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Appendix D: Client Tx Forms

Last modified: 1/17/2014 8:45 AM

 

 

Tab D-1​ Capacity Report Form
​Tab D-2 Forms Primarily Used for Client entry, referral, and transfer
DADS Referral for Service
DADS Referral for Service- Guide:
WTT Reassessment
Continuum of Care Referral Summary
Psychiatric Referral Client Information
VHP Confidential Patient Information Form
VHP Gateway Referral Form
Authorization for the Release of Confidential
Auth - 2-Party for the Release of Confidential Client Info
Auth - 2-Party for the Release of Confidential Client Info-Span
Auth - 2-Party for the Release of Confidential Client Info-Viet
Auth-Systems - for the Release of Confidential Client Info
Auth-Systems - for the Release of Confidential Client Info-Span
Auth-Systems - for the Release of Confidential Client Info-Viet
Auth-CJS DADS
Auth-CJS DADS-Span
Auth-CJS DADS-Viet
Auth-BASN CJS DADS
Auth-Dependency Court
Auth-Moorpark Care Team
​THU
THU Advisement Form DA cert.
THU Advisement Form DA cert -Span
THU Advisement Form DA cert -Viet
THU Client Disposition Form
THU Exit Plan
THU Request for Extension
UNI/Care
UNI/Care Annual Update
UNI/Care CalOMS Admission Form
UNI/Care CalOMS Admission Form Data Definitions
UNI/Care CalOMS Discharge Summary
UNI/Care CalOMS Discharge Data Definition
UNI/Care CalOMS CFCS_DETOX Admit Form
UNI/Care CalOMS CFCS_DETOX Discharge
UNI/Care CalOMS Registration Form
UNI/Care CalOMS Registration Form Data Definitions
UNI/Care SRD (Services Rendered) Form
UNI/Care SRD Form Data Definitions
UNI/Care THU Admission/Discharge Form
DADS UNI/Care Username Request Form
UNI/Care Oath of Confidentiality
UNI/Care User Responsibility Statement Instructions
Tab D-3​ ​ Forms Primarily Used for Client Treatment​
Clinical Protocol: Threats of Violence
Clinical Protocol: Suicide Potential
Unamenable/Ineligible/Suspended Client Report Form
Continuum of Care Referral Summary
ORS/SRS Forms
Progress Notes
Progress Form Psycho-Ed (Structured- Discovery Group)
Request for Residential Extension Form
Treatment Assessment
Treatment Assessment – Spanish
Treatment Assessment – Viet
Treatment Assessment Codes
Treatment Plan Form - Counselor Version-Viet
Treatment Status Report (TSR)
Tab D-4 Forms Primarily used for “Reporting” Purposes
Accident/Incident Report-Contract Agency
Accident/Incident Report-County Agency
Detox Status Report Form
Detox Status Report Dropdown Guide
Gateway Status Report Form
Patient Death Report
System Feedback Form
Temporary Agency Closures
Temporary Closure Form
THU Client Status Report (CSR)
THU Exit Plan
Treatment Status Report (TSR)
Unamenable-Suspended-Ineligible Dropdown Guide
Unamenable/Ineligible/Suspended Client Report Form
Unusual Incident/Injury/Death Report
Tab D-5 Forms related to client outcomes measurement
ORS Form
SRS Form
Tab D-6 Forms: Continuous Recovery Monitoring (CRM)
CRM Client Consent
CRM Call Record (paper)
CRM Call Record (fillable)
CRM Call Record (Excel Spreadsheet)
CRM Immediate Needs Profile
CRM Discharge/Referral to Tx Form (fillable only)
CRM Discharge/Referral to Tx Form Dropdown Menu
CRM E-mail Consent
Template Forms Available
​COC Template ​Apr 2011
​Detox Status Report Form Template
​Gateway Status Report
​Feedback Form Template Apr 2011 (New)​
​Psych Referral Template
​Suicide Protocol Template
​Temporary Closure Template Apr 2011​
​Threat of Violence Protocol Template
​TSR Template updated Apr 2011​
​Unamenable-Suspended-Ineligible Template
​VHP GW Referral Template
​WTT Template Apr 2011​