BHAAdmissionQuestionnaire
type: Questionnaire
node role: treeRoot
id:
  v: BHAAdmissionQuestionnaire
meta:
  profile:
    v: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire|4.0.0
    l: http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire
language:
  v: en
text:
  status:
    v: extensions
  div:
    v: Generated Narrative: Questionnaire BHAAdmissionQuestionnaire Profile: SDC Base Questionnaire version: 4.0.0 LinkID Text Cardinality Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> BHAAdmissionQuestionnaire Questionnaire used during admission process to collect demographic, social, clinical, and administrative information from patients entering behavioral health services Questionnaire http://bha.colorado.gov/fhir/bha-ig/Questionnaire/BHAAdmissionQuestionnaire#0.3.0-current #xD; lastUpdated Last Updated DateTime of the data in the QuestionnaireResponse 1..1 dateTime #xD; SERVICE_IDENTIFIER Service Identifier 1..1 choice Value Set: ValueSet for BHA Service Identifier Codes #xD; FIRST_CONTACT_DATE Date of First Contact 1..1 date #xD; FIRST_APPOINTMENT_OFFERED_DATE Date of First Appointment Offered 1..1 date #xD; MEDICATION_ASSISTED_THERAPY Medication Assisted Therapy 1..1 boolean #xD; REFERRAL_SOURCE Referral Source 1..1 choice Value Set: ValueSet for BHA Referral Source #xD; ARRESTS_PAST_30_DAYS Arrests in Past 30 Days 1..1 integer #xD; EMPLOYMENT_STATUS Employment Status 1..1 choice Value Set: ValueSet for BHA Employment Status #xD; LIVING_SITUATION Living Situation 1..1 choice Value Set: ValueSet for BHA Living Situation #xD; MONTHLY_INCOME Monthly Income 0..1 decimal #xD; PRIMARY_INCOME_SOURCE Primary Source of income/support for client (or for client's parent if client >18 years of age) 1..1 choice Value Set: ValueSet for BHA Income Source #xD; PREGNANCY_STATUS Pregnancy Status 1..1 boolean #xD; WITHIN_1_YEAR_POSTPARTUM_STATUS Within 1 Year Postpartum Status 1..1 boolean #xD; SPECIAL_CONNECTIONS_ENROLLMENT Enrollment in Special Connections 1..1 boolean #xD; ACT_ENROLLMENT Enrollment in ACT? 1..1 boolean #xD; ASCENT_ENROLLMENT Enrollment in Ascent (FEP)? 1..1 boolean #xD; NUMBER_DEPENDENT_CHILDREN Number of Dependent Children 1..1 integer #xD; SELF_HELP_ATTENDANCE Self Help Attendance (Last 30 days at admission)/ Peer…
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/artifact-versionAlgorithm
    l: artifact-versionAlgorithm
  value: Coding
    system:
      v: http://hl7.org/fhir/version-algorithm
      l: version-algorithm
    code:
      v: semver
    display:
      v: SemVer
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm
    l: structuredefinition-fmm
  value: Integer
    v: 1
    extension:
      url:
        v: http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom
        l: structuredefinition-conformance-derivedFrom
      value: Canonical
        v: http://bha.colorado.gov/fhir/bha-ig/ImplementationGuide/bha-ig
        l: bha-ig
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status
    l: structuredefinition-standards-status
  value: Code
    v: trial-use
    extension:
      url:
        v: http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom
        l: structuredefinition-conformance-derivedFrom
      value: Canonical
        v: http://bha.colorado.gov/fhir/bha-ig/ImplementationGuide/bha-ig
        l: bha-ig
url:
  v: http://bha.colorado.gov/fhir/bha-ig/Questionnaire/BHAAdmissionQuestionnaire
  l: BHAAdmissionQuestionnaire
version:
  v: 0.3.0-current
name:
  v: BHAAdmissionQuestionnaire
title:
  v: BHA Admission Questionnaire
status:
  v: active
subject type:
  v: Patient
date:
  v: 2025-12-13
publisher:
  v: Colorado Behavioral Health Administration
contact:
  name:
    v: Colorado Behavioral Health Administration
  telecom:
    system:
      v: url
    value:
      v: https://bha.colorado.gov
  telecom:
    system:
      v: email
description:
  v: Questionnaire used during admission process to collect demographic, social, clinical, and administrative information from patients entering behavioral health services
jurisdiction:
  coding:
    system:
      v: urn:iso:std:iso:3166
      l: 3166
    code:
      v: USA
item:
  link id:
    v: lastUpdated
  text:
    v: Last Updated DateTime of the data in the QuestionnaireResponse
  type:
    v: dateTime
  required:
    v: true
item:
  link id:
    v: SERVICE_IDENTIFIER
  text:
    v: Service Identifier
  type:
    v: choice
  required:
    v: true
  answer value set:
    v: http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-service-identifier-vs
    l: bha-service-identifier-vs
item:
  link id:
    v: FIRST_CONTACT_DATE
  text:
    v: Date of First Contact
  type:
    v: date
  required:
    v: true
item:
  link id:
    v: FIRST_APPOINTMENT_OFFERED_DATE
  text:
    v: Date of First Appointment Offered
  type:
    v: date
  required:
    v: true
item:
  link id:
    v: MEDICATION_ASSISTED_THERAPY
  text:
    v: Medication Assisted Therapy
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: REFERRAL_SOURCE
  text:
    v: Referral Source
  type:
    v: choice
  required:
    v: true
  answer value set:
    v: http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-referral-source-vs
    l: bha-referral-source-vs
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue
      l: minValue
    value: Integer
      v: 0
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue
      l: maxValue
    value: Integer
      v: 30
  link id:
    v: ARRESTS_PAST_30_DAYS
  text:
    v: Arrests in Past 30 Days
  type:
    v: integer
  required:
    v: true
item:
  link id:
    v: EMPLOYMENT_STATUS
  text:
    v: Employment Status
  type:
    v: choice
  required:
    v: true
  answer value set:
    v: http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-employment-status-vs
    l: bha-employment-status-vs
item:
  link id:
    v: LIVING_SITUATION
  text:
    v: Living Situation
  type:
    v: choice
  required:
    v: true
  answer value set:
    v: http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-living-situation-vs
    l: bha-living-situation-vs
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/questionnaire-unit
      l: questionnaire-unit
    value: Coding
      system:
        v: urn:iso:std:iso:4217
        l: 4217

