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Drug Court Progress Report Services Provided

  1. Is Youth on this week's Docket?*

  2. Enter Services Provided - Appointments

    Please enter Appointments attended or missed/Services Provided

  3. New: Does this youth's funding source apply to all Services?*

    If all appointments use the same funding source, click Yes and enter to the right. It must be Medicaid, Insurance, IDF or JDC/RF funding.

  4. 900 character limit (about 9 lines)

  5. Change Level of Care?*

    Enter Initial or Change in Level of Care

  6. Group or Individual Service*

  7. Funding Source /Participants:

  8. Enter Residential Range of Dates (span must be at least 2 days)

  9. Attendance*

  10. Another Appointment /Service?*

  11. 2. Group or Individual Service*

  12. Funding Source /Participants:

  13. Enter Residential Range of Dates

  14. Attendance*

  15. Another Appointment /Service?*

  16. 3. Group or Individual Service*

  17. Funding Source /Participants:

  18. Enter Residential Range of Dates

  19. Attendance*

  20. Another Appointment /Service?*

  21. 4. Group or Individual Service*

  22. Funding Source /Participants:

  23. Enter Residential Range of Dates

  24. Attendance

  25. Another Appointment /Service?*

  26. 5. Group or Individual Service*

  27. Funding Source /Participants:

  28. Attendance

  29. Another Appointment /Service?*

  30. 6. Group or Individual Service*

  31. Funding Source /Participants:

  32. Attendance

  33. Another Appointment /Service?*

  34. 7. Group or Individual Service*

  35. Funding Source /Participants:

  36. Attendance

  37. Another Appointment /Service?*

  38. 8. Group or Individual Service*

  39. Funding Source /Participants:

  40. Attendance

  41. Another Appointment /Service?*

  42. 9. Group or Individual Service*

  43. Funding Source /Participants:

  44. Attendance

  45. Another Appointment /Service?*

  46. 10. Group or Individual Service*

  47. Funding Source /Participants:

  48. Attendance

  49. Another Appointment /Service?*

  50. 11. Group or Individual Service*

  51. Funding Source /Participants:

  52. Attendance

  53. Another Appointment /Service?*

  54. 12. Group or Individual Service*

  55. Funding Source /Participants:

  56. Attendance

  57. Another Appointment /Service?*

  58. 13. Group or Individual Service*

  59. Funding Source /Participants:

  60. Attendance

  61. Another Appointment /Service?*

  62. 14. Group or Individual Service*

  63. Funding Source /Participants:

  64. Attendance

  65. Another Appointment /Service?*

  66. 15.Group or Individual Service*

  67. Funding Source /Participants:

  68. Attendance

  69. External Agency Referral

    Were referrals made from your agency to an external provider? (enter up to 3)

  70. 1a. Please Enter the Date referred

  71. 1b. Name of the Agency or Organization that an external referral was made to

  72. Reoffered to this organization for the following services

  73. 1d. Please describe other services

  74. 2a. Please Enter the Date referred

  75. 2b. Name of the Agency or Organization that an external referral was made to

  76. Services Provided by this Agency / Organization

  77. 2d. Please describe Other Services

  78. 3a. Please enter the Date referred

  79. 3b. Name of the Agency or Organization that an external referral was made to

  80. Services Provided by this Agency / Organization

  81. 3d. Please describe Other Services

  82. Any Drug Screens?*

    Please enter Drug Screen results.

  83. Please specify

  84. Enter Date of Drug Screening

  85. Result of Screen*

    Enter Drug Test Result

  86. Creatine?

  87. Another Test ?*

  88. Please specify

  89. Result of Screen*

  90. Creatine?

  91. Another Test?*

  92. Please specify

  93. Result of Screen*

  94. Creatine?

  95. Another Test?*

  96. Please specify

  97. Result of Screen*

  98. Creatine?

  99. Another Test?*

  100. Please specify

  101. Result of Screen*

  102. Creatine?

  103. Leave This Blank:

  104. This field is not part of the form submission.