Laserfiche WebLink
lf�� <br />Minnesota Department of Human Services <br />LOCUS Recording Form <br />DHS -6249 -ENG 6-16 <br />DATE OF ASSESSMENT <br />DIAGNOSIS <br />RECIPIENT DATE OF BIRTH <br />RECIPIENT GENDER <br />RECIPIENT PMI or SOCIAL SECURITY NUMBER <br />Q Male Q Female <br />PROVIDER NAME <br />PROVIDER NPI <br />SERVICE TYPE <br />ACTUAL LEVEL OF CARE PROVIDED <br />SERVICE(S) RECIPIENT IS RECEIVING OR REFERRED TO <br />REASON FOR VARIANCE (if applicable) <br />I. Risk of Harm <br />IV -B. Recovery Environment - Level of support <br />❑ 1. Minimal <br />❑ 1. Highly Supportive <br />❑ 2. Low <br />❑ 2. Supportive <br />❑ 3. Moderate <br />❑ 3. Limited Support <br />❑ 4. Serious <br />❑ 4. Minimal Support <br />❑ 5. Extreme <br />❑ 5. No Support <br />II. Functional Status <br />V. Treatment and Recovery History <br />❑ 1. Minimal <br />❑ 1. Full Response <br />❑ 2. Mild <br />❑ 2. Significant Response <br />❑ 3. Moderate <br />❑ 3. Moderate or Equivocal Response <br />❑ 4. Serious <br />❑ 4. Poor Response <br />❑ 5. Severe <br />❑ 5. Negligible Response <br />III. Co -Morbidity <br />VI. Engagement <br />❑ 1. None <br />❑ 1. Optimal <br />❑ 2. Minor <br />❑ 2. Positive <br />❑ 3. Significant <br />❑ 3. Limited <br />❑ 4. Major <br />❑ 4. Minimal <br />❑ 5. Severe <br />❑ 5. Unengaged <br />IV -A. Recovery Environment - Level of Stress <br />COMPOSITE SCORE <br />❑ 1. Low <br />❑ 2. Mildly <br />LEVEL OF CARE RECOMMENDATION <br />❑ 3. Moderately <br />❑ 4. Highly <br />❑ 5. Extremely <br />NAME AND CREDENTIALS OF WHO COMPLETED <br />SIGNATURE <br />DATE <br />NAME OF CLINICAL SUPERVISOR (MH PROFESSIONAL) <br />SIGNATURE <br />DATE <br />As a mental health provider in the State of Minnesota, Deerfield Behavioral Health, Inc. is granting you permission to scan this completed <br />LOCUS Recording Form, where the dimensional scores, criteria, composite score and level of care recommendation have been documented, <br />into your electronic medical record. <br />