DHS 35: Forms   NOTE update to Consent Forms: language on discharge policy 9.30.2010

Forms

• DHS 35 Compliance Checklist (Word format) - posted 9.17.2009

• Assessments

  • Adult Initial Assessment

  • Child-Adolescent Initial Assessment

  • Suicide Risk Assessment - revised 1.17.2012 (see also Suicide Safety Plan below)

• Consent Forms

  • Consent for Adult Admission for Evaluation and/or Treatment - revised 9.30.2010

  • Consent for Child Admission for Evaluation and/or Treatment - revised 9.30.2010

• Progress Notes

  • Progress Notes - template 1

  • Progress Notes - template 2

  • Progress Notes - template 3 - small font / 1 page document

  • Progress Notes - template 3 - large font / 2 page document

• Questionnaires

  • Adult Pretreatment Questionnaire

  • Child-Adolescent Pre-treatment Questionnaire

  • Intake Questionnaire – Adult

  • Intake Questionnaire – Child

  • Intake Questionnaire - computer friendly

• Treatment Plans

  • Child or Adult Initial Treatment Plan - template set 1

  • Child or Adult Updated Treatment Plan - template set 1

  • Child or Adult Discharge Summary - template set 1

  • Comprehensive Treatment-Discharge Plan - template 2 - revised 9.28.2010

  • Suicide Safety Plan - posted 1.17.2012

• Business Associate Agreement form, which includes new HITECH ACT requirements, provided by HIPAA Collaborative of Wisconsin (see "Other Resources" on main page)

• GRAD Student – Permission to Audio/Video Tape

• GRAD Student – Permission to Provide Therapy

• Information for Clients – blank

• Joint Notice of Privacy Practices – English

• No Contact Letter – case closing

• Phone Intake – billing info & insurance verification

• Prior Authorization Form: see F-00212 (under "DHS Resources" on main page)

• Referral for Psychotherapy (master level therapist)

• Referral for Psychotherapy (psychiatrist)

• Release of Records Log

• Substance Usage – addendum to intake evaluation

• Supervision Case Review

• Treatment (Evaluation) Consent Form

• Welcome Letter - version 1

• Welcome Letter - version 2 - posted 07.2011

*Considerations regarding use of documents on this website