Locus Worksheet Form – Fill Out and Use This PDF

NAME AND CREDENTIALS OF WHO COMPLETED

SIGNATURE

DATE

NAME OF CLINICAL SUPERVISOR (MH PROFESSIONAL)

SIGNATURE

DATE

Date of Assessment

he date the LOCUS assessment was completed.

Date of Birth

Month/Day/Year (MM/DD/YYYY)

Gender

Male or Female

Recipient PMI or Social Security number

PMI number is preferred over the social security number.

Diagnosis

Primary (Write in the full diagnostic name of the primary diagnosis or use the ICD code).

Provider Name, NPI and Service Type

NPI number and the name of the organization completing the LOCUS and what type of service is being provided by the staf completing the LOCUS assessment.

Actual Level of Care

What is the actual Level of Care the recipient is receiving? Write the actual name of the level (i.e. Medically Monitored Non-Residential). It may not necessarily be the same as the ‘Level of Care Recommendation’ if a variance is being made.

Service/Program Referred to

Write the current program(s) recipient is in or what program(s) recipient has been referred to (example: ARMHS, Day Treatment, Case Management, Psychiatry, housing programs, etc.). Please keep in mind that there may be multiple services used to reach an individual’s resource intensity needs.

Reason for Variance (if applicable)

If the service provided is at a diferent level of care from the level of care recommendation, provide the brief clinical justiication as to why the variance was made. Clinical justiication also needs to be documented in more detail as a separate document from the recording form.

In the dimension being evaluated please check which rating was given. On the line following the rating please indicate the letter(s) of the criteria that was used to determine the score. his information can be located in the AMHD LOCUS Questionnaire Booklet or in the training manual.

Composite Score

Add up the score from each dimension to determine the composite score.

Level of Care Recommendation

From the score and use of the decision tree, what is the Level of Care recommended. Write the actual name of the level (i.e. Medically Monitored Non-Residential)

NOTE: the Level of Care recommendation may be diferent from the composite score if Independent Criteria is indicated that requires admission to a Level 5 or Level 6 service. It may also be diferent if clinical judgment is used in determining that a diferent level of care is more appropriate than what the completed LOCUS assessment recommends.

Signature spaces

Signature spaces are located at the bottom of the page on the LOCUS Recording Form. If a Mental Health (Rehab) Professional is completing the LOCUS assessment, there does not need to be a signature by a clinical supervisor.