County of Sonoma Department of Health Services Behavioral Health Division
CSI (Client Service Information) ANNUAL UPDATE FORM
Legend instructions: Use the numeric section for the appropriate category when applicable. Each field must be completed.
CSI Annual form may not be submitted with blank fields.
1. Client’s Living Arrangements
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Alcohol Abuse Facility
Adult residential/Social Rehab St Hospital
Adult Residential/Social Rehabilitation
Community Treatment Facility
CRTS long-term or transitional housing
Drug Abuse Facility
Foster family home (for Children)
General Hospital
Group Home
Grp quart-dorm, barracks, camp, Long
Term shelter
Homeless, in transit
Homeless, no identifiable county
residence
Homeless, no identifiable residence
House or apartment
House or apartment w/supervision
House or apartment w/support
Justice Related
Large Board & Care home (7 beds or
more)
Mental Health Rehabilitation Center
Other
PHF/Inpatient Psych
Residential Treatment Center
Satellite housing
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Single Room-hotel, motel, rooming house
Small Board & Care home (6 beds or less)
24
25
26
SNF/ICF/IMD, for Psychiatric Reasons
26
27
28
SNF/ICF/Nursing home-physical health
27
28
29
Supported housing
30
Temporary Arrangement
31
32
Unknown/Not Reported
VA Hospital
10
11
12
13
14
15
16
17
Rehabilitative work, less 20 hrs a week
Resident Inmate
Retired
School, full-time
Unemployed, actively seeking work
Unemployed, not actively seeking work
Unknown
Volunteer Work
4. Conservatorship/Court Status
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
16 Years
17 Years
18 Years
19 Years
20 + Years
1 Yr Vocational /Technical
2 Yrs Vocational/Technical
1 Yr Special Education
2 Yrs Or More Special Education
1
2
Juvenile Court, Dependent of the Court
3
4
5
6
7
8
Juvenile Court, Ward - Status Offender
Lanterman-Petris-Short
Murphy
Not Applicable
PC 2974
9
Representative Payee Without
Conservatorship
Temporary Conservatorship
Unknown/Not Reported
10
11
Juvenile Court, Ward - Juvenile Offender
Probate
5. Caregiver (Number of children less than
18 years old client
responsible for at least 50% of the time)
Enter total persons
1 Yr Preschool
2 Yrs Or More Preschool
None
6. Diagnosis: ICD-9 and ICD-10 Codes (P)
Primary or (S) Secondary
Unknown
7. Trauma
3. Employment Status
1
2
Compet job market 20-35 hrs a week
Yes
No
Compet job market 35 hrs or more a week
Unknown
3
Compet job market less thn 20 hrs a week
4
Full-time homemaking responsibility
5
Job Training, FullTime
Yes
6
Not in the labor force Resident Inmate
No
7
Part-time school/job training
MHS 111 Legend (03-17)
(cont’d Employment Status)
09 Years
23
24
25
State Hospital
2. Education
01 Years
02 Years
03 Years
04 Years
05 Years
06 Years
07 Years
08 Years
8
Rehabilitative work, 20 to 35 hrs a week
9
Rehabilitative work, 35 hrs or more a week
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8. Substance Abuse/Dependence
Unknown/Not Reported
9. Diagnosing Practitioner
Enter Practitioner staff number
assigned by Sonoma County
County of Sonoma Department of Health Services Behavioral Health Division
CSI (Client Service Information) ANNUAL UPDATE FORM
Legend instructions: Use the numeric section for the appropriate category when applicable. Each field must be completed.
CSI Annual form may not be submitted with blank fields.
1
21. General Medical Condition Summary Code
Allergies
Anemia
3
Arterial Sclerotic Disease
4
5
6
7
8
9
Arthritis
Asthma
Birth Defects
Blind / Visually Impaired
Cancer
Carpal Tunnel Syndrome
10
Chronic Pain
11
Cirrhosis
12
Cystic Fibrosis
13
14
15
16
17
Deaf / Hearing Impaired
Diabetes
Digestive Disorders (Reflux, Irritable Bowel Syndrome)
Ear Infections
Epilepsy / Seizures
18
Heart Disease
19
20
Hepatitis
Hypercholesterolemia
21
Hyperlipidemia
22
Hypertension
23
Hyperthyroid
24
Infertility
25
Migraines
26
Multiple Sclerosis
27
28
29
30
31
Muscular Dystrophy
No General Medical Condition
Obesity
Osteoporosis
Other
32
Parkinson's Disease
33
34
35
36
37
38
39
Physical Disability
Psoriasis
Sexually Transmitted Disease (STD)
Stroke
Tinnitus
Ulcers
Unknown / Not Reported General Medical Condition
MHS 111 Legend (03-17)
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