DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-21168 (08/2008)
STATE OF WISCONSIN
CASE-FOCUSED CASE MANAGEMENT EDUCATION
Completion of this form is voluntary. The information is being collected as part of a pilot project being conducted by the Bureau of Mental Health and Substance Abuse Services of the Department of Health Services and the Mental Health and Education Resource Center at the University of Wisconsin-Madison to provide a case-focused continuing education program for Wisconsin mental health professionals. PERSONAL INFORMATION Name Participant (Last) Your name as you would like it to appear on the CME/CEU Certificate (if different than above) Contact Address (Street) Telephone Number Home
(First)
(MI)
Apt. / Unit #
City
State
Zip Code
WI
Telephone Number Alternate Title / Medical Specialty
(
)
(
)
E-mail Address Please share comments or concerns about your continuing education needs, history, and preferences
EMPLOYER INFORMATION (Optional) Name Employer Department Contact Address (Street) Telephone Number Work Fax Number City Employer Webpage URL State Zip Code
WI ( ) ( )
Specialty Licensure/Credentials Earned OTHER PROFESSIONALS ACTIVELY WORKING WITH CHILD / ADOLESCENT (Please check all that apply) School Psychologists--how many? Clinical Psychologists--how many? Counseling Psychologists--how many? Rehabilitation Psychologists--how many? Licensed Foster Parents--how many? Social Workers--how many? Other Caseworkers--how many? Other Mental Health Professionals--how many? Behavioral Neurologists--how many? Pediatricians--how many? Psychiatrists--how many? Judges--how many? Attorneys--how many? Pastor / Rabbi--how many? Other Counselors--how many? Please describe
Other Professionals--how many?
Please describe
F-21168
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CHILD / ADOLESCENT CASE INFORMATION (NOTE: Please do not include any personally identifiable patient information) Current Primary Diagnosis (If no formal diagnosis, provide working diagnosis and/or detail below) Male Female Age years old Concurrent Comorbid Diagnoses
Current Medications and Dosing Information Drug (Brand) Dosage/Administration
Active Symptoms and Concerns
Yes Yes Yes For Office Use:
No No No
Current or past history of substance abuse/misuse? Current or past history of juvenile justice involvement? Are you willing to provide case records with personally identifiable information redacted?