEXT      12.Number of hours of out-of-home respite care provided.12. FORMTEXT      13.Unduplicated number of families provided with respite care services.13. FORMTEXT       14. Total Units of Service (Sum of 3, 4, 5, 6, 8, 10, 11, 12). 14.  FORMTEXT        INTENSIVE FAMILY SUPPORT SERVICES SERIOUS MENTAL ILLNESS (SMI): Persons who are (1) age 18 and over and (2) who currently have, or at any time during the past year, had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-IV or their ICD-9-CM equivalent (and subsequent revisions) with the exception of DSM-IV V codes, substance use disorders, and developmental disorders which are excluded, unless they co-occur with another diagnosable serious mental illness, and (3) that has resulted in functional impairment, which substantially interferes with or limits one or more major life activities. Enter the number of individual family members associated with all active families reported in item Aa. For this purpose, include all family members who have received services within the previous reporting quarter (90 days). These family members will be enrolled on the last day of the previous quarter. Enter the number of individual family members newly enrolled in your program within the reporting quarter who received services. Also, include family members associated with active families but who are not included in item A and who began receiving services within the reporting quarter. Enter the number of individual family members that were re-enrolled in your program within the reporting quarter. Enter the number of individual family members that were terminated from your programs within the reporting quarter. Enter the ending number of enrolled individuals on the last day of the reporting quarter. Calculate the number as follows: Add letters A, B, C and then subtract D to get the total for E. This will be your beginning number of active individual family members for the next reporting quarter. Aa. Enter the number of active families in your program at the beginning of the reporting quarter. For these purposes, an active family is defined as one in which as least one family member received services within the reporting quarter (90 days), and who enrolled on the last day of the previous quarter. Bb. Enter the number of new families enrolled during this quarter. Cc. Enter the number of families that are re-enrolled during the reporting quarter. Dd. Enter the number of families formally terminated during the quarter. Ee. Enter the number of active families on the last day of the reporting quarter. Calculate the number as follows: Add letters Aa, Bb, and Cc then subtract Dd to get the total for Ee. This will be your beginning number of active families for the next reporting quarter.  INTENSIVE FAMILY SUPPORT SERVICES Intensive Family Support Services are a range of supportive activities designed to improve the overall functioning and quality of life of families with a mentally ill relative. These support activities may include psychoeducation groups, singe family consultations, respite, family support groups, systems advocacy, referral/service linkage and medication monitoring. Services may be delivered in the familys home, at the agency, or at other sites in the community. FACE-TO-FACE CONTACTS (Excluding Psychoeducation and Multifamily Support Groups): Refers to staff contacts with 1 or more family members lasting 15 minutes to 1 hour. If contact lasts a minimum of 1 hour and 15 minutes, count as 2 face-to-face contacts. If 2 staff simultaneously serve 1 family, count as 2 face-to-face contacts. If 1 staff member serves 2 or more families simultaneously, count as 1 face-to-face contact. 3/4. SINGLE FAMILY CONSULTATION: Contact consists of a family receiving information from and consulting with staff on an as needed basis in order to enhance the overall functioning of the family with a mentally ill member. 5. 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MULTIPLE FAMILY SUPPORT GROUPS: Multiple family support group contacts consist of participation in a time-limited or ongoing support group in which families meet together to provide mutual support, information and an opportunity for interaction with other families. A support group contact unit is at least 15 minutes and up to 1 hour. An additional unit is awarded for each 15 minute time period beyond the first hour for the duration of the session. No additional units will be awarded for each staff member conducting the group or for each family or family member. 7/9. AVERAGE UNDUPLICATED NUMBER OF PARTICIPANTS: Identify the average number of individuals to attend 1 or more multiple family support sessions or psychoeducation programs. If an individual attends 4 sessions, count as 1 participant. 