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Day Program Admission
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REGISTRATION FORM
General Consent Form
Transportation Request Form
General Consent Form
Refer a Client
Consent Form
General Consent Form(Part-1)
General Consent Form(Part-1)
General Consent Form(Part-1)
General Consent Form(Part-1)
General Consent Form(Part-1)
General Consent Form(Part-1)
General Consent Form(Part-1)
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General Consent Form(Part-1)
Contact Us
Inquiries
Behavioral Health Treatment and Supportive Services
Report type
*
Admission Summary
Bi-Monthly Report
Semi-Annual Report (June/December)
Other
Client's first name
*
Client's last name
*
Age
*
HE. P.ID
*
Admission / EOC date
*
Service request date
*
Providers / clinician / triage team members
*
Client chart code
Service period (from)
Service period (to)
Type of service
*
Diagnosis code
*
Modality
Theory
Intervention
Prior Auth. ID
DMES Auth. ID
Auth. date
Satisfaction survey – client
*
Yes
No
Pending
Satisfaction survey – parent / guardian
*
Yes
No
Pending
Safety plan attached
*
Yes
No
Not Needed
Type of discharge
*
Successful
Unsuccessful
Administrative
Level of care at discharge
*
Higher level of care
Lower level of care
Same level of care
Percent of goals met on the treatment plan at discharge
Agency representative completing clinical service review
*
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