Appendix D: Client Treatment Forms

Tab D-1 | Capacity 

YSOC Waitlist

​ ​

Tab D-2 | Forms primarily used for client entry, referral, and transfer

CALOMS for 18 yrs or Older

Client Rights and Consent for Treatment

Health Screen Questionnaire (HSQ)

Notice of Grievance Procedure of Clients

Notice of Title 22 Fair Hearing Rights

Santa Clara County Juvenile Justice System Referral

YSOC Referral for Services

Authorization for the Release of Confidential

Authorization for the Release of Confidential

HHS Privacy Notice Practices Acknowledgement of Receipt

System Authorization for the Release of Confidential

Residential

Adolescent Residential Treatment Services (ARTS) – Cover Page

Adolescent Residential Treatment Services (ARTS) – Referral Form

UNI/Care CALOMS

UNI/Care Administrative Discharge

UNI/Care Annual Update

UNI/Care Annual Update for 18 years of Age or Older

UNI/Care CFCS DETOX CALOMS Admit Questionnaire

UNI/Care CFCS Client Registration Form

UNI/Care CFCS DETOX CALOMS Discharge Questionnaire

UNI/Care Discharge Summary for 18 years of Age or Older

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

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

Tab D-3 | Forms Primarily Used For Client Treatment

CFCS CALOMS Annual Update

Annual Update: for 18 years of Age or Older

​​ Clinical Protocol:  Suicide Potential Rating Scale

Discharge Summary and Continuing Care Plan

Progress Note

Safety Plan Quick Guidelines

Suicide Prevention Planning

Suicide Prevention Planning Guidelines

YSOC Adolescent ASAM Treatment Assessment (ASAM)

Treatment Plan

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

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

Agency Incident Report Form

Tab D-5 | Forms related to client outcomes measurement

Tab D-6 | Forms:  Seven Challenges

Seven Challenges

Seven Challenges Collaboration System Authorization

Seven Challenges Journal Authorization

Seven Challenges Journal Disposition Policy

Seven Challenges Continuing Care – Counselor Summary

Seven Challenges Moving On to Challenges

The Seven Challenges Youth Survey

Support Commitment Letter

©2021 County of Santa Clara. All rights reserved.