v: USD

url:
  v: http://hl7.org/fhir/StructureDefinition/minValue
  l: minValue
value: Decimal
  v: 0

url:
  v: http://hl7.org/fhir/StructureDefinition/maxValue
  l: maxValue
value: Decimal
  v: 9999

v: MONTHLY_INCOME

v: Monthly Income

v: decimal

v: false

link id:
  v: PRIMARY_INCOME_SOURCE
text:
  v: Primary Source of income/support for client (or for client's parent if client >18 years of age)
type:
  v: choice
required:
  v: true
answer value set:
  v: http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-income-source-vs
  l: bha-income-source-vs

link id:
  v: PREGNANCY_STATUS
text:
  v: Pregnancy Status
type:
  v: boolean
required:
  v: true

link id:
  v: WITHIN_1_YEAR_POSTPARTUM_STATUS
text:
  v: Within 1 Year Postpartum Status
type:
  v: boolean
required:
  v: true

link id:
  v: SPECIAL_CONNECTIONS_ENROLLMENT
text:
  v: Enrollment in Special Connections
type:
  v: boolean
required:
  v: true

link id:
  v: ACT_ENROLLMENT
text:
  v: Enrollment in ACT?
type:
  v: boolean
required:
  v: true

link id:
  v: ASCENT_ENROLLMENT
text:
  v: Enrollment in Ascent (FEP)?
type:
  v: boolean
required:
  v: true

extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/minValue
    l: minValue
  value: Integer
    v: 0
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/maxValue
    l: maxValue
  value: Integer
    v: 99
link id:
  v: NUMBER_DEPENDENT_CHILDREN
text:
  v: Number of Dependent Children
type:
  v: integer
required:
  v: true

extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/minValue
    l: minValue
  value: Integer
    v: 0
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/maxValue
    l: maxValue
  value: Integer
    v: 30
link id:
  v: SELF_HELP_ATTENDANCE
text:
  v: Self Help Attendance (Last 30 days at admission)/ Peer Support Attendance
type:
  v: integer
required:
  v: true

extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/minValue
    l: minValue
  value: Integer
    v: 0
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/maxValue
    l: maxValue
  value: Integer
    v: 30
link id:
  v: TOTAL_SUBSTANCE_USE_PRIOR_TREATMENT
text:
  v: Substance Use Prior Treatment (Total Lifetime admissions)
type:
  v: integer
required:
  v: true

link id:
  v: PSYCHIATRIC_HOSPITAL_ADMISSION
text:
  v: Psychiatric Hospital Admission (Last 30 days)
type:
  v: boolean
required:
  v: true

link id:
  v: LEGAL_STATUS
text:
  v: Legal Status
type:
  v: choice
required:
  v: true
answer value set:
  v: http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-legal-status-vs
  l: bha-legal-status-vs

link id:
  v: INVOLUNTARY_COMMITMENT_REASON
text:
  v: Involuntary Commitment Reason
type:
  v: choice
enable when:
  question:
    v: LEGAL_STATUS
  operator:
    v: =
  answer: Coding
    system:
      v: http://bha.colorado.gov/fhir/bha-ig/CodeSystem/bha-legal-status
      l: bha-legal-status
    code:
      v: 04
    display:
      v: 72-hour evaluation and treatment
enable when:
  question:
    v: LEGAL_STATUS
  operator:
    v: =
  answer: Coding
    system:
      v: http://bha.colorado.gov/fhir/bha-ig/CodeSystem/bha-legal-status
      l: bha-legal-status
    code:
      v: 05
    display:
      v: Short-term certification
enable when:
  question:
    v: LEGAL_STATUS
  operator:
    v: =
  answer: Coding
    system:
      v: http://bha.colorado.gov/fhir/bha-ig/CodeSystem/bha-legal-status
      l: bha-legal-status
    code:
      v: 06
    display:
      v: Long-term certification
enable when:
  question:
    v: LEGAL_STATUS
  operator:
    v: =
  answer: Coding
    system:
      v: http://bha.colorado.gov/fhir/bha-ig/CodeSystem/bha-legal-status
      l: bha-legal-status
    code:
      v: 09
    display:
      v: Emergency/Involuntary Alcohol/Drug Commitment
enable behavior:
  v: any
answer value set:
  v: http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-involuntary-commitment-reason-vs
  l: bha-involuntary-commitment-reason-vs

link id:
  v: CRIMINAL_JUSTICE_INVOLVEMENT
text:
  v: Criminal Justice Involvement
type:
  v: boolean
required:
  v: false

link id:
  v: EDUCATION_LEVEL
text:
  v: Education Level
type:
  v: choice
required:
  v: true
answer value set:
  v: http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-education-level-vs
  l: bha-education-level-vs

link id:
  v: SCHOOL_ATTENDANCE_STATUS
text:
  v: School Attendance Status (in the previous 3 months)
type:
  v: choice
required:
  v: true
answer value set:
  v: http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-school-attendance-status-vs
  l: bha-school-attendance-status-vs

extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/minValue
    l: minValue
  value: Integer
    v: 0
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/maxValue
    l: maxValue
  value: Integer
    v: 99
link id:
  v: PSYCHIATRIC_ER_VISIT_6_MONTHS
text:
  v: Visit to Psychiatric ER in last 6 months
type:
  v: integer
required:
  v: true

link id:
  v: COMMUNICATION_ACCOMMODATIONS
text:
  v: Communication Accommodations
type:
  v: boolean
required:
  v: false

extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource
    l: questionnaire-referenceResource
  value: Code
    v: EpisodeOfCare
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-referenceProfile
    l: questionnaire-referenceProfile
  value: Canonical
    v: http://bha.colorado.gov/fhir/bha-ig/StructureDefinition/bha-episodeOfCare
    l: bha-episodeOfCare
link id:
  v: episodeOfCare
text:
  v: Episode of Care Information
type:
  v: reference
required:
  v: true
repeats:
  v: true

extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource
    l: questionnaire-referenceResource
  value: Code
    v: Condition
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/questionnaire-referenceProfile
    l: questionnaire-referenceProfile
  value: Canonical
    v: http://bha.colorado.gov/fhir/bha-ig/StructureDefinition/BHAEpisodeDiagnosis
    l: BHAEpisodeDiagnosis
link id:
  v: diagnosis
text:
  v: Diagnosis Information
type:
  v: reference
required:
  v: true
repeats:
  v: true