DHS 35: Forms

Forms

• DHS 35 Compliance Checklist (Word format) (posted 9/17/09)

• Assessments

  • Adult Initial Assessment

  • Child-Adolescent Initial Assessment

  • Risk Assessment

  • Suicide Risk Assessment

• Questionnaires

  • Adult Pretreatment Questionnaire

  • Child-Adolescent Pre-treatment Questionnaire

  • Intake Questionnaire – Adult

  • Intake Questionnaire – Child

  • Intake Questionnaire - computer friendly

• Treatment Plans

  • Adult Treatment Plan

  • Child/Adolescent Treatment Plan

  • Discharge Summary

  • Treatment Plan - Discharge Plan

  • Updated Treatment Plan

• 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

*Considerations regarding use of documents on this website