Client Placement Forms
The Division of Substance Abuse and Mental Health has provided the following list of Client Placement Forms:
Emergency Admissions
- 24 Hour Emergency Admission Form (Updated February 04, 2008)
To be used for 24 hour commitments and must be completed prior to presenting to the admitting physician. Text - 24-hour form - 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
CRF Forms
- Consumer Reporting Form (CRF) Admissions (Updated
August 10, 2006)
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 (Updated
August 10, 2006)
This form is used during discharge from the treatment unit.Text - CRF Discharge. - Instructions and Code Sheet for CRF (Updated May 15, 2006) Text - CRF Instructions
EEU Forms
- Authorization for Release of Confidential Information (Updated May 15, 2006) Text - Authorization
- Eligibility and Enrollment Unit Enrollment Application (Updated May 15, 2006)
This form is to be completed for those enrolling in the Eligibility and Enrollment Unit.Text - EEU App. - Initial Psychiatric Screening Information Form (Updated 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 (Updated May 15, 2006) Text - Redetermination App.
- Long Term Care Program (LTC) Recertification Form (Updated May 15, 2006) Text - LTC Form
- Procedures for enrollment to the EEU. (Updated May 15, 2006) (Site Link)
Discharge and Transfer Forms
- Detox Discharge Form (Added October
1, 2001)
This form is to be completed for all patients being discharged from a residential detoxification program. Text - Detox Discharge - Hospital Discharge Form (Added
February 2, 2002)
This form is to be completed for all patients being discharged from Delaware Psychiatric Center. Text - Hospital Discharge - Intra-agency Transfer Form (Updated
February 2, 2002)
Use this form for transferring individuals between DSAMH treatment units. Text - Intragency Transfer
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
