CLINICAL FORMS

 

 

AHCCCS COVERAGE LETTERS

60 day Letter for all clients

30 day Letter for all clients

AHCCCS expired GMH/SA

AHCCCS expired SMI

Financial Screening Letter

 

CASE MANAGEMENT FORMS

Acronym List

AHCCCS Application Checklist

ART Participation Sheet

 

Assessment and Service Plan

Annual Behavioral Health Update and Review Summary

Behavioral Health Service Plan 

Behavioral Health Service Plan Review of Progress

CORE Intake and Assesment and Service Plan (Spanish)

DD/BH Emergency Info & Crisis Plan (PL 3.8.5)

Pain Assessment

Special Assistance (5.4.1)

Special Suicide Risk-assessment Addendum (Protocol)

 

CLIENT TRANSFER/DISCHARGE FORMS

Internal Transfer:

Change-request Form

Provider Transfer:

Client Transfer Application

Client Transfer Tracking Log

Closure Forms: Click here for closure forms

Member Transfer Cover Sheet (CPSA 3.17.1)

 

 

COT (Title-36)

ASH Affidavit

Court Ordered Treatment Plan (3.18.1) [revision procedure]

SMI NTXIX Court Ordered Treatment Plan (3.18.1B)

Non-emergency petition

Emergency petition

PAD rollover

GD rollover

Confirmation of Receipt (3.18.13)

Judicial Review

Revocation/Suspension(CPSA PM Form 3.18.3)

Law Enforcement Committal Information Form (PM 3.18.2)

Title 36 Process –Petitioned Clients

Title-36 Hearing Preparation Documents

Discharge/Transfer Summary

 

 

DBT TOOLS

DBT Chain Analysis of Problem Behavior

DBT Diary Card

DBT-program Referral

DBT Program - When & How to Call Your Therapist

Therapy Agreement

 

DOMESTIC VIOLENCE

Certificate of Completion:

101 South Stone (26/39, 36/54, 52/78)

1501 W. Commerce Court (26/39, 36/54, 52/78)

Addendum to Assessment

Client Conduct

Client Face Sheet

Client Status Report

Check list for Referral Packet

Consent to Treat

Court Notification Requirements

Discharge/Transfer Summary

Discharge/Transfer Summary Domestic Violence

Domestic Violence Referral Form

Facesheet

 

 

EMPLOYMENT SERVICES

Employment Assessment

Employment Services Referral Form

 

FINANCIAL FORMS

Client Acknowledgement of Receipt of Policy #3042 (Spanish)

 

FLEX FUNDS

Request for Flex Funds

 

FREE PROGRAM

FREE Program Let's Go Evaluation

FREE Program Client Monthly Assessment

FREE Consent for Treatment

FREE Registration and Certification of Eligibility

FREE Program Satifaction Survey

Substance Abuse Questionnaire

 

HIPAA/RELEASE OF INFORMATION

ADHS Notice of Privacy Practices

Auth for Use/Discl of Protected Health Info (VM) (Spanish)

Auth for Use/Discl of SA or HIV Info (VM) (Spanish)

COPE Notice of Privacy Practices (Spanish)

CPSA HIPAA Notice of Privacy Practices (Spanish)

Request to Amend Protected Health Information

 

HOUSING FORMS

Boarding-home Resident Assessment (protocol)

Notes/Application Status

 

INTAKE FORMS

Click here for Intake forms

 

IRT PROGRAM

Intensive Recovery Team Referral (protocol)

 

MEDICAL SERVICES

Abnormal Involuntary Movement Scale (AIMS)

BHMP Appointment Intervals

Coordination of Care with PCP

ECG/EKG Referral

ECT Pay-code Submission

ICD-9 Codes(diagnostic codes sorted alphabetically)

ICD-9 Codes (diagnostic codes sorted numerically)

Informed-consent memo

Informed-consent guidelines

Informed-consent form (Spanish)

Pharmacy: CPSA Pharmacy Net (pharmacy list)

 

NOTICES

Notice of Action Templates (link to Provider Manual)

Notification of Decision & Right to Appeal (SMI only)(Spanish)

Notice of Grievance and Appeal Procedure (Spanish)

 

OPIOID TREATMENT: BUPRENORPHINE/SUBOXONE

Buprenorphine/Suboxone Program Rules

Buprenorphine/Suboxone Services Information Shee

Cardiac Disclaimer

Central Registry Disclosure (Spanish)

Client Medication History

Courtesy Dosing

Informed Consent for Buprenorphine/Suboxone

Instant Urine Pregnancy Test

Opioid Treatment Record of Vitals

Subjective Opiate Withdrawal Scale

 

OPIOID TREATMENT: METHADONE

ASAM Admittance Screen

Cardiac Disclaimer

Central Registry Disclosure (Spanish)

