# BHA Admission Questionnaire - Colorado BHA FHIR Implementation Guide v0.1.0-current

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **BHA Admission Questionnaire**

## Questionnaire: BHA Admission Questionnaire 

| | | |
| :--- | :--- | :--- |
| *Official URL*:http://bha.colorado.gov/fhir/bha-ig/Questionnaire/BHAAdmissionQuestionnaire | *Version*:0.1.0-current | |
| * Standards status: *[Trial-use](http://hl7.org/fhir/R4/versions.html#std-process) | [Maturity Level](maturity.md): 0 | *Computable Name*:BHAAdmissionQuestionnaire |

 
Questionnaire used during admission process to collect demographic, social, clinical, and administrative information from patients entering behavioral health services 

### Example Questionnaire Responses

* [example BHA Admission Questionnaire Response](QuestionnaireResponse-BHAAdmissionQuestionnaireResponseExample.md)



## Resource Content

```json
{
  "resourceType" : "Questionnaire",
  "id" : "BHAAdmissionQuestionnaire",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire|3.0.0"]
  },
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
    "valueInteger" : 0,
    "_valueInteger" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical" : "http://bha.colorado.gov/fhir/bha-ig/ImplementationGuide/bha-ig"
      }]
    }
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "valueCode" : "trial-use",
    "_valueCode" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical" : "http://bha.colorado.gov/fhir/bha-ig/ImplementationGuide/bha-ig"
      }]
    }
  }],
  "url" : "http://bha.colorado.gov/fhir/bha-ig/Questionnaire/BHAAdmissionQuestionnaire",
  "version" : "0.1.0-current",
  "name" : "BHAAdmissionQuestionnaire",
  "title" : "BHA Admission Questionnaire",
  "status" : "active",
  "subjectType" : ["Patient"],
  "date" : "2025-12-13",
  "publisher" : "Colorado Behavioral Health Administration",
  "contact" : [{
    "name" : "Colorado Behavioral Health Administration",
    "telecom" : [{
      "system" : "url",
      "value" : "https://bha.colorado.gov"
    },
    {
      "system" : "email",
      "value" : "FHIRFeedback@state.co.us"
    }]
  }],
  "description" : "Questionnaire used during admission process to collect demographic, social, clinical, and administrative information from patients entering behavioral health services",
  "jurisdiction" : [{
    "coding" : [{
      "system" : "http://unstats.un.org/unsd/methods/m49/m49.htm",
      "code" : "840"
    }]
  }],
  "item" : [{
    "linkId" : "FIRST_CONTACT_DATE",
    "text" : "Date of First Contact",
    "type" : "date",
    "required" : true
  },
  {
    "linkId" : "FIRST_APPOINTMENT_OFFERED_DATE",
    "text" : "Date of First Appointment Offered",
    "type" : "date",
    "required" : true
  },
  {
    "linkId" : "MEDICATION_ASSISTED_OPIOID_THERAPY",
    "text" : "Medication Assisted Opioid Therapy",
    "type" : "boolean",
    "required" : true
  },
  {
    "linkId" : "REFERRAL_SOURCE",
    "text" : "Referral Source",
    "type" : "choice",
    "required" : true,
    "answerValueSet" : "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-referral-source-vs"
  },
  {
    "extension" : [{
      "url" : "http://hl7.org/fhir/StructureDefinition/minValue",
      "valueInteger" : 0
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/maxValue",
      "valueInteger" : 30
    }],
    "linkId" : "ARRESTS_PAST_30_DAYS",
    "text" : "Arrests in Past 30 Days",
    "type" : "integer",
    "required" : true
  },
  {
    "linkId" : "EMPLOYMENT_STATUS",
    "text" : "Employment Status",
    "type" : "choice",
    "required" : true,
    "answerValueSet" : "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-employment-status-vs"
  },
  {
    "linkId" : "MARITAL_STATUS",
    "text" : "Marital Status",
    "type" : "choice",
    "required" : true,
    "answerValueSet" : "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-marital-status-vs"
  },
  {
    "linkId" : "LIVING_SITUATION",
    "text" : "Living Situation",
    "type" : "choice",
    "required" : true,
    "answerValueSet" : "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-living-situation-vs"
  },
  {
    "extension" : [{
      "url" : "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
      "valueCoding" : {
        "system" : "urn:iso:std:iso:4217",
        "code" : "USD"
      }
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/minValue",
      "valueDecimal" : 0
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/maxValue",
      "valueDecimal" : 9999
    }],
    "linkId" : "MONTHLY_INCOME",
    "text" : "Monthly Income",
    "type" : "decimal",
    "required" : false
  },
  {
    "linkId" : "PRIMARY_INCOME_SOURCE",
    "text" : "Primary Source of income/support for client (or for client's parent if client >18 years of age)",
    "type" : "choice",
    "required" : true,
