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Client Placement Forms and Procedures

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

Emergency Detention and Provisional Admission Forms

  • 24 Hour Emergency Detention Form  (Updated August 27, 2013)
    To be used for 24-hour emergency detention. Detainment shall not exceed 24 hours after transfer to a designated psychiatric facility. This is the only form that will be accepted after June 30, 2013.
  • Initial Behavioral Health Assessment Form(Added May 16, 2013)
  • Psychiatrists' Certificate for Provisional Hospitalization (Civil Commitment Form)(Updated October 22, 2013)
    The Civil Commitment is to be completed only by a psychiatrist and may be used to hospitalize a person who is unable or unwilling to consent to voluntary treatment, is deemed to be a threat to himself, others or property or who is unable to make responsible decisions about his or her treatment and care.
  • 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.
  • Transportation Reimbursement Form  (Uploaded April 26, 2013)
    To be used by law enforcement agencies requesting reimbursement for transfer of a client to a designated psychiatric facility. This is the only form that will be accepted after June 30, 2013.

Consumer Reporting Forms

  • NEW Community and Hospital Coordinated Care Form   (Uploaded December 12, 2013)
    To enhance care coordination, as part of ongoing quality improvement, this form is mandatory for all interactions with client receiving inpatient care at DPC. Community Service Providers must complete and sign this form and submit to Admissions upon signing out.
  • 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 DSM-5 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 October 8, 2013)
    This form is used during admission and discharge to and from the Mental Health treatment unit.
  • 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 April 28, 2013)
  • CRF Specifications and Programmer Documentation(Uploaded November 18, 2011)
  • Referral Agency List(Uploaded February 26, 2014)
    This list provides the current agency codes to be used on Consumer Reporting Forms

EEU Forms and Procedures

Eligibility and Enrollment Unit Procedures

Certification Forms


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Last Updated: Thursday February 27 2014
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