Chain-of-custody Record - Clt in Residential Tx

Chain-of-custody Record - Incarcerated Client

Client Medication History

Client Service Form

Clinic Program Rules

Consent for Follow-up Contact (Spanish)

Consent for Methadone Treatment(Spanish)

Courtesy Dosing

DSM-IV Criteria

Fee-for Service agreement

Health History and Phys Assessment

Impaired Client Assessment Form

Instant Urine Pregnancy Test

Medical Compliance Form

Medical Screening for Pregnant Clients

Medication Informed Consent Form

Medication Management Flow-sheet

Medication PRN Log

Medication Withdrawal Form (AMA) [Spanish]

Medication Withdrawal Form (Medically supervised) [Sp]

Nine-point Evaluation of Client Responsibility

Opioid Treatment Client Follow-up Form

Opioid Treatment Orientation Form(Spanish)

Opioid Treatment Utilization Review

Program Admission Checklist

PCP Notification (see HMS)

PCP Request for Information

PPD Mantoux Test (TB skin test)

Pregnancy Protocol Audit

Pregnancy Protocol Requirements

Prenatal-care Recommendations (Spanish)

Referral Information Form

Take-home Privileges

Take-home Transition Record (Spanish)

Transition Plan for Follow-Up Services (Spanish)

UA Results

 

PCP

PCP Notification (see HMS) (Addendum [opioid tx only])

PCP Request for Information

 

PRIMARY CARE SERVICES

Consent for Medical and Surgical Procedures

Facesheet

Glucometer Test Log

Infection Control: Staff/Client Infection Report

Injectable Medication Storage Log

Intake Medical History

Medical History

Medication Disposal Record

Medical Abbrevation List

Medical Equipment Log

Monthly Medication Inspection Log

Needle-Stick Incident Log

Pain Assesment

Patient Information Sheet

Patient Rights

Patient Responsibilities

Temperature Log

 

REFERRALS

Care Management Initial Case Review (Care Management Referral)

Counseling Referral Information

Day Program Referral Form

DBT-program Referral

Ocotillo

Transitional Paperwork Checklist

 

RESIDENTIAL

Acknowledgement of Receipt of Co-Pay/Refund Policy

Assesment Addenda

Client Medication History

Client Self-administration Medication Form

Consent for Security-box Access

Controlled-medication Log

Diabetic Tracking Record

Discharge/Transfer Summary

Final Level-II Chart Audit Tool

Injectable Medication Form

Level-II 3rd-shift Observation

Level-II Cleaning Checklist

Level-II Nursing Review

Level-II Residential Utilization Review

Level-II Service Note

Living Skills Assessment

Medical Information Sheet

Medication Protocols

Nursing Service Note

OTC Medications Order

Personal-property Inventory

PPD Mantoux Test (TB skin test)

PRN Medication Log (Not Controlled)

Residential Counseling form (fill-in version)

Residential/OPS Client Add/Change Form

Residential/OPS Consent for treatment

Residential/OPS Interdisciplinary Staffing Note

Residential/OPS Weekly Progress Note

Residential Orientation Schedule of Fees

Scheduled-medication Record

Self-administration of Medication Record

Support-services Progress Note

Weekly Support Services

 

Ocotillo Transitional Services

Discharge/Transfer Summary

Ocotillo Admission Packet

Ocotillo Discharge Room & Board Invoice

Ocotillo Graveyard Cleaning/Task Checklist

Ocotillo Referral Form

Ocotillo Treatment Plan

Ocotillo On-call Contact Information Sheet

PPD Mantoux Test (TB skin test)

Post-intake Checklist

Pre-screening Tool for Ocotillo Admissions

Transitional Paperwork Checklist

 

 

SMI FORMS

ADHS/DBHS Appeal or SMI Grievance (5.3.1)

ADHS/DBHS Appeal or SMI Grievance (Spanish)

CPSA PM Form 3.10.3 Waiver of 3-day SMI Eligibility Determination

SMI Determination

Notification of SMI Determination CPSA PM Form 7.5.4 (spanish)

Sign in sheet

 

SOL PROGRAM

Behavioral Health Service Plan 

Consent for Treatment - SOL

Discharge/Transfer Summary

 

SUPPORT SERVICE AGENCIES (SSA)

Support Service Agency Flowchart

Support Service Agency Information

Support Service Agency Provider List

Support Service Agency Referral Checklist

Support Service Agency Referral Protocol

 

 

THERAPY

Individual Therapy Consent for Treatment

Therapy Agreement (this form is now available on HMS)

 

THERAPEUTIC DAY PROGRAM

Consent for Treatment Form

Day Program Referral Form

Day Program Utilization R 

Therapeutic Day Program Check List

Therapeutic Day Program Rules

 

 

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