Client Placement Forms and Procedures
The Division of Substance Abuse and Mental Health has provided the following list of ClientPlacement Forms & Procedures:
Emergency Detention and Provisional Admission Forms
- 24 Hour Emergency DetentionForm (Updated November 1, 2014)
To be used for 24-hour emergency detention. Detainment shall not exceed 24 hours after transfer to adesignated psychiatric facility.
- Initial BehavioralHealth Assessment Form (Added May 16, 2013)
- Psychiatrists' Certificate forProvisional Hospitalization (Civil Commitment Form) (Updated October 13, 2014)
The Civil Commitment is to be completed only by a psychiatrist and may be used to hospitalize a personwho is unable or unwilling to consent to voluntary treatment, is deemed to be a threat to himself, othersor property or who is unable to make responsible decisions about his or her treatment and care. To beused by a psychiatrist in the event of determining an individual's non-amenability to outpatient treatment.
- Transportation ReimbursementForm (Uploaded April 26, 2013)
To be used by law enforcement agencies requesting reimbursement for transfer of a client to a designatedpsychiatric facility. This is the only form that will be accepted after June 30, 2013.
Consumer Reporting Forms
- Community and HospitalCoordinated Care Form (Uploaded December 12, 2013)
To enhance care coordination, as part of ongoing quality improvement, this form is mandatory for allinteractions with client receiving inpatient care at DPC. Community Service Providers must complete andsign this form and submit to Admissions upon signing out.
- 2011 CRF Changes (Uploaded April18, 2011)
Several modifications to the CRF field data will go into effect July 1, 2011. These modifications arecurrently being finalized by the dedicated DSAMH staff. Please click the link above to reviewthe Uploaded specifications.
- Annual Consumer Reporting Form (CRF) (Uploaded September 28, 2015)
The Annual CRF form is completed for DSAMH Community Mental Health (CMH) clients annually based on theanniversary date of their admission to the program. Paper copies are submitted to the DSAMH MIS unit monthlyfor entry into the database. This information is critical since it provides information about client progressin long term programs and is used in the National Outcome Measurement System (NOMS) reported annuallyto 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 (UploadedSeptember 28, 2015)
The Consumer Reporting Form (CRF) is a data collection tool that provides information about clients inDSAMH-funded programs. This form is used at admission to the treatment unit. Mental health programs useDSM-5 diagnosis form in addition to the two page admission and the two page discharge forms. By usingthe CRF to obtain demographic and background information on clients, DSAMH can better understand the clientswho utilize its services. DSAMH also uses the CRF form to assess its success in treating community andinpatient populations.
- Consumer Reporting Form (CRF) Discharge (Uploaded September 28, 2015)
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 contractto DSAMH. The Detox Discharge form is truncated from the regular CRF discharge form because many of thedata items normally collected on a CRF discharge haven't changed during the short intervention providedby the Detox Program under contract to DSAMH.
- Consumer Reporting Form (CRF) HospitalDischarge (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 regularCRF discharge form because many of the data items normally collected on a CRF discharge haven't changedduring the short intervention provided by the Inpatient Facilities (Psychiatric Hospitals) under contractto DSAMH.
- Consumer Reporting Form (CRF)Diagnosis (Uploaded September 28, 2015)
This form is used during admission and discharge to and from the Mental Health treatment unit.
- Intra-agency Transfer Form (UploadedFebruary 2, 2002)
Use this form for transferring individuals between DSAMH treatment units. Text - Intragency Transfer
- Consumer Reporting Form Training Manual (UploadedApril 28, 2013)
- CRF Specifications and Programmer Documentation (UploadedDecember 14, 2015)
- Referral Agency List (UploadedJuly 7, 2016)
Form for reporting critical incidents
- Critical Incident Reporting Form (UploadedFebruary 19, 2016)
This list provides the current agency codes to be used on Consumer Reporting Forms
EEU Forms and Procedures
- Authorization for Release of ConfidentialInformation (Uploaded October 31, 2013)
- Eligibility and Enrollment Unit Enrollment Application (UploadedOctober 28, 2015)
This form is to be completed for those enrolling in the Eligibility and Enrollment Unit
- Initial Psychiatric Screening InformationForm (Uploaded May 15, 2006)
This form is to be completed, signed, and dated on all patients who are being referred for psychiatriccommitment and disposition. Text - Screening Form
- Annual Re-Determination Application (UploadedJanuary 5, 2012)This form is to be used for client annual redetermination. Text - Redetermination App.
- Long Term Care Program (LTC) RecertificationForm (Uploaded May 15, 2006) Text - LTC Form
- Procedures for enrollment to the EEU. (UploadedMay 15, 2006) (Site Link)
- Mental Health Community Support Program CertificationForm (Added June 21, 2003) Text - MH CSP CertForm
- Substance Abuse Community Support Program CertificationForm (Added June 21, 2003) Text - SA CSP CertForm
- Community Support Program Recertification Form (AddedJune 21, 2003) Text - CSP Recert Form
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