<?xml version="1.0"?>
<!-- Sample Func1_1_Consumer_DLAandCPSStatusReport -->
<PreEncounter>
	<SenderData BatchNumber="20151202" ProviderETIN="xxxxxxxx" ProviderName="xxxxx"/>
	<DocumentFunction DocumentFunction="1" DocumentNumber="20151202_1">
		<ConsumerData>
			<Name FirstName="xxxxxx" LastName="xxxxx"/>
			<Demographics Occupation="19" EmploymentStatus="2" MaritalStatus="1" PreferredLanguage="164" HearingStatus="144" SSN="xxx-xx-xxxx" DateOfBirth="1800-01-01" Gender="01"/>
			<Address Country="US" Zip="xxxxx" County="xxx" State="MO" City="xxxxx" Street1="xxxxx xxxxx"/>
			<Race OtherHispanic="0" Hispanic_PuertoRican="0" Hispanic_Cuban="0" Hispanic_Mexican="0" NotOfHispanicOrigin="1" OtherRace="0" AmIndian_NativeAlaskan="0" NativeHawiian_PacificIslander="0" Asian="0" Black_AfricanAmerican="0" White="1"/>
			<StandardMeansTest PreparedBy="xxxxxxx" MonthlyAbilityToPayAmt="0.00" FromDate="2015-11-01"/>
		</ConsumerData>
		<EpisodeCare NumberOfChildrenInCare="0" FamilySize="1" LocalChartNumber="xxxxxxxxxx" ReferralSource="19" AdmissionReason="1" AdmissionDateTime="2015-11-16 00:00" EnrollingProviderSiteID="xxx" EnrollingProviderSiteName="xxxxx" Division="ADA">
			<Commitments PrimaryIndicator="1" CommitmentCounty="183" CommitmentFromDate="2015-11-16" CommitmentType="200"/>
			<Assessments>
				<AssessmentDLA RaterFirstName="xxxxx" RaterLastName="xxxx" AssessmentDate="2015-11-16" AssessmentDLAType="AD">
					<AssessmentDLAAnswer Question="1" Score="2"/>
					<AssessmentDLAAnswer Question="2" Score="2"/>
					<AssessmentDLAAnswer Question="3" Score="2"/>
					<AssessmentDLAAnswer Question="4" Score="2"/>
					<AssessmentDLAAnswer Question="5" Score="2"/>
					<AssessmentDLAAnswer Question="6" Score="2"/>
					<AssessmentDLAAnswer Question="7" Score="2"/>
					<AssessmentDLAAnswer Question="8" Score="2"/>
					<AssessmentDLAAnswer Question="9" Score="2"/>
					<AssessmentDLAAnswer Question="10" Score="2"/>
					<AssessmentDLAAnswer Question="11" Score="2"/>
					<AssessmentDLAAnswer Question="12" Score="2"/>
					<AssessmentDLAAnswer Question="13" Score="2"/>
					<AssessmentDLAAnswer Question="14" Score="2"/>
					<AssessmentDLAAnswer Question="15" Score="2"/>
					<AssessmentDLAAnswer Question="16" Score="2"/>
					<AssessmentDLAAnswer Question="17" Score="2"/>
					<AssessmentDLAAnswer Question="18" Score="2"/>
					<AssessmentDLAAnswer Question="19" Score="2"/>
					<AssessmentDLAAnswer Question="20" Score="2"/>
				</AssessmentDLA>
				<AssessmentCPSStatusReport ReportingDate="2015-11-16" ModifiedGAFScore="10" CPSAssessmentType="ADMIT" CPSResidentialStatus="RESCARE" CPSEducationAttendanceStatus="UNKN" CPSEducationLevel="GRAD" CPSEmploymentStatus="PART" PartTimeEstWeeklyHours="10" NumberOfArrestsLast30Days="00" TobaccoUse="0" MoreThanStandardDrinks="0" DrinkingMoreThanMeant="2" DrinkingThinkShouldCutBack="0" DrugUsage="0"/>
			</Assessments>
		</EpisodeCare>
	</DocumentFunction>
</PreEncounter>
