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Appendix D: Client Treatment Forms

Last modified: 10/23/2015 11:37 AM



​Tab D-1 Capacity​​
YSOC Waitlist​ ​
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Tab D-2 Forms primarily used for client entry, referral, and transfer
CALOMS for 18 yrs or Older
Client Rights and Consent for Treatment
Health Screen Questionnaire (HSQ)
Notice of Grievance Procedure of Clients
Notice of Title 22 Fair Hearing Rights
Santa Clara County Juvenile Justice System Referral
YSOC Referral for Services
Authorization for the Release of Confidential
Authorization for the Release of Confidential
HHS privacy Notice Practices Acknowledgement of Receipt
System Authorization for the Release of Confidential
Adolescent Residential Treatment Services (ARTS) – Cover Page
Adolescent Residential Treatment Services (ARTS) – Referral Form
UNI/Care Administrative Discharge​
UNI/Care Annual Update
UNI/Care Annual Update for 18 years of Age or Older
UNI/Care CFCS DETOX CALOMS Admit Questionnaire
UNI/Care CFCS Client Registration Form
UNI/Care CFCS DETOX CALOMS Discharge Questionnaire
UNI/Care Discharge Summary for 18 years of Age or Older
UNI/Care SRD (Services Rendered) Form (colored)
UNI/Care SRD (Services Rendered) Form (non-colored)
Tab D-3 Forms Primarily Used For Client Treatment
CFCS CALOMS Annual Update
Annual Update: for 18 years of Age or Older
​​Clinical Protocol:  Suicide Potential Rating Scale
Discharge Summary and Continuing Care Plan
Progress Note
Safety Plan Quick Guidelines
Suicide Prevention Planning
Suicide Prevention Planning Guidelines
YSOC Adolescent ASAM Treatment Assessment (ASAM)
Treatment Plan
Treatment Status Report (TSR)
Tab D-4 Forms Primarily used for “Reporting’ Purposes
Agency Incident Report Form
Tab D-5 Forms related to client outcomes measurement
Tab D-6 Forms:  Seven Challenges
Seven Challenges
Seven Challenges Collaboration System Authorization
Seven Challenges Journal Authorization
Seven Challenges Journal Disposition Policy
Seven Challenges Continuing Care – Counselor Summary
Seven Challenges Moving On to Challenges
The Seven Challenges Youth Survey
Support Commitment Letter