Maine DHHS - Questionnaire - Long-Term Supported Employment (LTSE) Clinical

Status: Incomplete

1. Employer:

2. Employer Type:

(Please select one.)

3. Client's Position:

4. What is the client hourly wage?

5. LOCUS Composite Score:

6. Date LOCUS Completed:


7. Is this a competitive employment position as defined by Maine OAMHS MH- LTSE Policy?

(Please select one.)

8. How long has your client been working at this position?

9. Does your client have plans to change jobs?

(Please select one.)

10. Is client receiving any job development support in addition to MH-LTSE?

(Please select one.)

11. What are the material and substantial duties of this client’s job?

12. What does LTSE support do to help this client?

13. How many hours a month is the client working?

14. How many hours of MH-LTSE job support are you providing client per week?

15. Does the amount of LTSE support equate to more than 25% of the client’s actual work hours?

(Please select one.)

Disclaimers (please check to confirm acceptance):