8. PSYCHOEDUCATION PROGRAMS: In these programs, families participate in a multi-family group which meets on a regular schedule and a time-limited basis for the purpose of enhancing the familys overall functioning. Functioning is enhanced through greater knowledge of mental illness and skills useful in managing the familys ill member. Interaction encourages collaboration between professionals and family members and provides for a mutual exchange of information. A psychoeducation group contact is at least 15 minutes and up to 1 hour. An additional unit is awarded for each 15 minute time period beyond the first hour for the duration of the program session. No additional units will be awarded for each staff conducting the program session or for each family or family member. 10. SUPPORTIVE TELEPHONE COUNSELING CONTACTS: Consists of telephone counseling contacts by staff to family members with a minimum of 15 minutes up to a maximum of 1 hour. (These contacts do not include routine telephone calls, such as scheduling appointments). 11/12. RESPITE CARE: Consists of a familys participation in a non-emergency service, which is designed to allow members planned time away from their ill relative living at home .Respite care can be provided in the home or out of the home and can be provided as a day, evening and/or overnight service. Count the number of staff hours providing respite care. If 2 staff provide 4 hours of respite, count as 8 hours. 13. AVERAGE UNDUPLICATED NUMBER OF FAMILIES: Refer to item 7/9 but count families, not individuals. 14. UNITS OF SERVICE = Sum of items 3, 4, 5, 6, 8, 10, 11 and 12.     4/09Submit Forms 30 days after the close of a Quarter to the QCMR Coordinator at the following address: Division of Mental Health Services, PO Box 727, Trenton, NJ 08625-0727Page  PAGE 1 of  NUMPAGES 5 BTY  Ncɫʫͫϫ &iGƺzncXhu hJEFOJQJhu h ^ROJQJhu hu5OJQJhu h ^R5OJQJhPOJQJhu hPOJQJhu hfoOJQJhu huOJQJhu h@OJQJhu h@5OJQJhu hJEF5OJQJhu hd%5OJQJhu h 7OJQJhu h%5OJQJhu h%OJQJ"  !±&'kmnpqstvw|)K $$Ifa$gdZ $IfgdZ$ ] ^a$gdA:GL IůƯݯ !(6±űƱ%&'+,<ƾƾƾѲƧxxxlhu hu 5OJQJhu hdqOJQJhu hdq5OJQJhu h ^R5OJQJhu hfo5OJQJhu hHOJQJhu hH5OJQJhPOJQJhu h $`OJQJhu h $`5OJQJhu huOJQJhu hJEFOJQJhu hJEF5OJQJ&<=NOQRTUWXZ[^_jklnoqrtuw{Ų߲()./5678ƾrchc0JCJaJmHnHuhd%h{0JCJaJ!jhd%h{0JCJUaJhd%h{CJaJhih{5CJaJhvh{5CJaJhvh{CJaJh{CJaJh%=jh%=Uhu hd%5OJQJhu h ^R5OJQJhu hdq5OJQJh5OJQJ&8<=GHIJKLNOPhu hdq5OJQJh%=h{hvh{CJaJhc0JCJaJmHnHuhd%h{0JCJaJ!jhd%h{0JCJUaJhd%h{CJaJ KLMNOP$ ] ^a$gdA:dkd*$$IflF!'< ! t6    44 laz+p,p-p.p1h/R 4567:pz/ =!8"#8$% tD@Text1[$$If!vh5e5#ve#v:Vl t65yt2tD@Text2tD@Text6y$$If!vh5e55#ve#v#v:Vl t6555@yt2tD@Text3tD@Text7y$$If!vh5e55#ve#v#v:Vl t6555@yt2tD@Text4tD@Text8y$$If!vh5e55#ve#v#v:Vl t6555@yt2tD@Text5tD@Text9y$$If!vh5e55#ve#v#v:Vl t6555@yt2vD@Text10vD@Text11vD@Text12vD@Text13$$If!vh5e5555#ve#v#v#v:Vl t655=yt2vDText14vDText15vDText16vDText17vDText18$$If!vh55o5|5557 #v#vo#v|#v5#v7 :Vl t0a6535555^ytOA$$If!vh55o5|5557 #v#vo#v|#v5#v7 :Vl t0a6535555^ytOA$$If!vh55o5|5557 #v#vo#v|#v5#v7 :Vl t0a6535555^ytOAvDText19vDText20vDText21vDText22vDText23$$If!vh55o5|5557 #v#vo#v|#v5#v7 :Vl t0a6535555^ytOA$$If!vh55o5|5557 #v#vo#v|#v5#v7 :Vl t0a6535555^ytOA$$If!vh55o5|5557 #v#vo#v|#v5#v7 :Vl t0a6535555^ytOAvDText24$$If!vh55558#v#v#v#v8:Vl t06595B55 yt~Q$$If!vh555S#v#v#vS:Vl t06595B5 yt~QvDText25$$If!vh55558#v#v#v#v8:Vl t06595B55 yt~Q$$If!vh555S#v#v#vS:Vl t06595B5 yt~QvDText26$$If!vh55558#v#v#v#v8:Vl t06595B55 yt~Q$$If!vh555S#v#v#vS:Vl t06595B5 yt~QvDText27$$If!vh55558#v#v#v#v8:Vl t06595B55 yt~Q$$If!vh555S#v#v#vS:Vl t06595B5 yt~QvDText28$$If!vh55558#v#v#v#v8:Vl t06595B55 yt~Q$$If!vh555S#v#v#vS:Vl t06595B5 yt~QvDText29$$If!vh55558#v#v#v#v8:Vl t06595B55 yt~Q$$If!vh555S#v#v#vS:Vl t06595B5 yt~QvDText30$$If!vh55558#v#v#v#v8:Vl t06595B55 yt~Q[$$If!vh55#v#v:Vl t65yt2y$$If!vh555#v#v#v:Vl t6555@yt2y$$If!vh555#v#v#v:Vl t6555@yt2y$$If!vh555#v#v#v:Vl t6555@yt2y$$If!vh555#v#v#v:Vl t6555@yt2$$If!vh55555#v#v#v:Vl t655=yt2vDText31$$If!vh555 54#v#v#v #v4:Vl t06595B55yt2$$If!vh555T#v#v#vT:Vl t06595B5 yt2vDText32$$If!vh555 54#v#v#v #v4:Vl t06595B55yt2$$If!vh555T#v#v#vT:Vl t06595B5 yt2vDText33$$If!vh555 54#v#v#v #v4:Vl t06595B55yt2$$If!vh555T#v#v#vT:Vl t06595B5 yt2vDText34$$If!vh555 54#v#v#v #v4:Vl t06595B55yt2$$If!vh555T#v#v#vT:Vl t06595B5 yt2vDText35$$If!vh555 54#v#v#v #v4:Vl t06595B55yt2$$If!vh5155{#v1#v#v{:Vl t065<5 !5a@@@ NormalOJQJ_HmH sH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k(No Listj@j A.H Table Grid7:V0T@ E Block TextV@@$d%d&d'dNOPQ]@^@OJQJ4@4 ZHeader  !4 @"4 ZFooter  !.)@1. d% Page Number\',Dfgz%9:\]st  78NOPpq,CDLMNOPQRSk6b,-./014y|,/CDEFGHKRUijklmnopqr $ % & 6 K L r s  # $ J K b c s   ! 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