    "answerValueSet" : "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-income-source-vs"
  },
  {
    "linkId" : "PREGNANCY_STATUS",
    "text" : "Pregnancy Status",
    "type" : "boolean",
    "required" : true
  },
  {
    "linkId" : "WITHIN_1_YEAR_POSTPARTUM_STATUS",
    "text" : "Within 1 Year Postpartum Status",
    "type" : "boolean",
    "required" : true
  },
  {
    "linkId" : "SPECIAL_CONNECTIONS_ENROLLMENT",
    "text" : "Enrollment in Special Connections",
    "type" : "boolean",
    "required" : true
  },
  {
    "linkId" : "ACT_ENROLLMENT",
    "text" : "Enrollment in ACT?",
    "type" : "boolean",
    "required" : true
  },
  {
    "linkId" : "ASCENT_ENROLLMENT",
    "text" : "Enrollment in Ascent (FEP)?",
    "type" : "boolean",
    "required" : true
  },
  {
    "extension" : [{
      "url" : "http://hl7.org/fhir/StructureDefinition/minValue",
      "valueInteger" : 0
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/maxValue",
      "valueInteger" : 99
    }],
    "linkId" : "NUMBER_DEPENDENT_CHILDREN",
    "text" : "Number of Dependent Children",
    "type" : "integer",
    "required" : true
  },
  {
    "extension" : [{
      "url" : "http://hl7.org/fhir/StructureDefinition/minValue",
      "valueInteger" : 0
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/maxValue",
      "valueInteger" : 30
    }],
    "linkId" : "SELF_HELP_ATTENDANCE",
    "text" : "Self Help Attendance (Last 30 days at admission)/ Peer Support Attendance",
    "type" : "integer",
    "required" : true
  },
  {
    "extension" : [{
      "url" : "http://hl7.org/fhir/StructureDefinition/minValue",
      "valueInteger" : 0
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/maxValue",
      "valueInteger" : 30
    }],
    "linkId" : "TOTAL_SUBSTANCE_USE_PRIOR_TREATMENT",
    "text" : "Substance Use Prior Treatment (Total Lifetime admissions)",
    "type" : "integer",
    "required" : true
  },
  {
    "linkId" : "PSYCHIATRIC_HOSPITAL_ADMISSION",
    "text" : "Psychiatric Hospital Admission (Last 30 days)",
    "type" : "boolean",
    "required" : true
  },
  {
    "linkId" : "LEGAL_STATUS",
    "text" : "Legal Status",
    "type" : "choice",
    "required" : true,
    "answerValueSet" : "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-legal-status-vs"
  },
  {
    "linkId" : "INVOLUNTARY_COMMITMENT_REASON",
    "text" : "Involuntary Commitment Reason",
    "type" : "choice",
    "enableWhen" : [{
      "question" : "LEGAL_STATUS",
      "operator" : "=",
      "answerCoding" : {
        "system" : "http://bha.colorado.gov/fhir/bha-ig/CodeSystem/bha-legal-status",
        "code" : "04",
        "display" : "72-hour evaluation and treatment"
      }
    },
    {
      "question" : "LEGAL_STATUS",
      "operator" : "=",
      "answerCoding" : {
        "system" : "http://bha.colorado.gov/fhir/bha-ig/CodeSystem/bha-legal-status",
        "code" : "05",
        "display" : "Short-term certification"
      }
    },
    {
      "question" : "LEGAL_STATUS",
      "operator" : "=",
      "answerCoding" : {
        "system" : "http://bha.colorado.gov/fhir/bha-ig/CodeSystem/bha-legal-status",
        "code" : "06",
        "display" : "Long-term certification"
      }
    },
    {
      "question" : "LEGAL_STATUS",
      "operator" : "=",
      "answerCoding" : {
        "system" : "http://bha.colorado.gov/fhir/bha-ig/CodeSystem/bha-legal-status",
        "code" : "09",
        "display" : "Emergency/Involuntary Alcohol/Drug Commitment"
      }
    }],
    "enableBehavior" : "any",
    "required" : true,
    "answerValueSet" : "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-involuntary-commitment-reason-vs"
  },
  {
    "linkId" : "CRIMINAL_JUSTICE_INVOLVEMENT",
    "text" : "Criminal Justice Involvement",
    "type" : "boolean",
    "required" : false
  },
  {
    "linkId" : "EDUCATION_LEVEL",
    "text" : "Education Level",
    "type" : "choice",
    "required" : true,
    "answerValueSet" : "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-education-level-vs"
  },
  {
    "linkId" : "SCHOOL_ATTENDANCE_STATUS",
    "text" : "School Attendance Status (in the previous 3 months)",
    "type" : "choice",
    "required" : true,
    "answerValueSet" : "http://bha.colorado.gov/fhir/bha-ig/ValueSet/bha-school-attendance-status-vs"
  },
  {
    "extension" : [{
      "url" : "http://hl7.org/fhir/StructureDefinition/minValue",
      "valueInteger" : 0
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/maxValue",
      "valueInteger" : 99
    }],
    "linkId" : "PSYCHIATRIC_ER_VISIT_6_MONTHS",
    "text" : "Visit to Psychiatric ER in last 6 months",
    "type" : "integer",
    "required" : true
  },
  {
    "linkId" : "COMMUNICATION_ACCOMMODATIONS",
    "text" : "Communication Accommodations",
    "type" : "boolean",
    "required" : false
  }]
}

```
