Appendix D: Client Tx Forms

Tab D-1 | Capacity Report Form

Tab D-2 | Forms Primarily Used for Client entry, referral, and transfer

DADS Referral for Service

DADS Referral for Service- Guide:

WTT Reassessment

Continuum of Care Referral Summary

Psychiatric Referral Client Information - Updated  (7.18.2018)

VHP Confidential Patient Information Form

VHP Gateway Referral Form

Authorization for the Release of Confidential

Auth - 2-Party for the Release of Confidential Client Info

Auth - 2-Party for the Release of Confidential Client Info-Span

Auth - 2-Party for the Release of Confidential Client Info-Viet

Auth-Systems - for the Release of Confidential Client Info

Auth-Systems - for the Release of Confidential Client Info-Span

Auth-Systems - for the Release of Confidential Client Info-Viet

Auth-CJS DADS

Auth-CJS DADS-Span

Auth-CJS DADS-Viet

Auth-BASN CJS DADS

Auth-Dependency Court

Auth-Moorpark Care Team

THU

THU Advisement Form PO cert.

THU Advisement Form PO cert/uncert

THU Advisement Form PO –Spanish

THU Advisement Form PO – Viet

THU Client Disposition Form

THU Exit Plan

THU Request for Extension

THU Extension Protocol

UNI/Care

UNI/Care Annual Update

UNI/Care CalOMS Admission Form

UNI/Care CalOMS Admission Form Data Definitions

UNI/Care CalOMS Discharge Data Definition

UNI/Care CalOMS CFCS_DETOX Admit Form

UNI/Care CalOMS CFCS_DETOX Discharge

UNI/Care CalOMS Registration Form

UNI/Care CalOMS Registration Form Data Definitions

UNI/Care SRD (Services Rendered) Form (colored)

UNI/Care SRD (Services Rendered) Form (non-colored)

UNI/Care THU Admission/Discharge Form

DADS UNI/Care Username Request Form

UNI/Care Oath of Confidentiality

​UNI/Care User Responsibility Statement Instructions

Tab D-3 | Forms Primarily Used for Client Treatment

Clinical Protocol: Threats of Violence

Clinical Protocol: Suicide Potential

Clinical Protocol: Suicide Prevention Planning

Continuum of Care Referral Summary

Progress Notes

Request for Residential Extension Form

Treatment Assessment

Treatment Assessment – Spanish

Treatment Assessment – Viet

Treatment Assessment Codes

Treatment Plan Form - Counselor Version-Viet

Tab D-4 | Forms Primarily used for “Reporting” Purposes

Accident/Incident Report-Contract Agency    Adobe PDF Format   Microsoft  Word Format

Accident/Incident Report-County Agency      Adobe PDF Format   Microsoft  Word Format

Detox Status Report Form

Detox Status Report Dropdown Guide

Gateway Status Report Form

Patient Death Report

System Feedback Form

​Client Status Report (CSR) Adobe PDF Format   Microsoft Word Format​​

THU Exit Plan

Treatment Status Report (TSR)

Unusual Incident/Injury/Death Report

Tab D-6 | Forms: Continuous Recovery Monitoring (CRM)

CRM Client Consent

CRM Call Record (paper)

CRM Call Record (fillable)

CRM Call Record (Excel Spreadsheet)

CRM Immediate Needs Profile

CRM Discharge/Referral to Tx Form (fillable only)

CRM Discharge/Referral to Tx Form Dropdown Menu

CRM E-mail Consent

Template Forms Available

COC Template | Apr 2011

Detox Status Report Form Template

Gateway Status Report

Feedback Form Template | Apr 2011 (New)

Psych Referral Template

Suicide Protocol Template

Temporary Closure Template | Apr 2011 

Threat of Violence Protocol Template

TSR Template updated | Apr 2011

VHP GW Referral Template

WTT Template | Apr 2011

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