Kentucky Determination Criteria Checklist for Serious Mental Illness (SMI) Name of Client First Last Medicaid Number HiddenMedicaid NumberDiagnostic Codes and DescriptionThe following table illustrates the criteria that shall be met for an individual to be designated as seriously mentally ill (SMI). In order to designate an individual as SMI, all of the criteria in Sections 1,2,3 and 4 shall be met. Please check the following criteria for age, diagnoses, disability and duration.Criteria1. Age: Is the person under age 18 or over (calculated at the time of service) Yes No And2. Diagnosis: * Has one or more of the following mental health diagnoses as designated in the latest edition of the Diagnositc and Statistical Manual of Mental Disorders Yes No Schizophrenia Spectrum and other Psychotic DisordersPlease check applicable diagnoses. F 22-Delusional Disorder F22 F20.81-Schizophreniform Disorder F20.9-Schizophtenia F25.0-SchizoAffective Disorder -Bipolar Type F25.1-Schizoaffective disorder-Depressive Type F28 Other Specified Schizophrenia Spectrum and other Psychotic Disorder F29-Unspecified Schizophrenia Spectrum and Other Psychotic Disorder Bipolar and Related Disorders F31.11 Bipolar I Disorder-Mild, Manic F31.12 Bipolar I Disorder-Manic F31.13 Bipolar I Disorder-Severe, Manic F31.31 Bipolar I Disorder-Mild, Depressed F31.32 Bipolar I Disorder-Moderate, Depressed F31.4 Bipolar I Disorder-Severe. Depressed F31.2 Bipolar I Disorder-With Psychosis, Manic F31.73 Bipolar I Disorder-In Partial Remission, Manic F31.0 Bipolar I Disorder- Unspecified Manic F31.5 Bipolar I Disorder-With Psychosis, Depressed F31.75 Bipolar I Disorder-In Partial Remission, Depressed F31.30 Bipolar I Disorder Unspecified, Depressed F31.81 Bipolar II Disorder F34.0 Cyclothymic Disorder F31.9 Other Specified Bipolar and Related Disorder Depressive Disorders F32.0 Major Depressive Disorder- Mild, Single F33.0 Major Depressive Disorder-Mild, Recurrent F32.1 Major Depressive Disorder-Moderate, Single F33.1 Major Depressive Disorder-Moderate, Recurrent F32.2 Major Depressive Disorder-Severe, Single F33.2 Major Depressive Disorder, Severe, Recurrent F32.3 Major Depressive Disorder-With Psychosis, Single F33.3 Major Depressive Disorder-With Psychosis, Recurrent F32.4 Major Depressive Disorder-In Partial Remission ,Single F33.41 Major Depressive Disorder-In Partial Remission, Recurrent F32.9 Major Depressive Disorder-Unspecified, Single F33.9 Major Depressive Disorder-Unspecified, Recurrent Trauma and Stress Related Disorders F43.10 Posttraumatic Stress Disorder And3. DisabilityMark this "Yes" if the person meets two of the criteria in the following question about functional domains. Yes No Clear Evidence of functional impairment in two of the following domains: Societal/Role Functioning: Functioning in the role most relevant to his/her contribution to society and, in making that contribution, how well the person maintains conduct within societal limits prescribed by laws, rules and strong social mores. Interpersonal Functioning: How well the person establishes and maintains personal relationships. Relationships include those made at work and in the family settings as well as those that exist in other settings. Daily Living/Personal Care Functioning: How well the person is able to care for him/herslef and provide for his/her needs such as personal hygiene, food, clothing, shelter and transportation. The capabilities covered are mostly those of making reliable arrangements appropriate to the person's age, gender and culture. Physical Functioning: Person's general physical health, nutrition, strength, abilities/disabilities and illnesses/injuries. Cognative/Intellelctual Functioning: Person's overall thought processes, capacity, stylle and memory in relation to what is common for the person's age, gender, and culture. Person's response to emotional and interpersonal pressures on judgments, beliefs and logical thinking should all be considered in making this rating. ANDDuration:Mark this "Yes" if the person meets one or more of the conditions of duration in the following question. Yes No One or more of these conditions of duration: Clinically significant symptoms of mental illness have persisted in the individual for a continuous period of at least 2 (two) years. The individual has been hospitalized for mental illness more than once in the past 2 (two) years. There is a history of one or more episodes with marked disability and the illness is expected to continue for a two-year period of time. Consent(Required) The individual meets the criteria for the designation of Serious Mental Illness (SMI). Documentation of the existence of these criteria of Age, Diagnosis, Disability and Duration is present in the individual's medical record and assessment has been conducted by a qualified licensed behavioral health professional.Print Name /Credentials SignatureEmail The Assessor must provide their HIPAA compliant secure email address with @transformationsllc.netDate MM slash DD slash YYYY
