Client ID: Client's IS number
Client DOB: Client's date of birth
Episode ID: 8 digit alphanumeric ID for FSP episode. Found on print out of confirmation of an open episode
Client L. Name: Client's Last Name
Client's F. Name: Client's First Name
Partnership Date is the first day that you provide FSP services (not outreach and engagement) after you receive countywide authorization to provide FSP services. This usually coincides with the opening of FSP episode and/or first billing of FSP services in the Integrated System (IS). This date can never precede the countywide authorization date. It does not change when the client transfers from one provider to another. However, if your client is coming back to FSP after being out of the program for more than 12 months, you will have to start a new baseline with a new partnership date.
Partnership Services Coordinator (Last Name) is the last name of the person who is responsible for the outcomes. This person is someone people will contact if there is a problem with the data. This might be the person completing the assessment, the team leader, the clinician, or the program manager, it's up to the individual agency.
Assessment Date: Date you are initiating this assessment. You will have 30 days to complete the Baseline from the partnership date. If you need to edit your assessment, you will have 60 days from the partnership date to make changes to your Baseline.
Assessment Completed by: This is the National Provider Identifier number (NPI #) of the person actually completing the outcomes. In the past this was formally the staff code. Now the NPI# is used for billing services as a rendering provider due to changes with IBHIS. This field will only accept the NPI# of the rendering provider associated with your site and no longer accepts the prior staff code.
FSP Program Name: Check the appropriate box for the program you have been approved to provide for this client. Please Note: We have added a couple of new FSP programs to the OMA online application that you will see in Online the drop down menu. However, the paper forms (as shown above) are in the process of being updated to reflect these new FSP programs. In the meanwhile please have your staff write in the correct program name if not shown above on the paper forms. For example: if a child aged client is authorized to enroll in the TAY FSP, make sure that TAY FSP is selected as the program.
Who referred the client? (Check only one): Try to get to the original source of the referral rather than just considering the Service Area Navigator or Impact Team. Note that CYA has been renamed Division of Juvenile Justice.
No selection -
Acute Psychiatric/State Hospital -
Emergency Room -
Faith-based organization -
Family Member - check this if family requested Service Area Navigator to enroll client in FSP. Includes parent, guardian, sibling, aunt, uncle, grandparent, etc.
Friend/Neighbor -
Homeless Shelter -
Jail/Prison -
Juvenile Hall/ Camp/ Ranch/ California Youth Authority/ Division of Juvenile Justice-
Mental Health Facility/Community Agency - Service Area Navigators and other mental health providers belongs in this category.
Other -
Other County/Community Agency - Other county agencies: e.g., DPSS, DCFS, DHS, or Probation Department.
Primary Care/Medical Office -
School -
Self -
Significant Other -
Social Services Agency - Non mental health agenceies such as domestic violence shelter, homeless shelter, etc.
Street Outreach -
Substance Abuse Treatment Facility/Agency -
In which program is the client currently involved? Check if the client is involved in AB 2034 or Governor's Homeless Initiative
AB2034 or
Governor's Homeless Initiative (GHI)
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