Client Placement Forms and Procedures

The Division of Substance Abuse and Mental Health has provided the following list of Client Placement Forms & Procedures:

Involuntary Inpatient Admission Forms

•  24 Hour Emergency Admission Form  (Uploaded June 10, 2010)
  To be used for 24 hour commitments and must be completed prior to presenting to the admitting physician.
•  Civil Commitment Form (Added April 16, 2007)
  The Civil Commitment is to be completed only by a psychiatrist and may be used to hospitalize a person who is deemed to be a threat to himself, others or property or to hospitalize a person who is unable to make responsible decisions about his or her treatment and care.  Text - Civil Commit Form 
•  Non-amenability Form (Uploaded December 10, 2009)
  To be used by a psychiatrist in the event of determining an individual's non-amenability to outpatient treatment.

CRF Forms

•  2011 CRF Changes   (Uploaded April 18, 2011)
  Several modifications to the CRF field data will go into effect July 1, 2011. These modifications are currently being finalized by the dedicated  DSAMH staff. Please click the link above to review the Uploaded specifications.
•  Annual Consumer Reporting Form (CRF)   (Uploaded July 27, 2011)
  The Annual CRF form is completed for DSAMH Community Mental Health (CMH) clients annually based on the anniversary date of their admission to the program. Paper copies are submitted to the DSAMH MIS unit monthly for entry into the database. This information is critical since it provides information about client progress in long term programs and is used in the National Outcome Measurement System (NOMS) reported annually to the federal government.
•  Annual Consumer Reporting Form (CRF) Coding Manual  (Uploaded July 27, 2011)
  Coding Manual specific to the Annual Consumer Reporting Form.
•  Consumer Reporting Form (CRF) Admissions  (Uploaded July 27, 2011)
  The Consumer Reporting Form ( CRF) is a data collection tool that provides information about clients in DSAMH-funded programs. This form is used at admission to the treatment unit. Mental health programs use the five axis  DSM-IV diagnosis form in addition to the two page admission and the two page discharge forms. By using the CRF to obtain demographic and background information on clients, DSAMH can better understand the clients who utilize its services. DSAMH also uses the CRF form to assess its success in treating community and inpatient populations.  Text - CRF .
•  Consumer Reporting Form (CRF) Discharge   (Uploaded July 27, 2011)
  This form is used during discharge from the treatment unit.
•  Consumer Reporting Form (CRF) Detox Discharge   (Uploaded July 27, 2011)
  The Detox Discharge form is the Consumer Reporting Form (CRF) used by the detox program under contract to DSAMH. The Detox Discharge form is truncated from the regular CRF discharge form because many of the data items normally collected on a CRF discharge haven't changed during the short intervention provided by the Detox Program under contract to DSAMH.
•  Consumer Reporting Form (CRF) Hospital Discharge   (Uploaded July 27, 2011)
  The Hospital Discharge form is the Consumer Reporting Form (CRF) used by the private Inpatient Facilities (Psychiatric Hospitals) under contract to DSAMH. The Hospital Discharge form is truncated from the regular CRF discharge form because many of the data items normally collected on a CRF discharge haven't changed during the short intervention provided by the Inpatient Facilities (Psychiatric Hospitals) under contract to DSAMH.
•  Consumer Reporting Form (CRF) Diagnosis   (Uploaded August 10, 2006)
  This form is used during admission and discharge to and from the Mental Health treatment unit.  Text - CRF Diagnosis .
•  Intra-agency Transfer Form (Uploaded February 2, 2002)
  Use this form for transferring individuals between DSAMH treatment units.  Text - Intragency Transfer 
•  Consumer Reporting Form Training Manual (Uploaded November 18, 2011)  Text - CRF Insructions  
•   CRF Specifications and Programmer Documentation (Uploaded November 18, 2011)
  
•  Referral Agency List (Uploaded January 04, 2012)
  This list provides the current agency codes to be used on Consumer Reporting Forms

EEU Forms and Procedures

 Eligibility and Enrollment Unit Procedures 

•  Authorization for Release of Confidential Information  (Uploaded May 15, 2006)  Text - Authorization  
•  Eligibility and Enrollment Unit Enrollment Application   (Uploaded January 5, 2012)
  This form is to be completed for those enrolling in the Eligibility and Enrollment Unit. Text - EEU App.  
•  Eligibility and Enrollment Unit Enrollment Application (Old)   (Uploaded January 5, 2012)
  This form can be used for those enrolling in the Eligibility and Enrollment Unit until 06/30/2012. Text - EEU App.(Old)  
•  Initial Psychiatric Screening Information Form  (Uploaded May 15, 2006)
  This form is to be completed, signed, and dated on all patients who are being referred for psychiatric commitment and disposition. Text - Screening Form 
•  Annual Re-Determination Application  (Uploaded January 5, 2012)This form is to be used for client annual redetermination.  Text - Redetermination App.  
•  Long Term Care Program (LTC) Recertification Form  (Uploaded May 15, 2006)  Text - LTC Form 
•  Procedures for enrollment to the EEU.  (Uploaded May 15, 2006) (Site Link)

Certification Forms

•  Mental Health Community Support Program Certification Form (Added June 21, 2003)  Text - MH CSP Cert Form 
•  Substance Abuse Community Support Program Certification Form (Added June 21, 2003)  Text - SA CSP Cert Form 
•  Community Support Program Recertification Form (Added June 21, 2003)  Text - CSP Recert Form 

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