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Drug Court Progress Report Services Provided
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
Youth First Initial
*
Youth Last Initial
*
Youth Court ID
*
Treatment Provider Agency Name
*
-- Select One --
A Renewed Mind
CHOICES
New Concepts
Unison
Zepf
Lucas County Juvenile Court
Treatment Provider Employee name
*
Is Youth on this week's Docket?
*
Yes
No
Current Hearing Date
*
Current Hearing Date
Enter Services Provided - Appointments
Yes
No
Please enter Appointments attended or missed/Services Provided
New: Does this youth's funding source apply to all Services?
*
Yes
No
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.
Youth's Main Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
JDC/RF Funds
State Funds
Self Pay
Unknown
None
If Other (Specify) funding source, it must be entered within each appointment. Click No on previous question.
Treatment Provider Notes
900 character limit (about 9 lines)
Seven Challenges Journal
-- Select One --
None
Journal 1 part 1
Journal 1 part 2
Journal 2
Journal 3
Journal 4
Journal 5
Journal 6
Journal 7 part 1
Journal 7 part 2
Enter Seven Challenges Journal the youth is working on that you wish to share with the team.
Change Level of Care?
*
Yes
No
Enter Initial or Change in Level of Care
Effective / Active Date
*
Effective / Active Date
Level of Care
-- Select One --
Intensive Outpatient
Non Intensive Outpatient
Individual Treatment
Extended Care
Aftercare
Residential
Discharged/Terminated
Group or Individual Service
*
Group
Individual
Both Group & Individual
Other (Parent, Caregiver, Family/Support People)
Residential Group Date Range
None
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Residential Group Dates
*
Residential Group Dates Start Date
—
Residential Group Dates End Date
Enter Residential Range of Dates (span must be at least 2 days)
Attendance
*
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
No Services Provided
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy/Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT (Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specifiy)
Enter the type of Service Provided, even if Client was absent for this service.(Seven Challenges, Case Management, Prosocial Activity, Cognitive-Behavioral Therapy/Motivational Enhancement Therapy, Other).
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Specify
Unknown
None
Enter funding source for this service.
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
2. Group or Individual Service
*
Group
Individual
Both Group & Individual
Other (Parent, Caregiver, Family/Support People)
Residential Group Date Range
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Residential Group Dates
*
Residential Group Dates Start Date
—
Residential Group Dates End Date
Enter Residential Range of Dates
Attendance
*
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter type of Service to be Provided
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Enter funding source for this service.
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
3. Group or Individual Service
*
Group
Individual
Both Group & Individual
Other
Residential Group Date Range
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Residential Group Dates
*
Residential Group Dates Start Date
—
Residential Group Dates End Date
Enter Residential Range of Dates
Attendance
*
Attended
Excused
Not Excused
Service to be Provided
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolexcent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter type of Service to be Provided
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
4. Group or Individual Service
*
Group
Individual
Both Group & Individual
Other
Residential Group Date Range
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Residential Group Dates
*
Residential Group Dates Start Date
—
Residential Group Dates End Date
Enter Residential Range of Dates
Attendance
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter type of Service to be Provided
Other Service (Specify)
Funding Source
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
5. Group or Individual Service
*
Group
Individual
Both Group & Individual
Other
Residential Group Date Range
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Residential Group Dates
*
Residential Group Dates Start Date
—
Residential Group Dates End Date
Attendance
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter type of Service to be Provided
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
6. Group or Individual Service
*
Group
Individual
Both Group & Individual
Other
Residential Group Date Range
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Residential Group Dates
*
Residential Group Dates Start Date
—
Residential Group Dates End Date
Attendance
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter type of Service to be Provided
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
7. Group or Individual Service
*
Group
Individual
Both Group & Individual
Other
Residential Group Date Range
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Residential Group Dates
*
Residential Group Dates Start Date
—
Residential Group Dates End Date
Attendance
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter type of Service to be Provided
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
8. Group or Individual Service
*
Group
Individual
Both Group & Individual
Other
Residential Group Date Range
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Residential Group Dates
*
Residential Group Dates Start Date
—
Residential Group Dates End Date
Attendance
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter Service to be Provided
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
9. Group or Individual Service
*
Group
Individual
Both Group & Individual
Other
Residential Group Date Range
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Residential Group Dates
*
Residential Group Dates Start Date
—
Residential Group Dates End Date
Attendance
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter Service to be Provided
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
10. Group or Individual Service
*
Group
Individual
Both Group & Individual
Other
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Attendance
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter Service to be Provided
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
11. Group or Individual Service
*
Group
Individual
Both Group & Individual
Other
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Attendance
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter Service to be Provided
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
12. Group or Individual Service
*
Group
Individual
Both Group & Individual
Other
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Attendance
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter Service to be Provided
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
13. Group or Individual Service
*
Group
Individual
Both Group & Individual
Other
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Attendance
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter Service to be Provided
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
14. Group or Individual Service
*
Group
Individual
Both Group & Individual
Other
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Attendance
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter Service to be Provided
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Other Specify Funding Source
Another Appointment /Service?
*
Yes
No
15.Group or Individual Service
*
Group
Individual
Both Group & Individual
Other
Funding Source /Participants:
Enter Specific Funding Source?
Client
Parent
Caregiver
Other
Date of Service
*
Date of Service
Attendance
Attended
Excused
Not Excused
Service to be Provided
*
-- Select One --
7 Challenges
ACC (Assertive Continuing Care)
ACRA (Adolescent Community Reinforcement Approach)
ART (Aggression Replacement Therapy)
CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)
Case Management
Community Review Boards
Continuing Care (Other)
CRAFT (Community Reinforcement and Family Training)
Education Services
FFT(Functional Family Therapy)
Home Visits
MATRIX
MRT (Moral Reconation Therapy)
Mentoring Program
Parenting Program
Prosocial Activities
REBT (Rational Emotive Behavior Therapy)
Restitution Orders
No Services Provided
School Visits
TFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma Services
Transportation
Other Service (Please Specify)
Enter Service to be Provided
Other Service (Specify)
Funding Source
*
-- Select One --
Medicaid
Insurance
Indigent Driver Funds
State Funds
Self Pay
JDC/RF Funds
Other Grant Funds
Other Federal Funds
Other Specify
Unknown
None
Other Specify Funding Source
External Agency Referral
Yes
No
Were referrals made from your agency to an external provider? (enter up to 3)
Date of Referral
Date of Referral
1a. Please Enter the Date referred
Agency / Organization Referred To
1b. Name of the Agency or Organization that an external referral was made to
Reoffered to this organization for the following services
Substance Abuse Treatment
Behavioral / Mental Health
Education
Employment
Family Services
Prosocial / Recreational
Other Services
Other Services
1d. Please describe other services
Date of Referral
Date of Referral
2a. Please Enter the Date referred
Agency / Organization Referred To
2b. Name of the Agency or Organization that an external referral was made to
Services Provided by this Agency / Organization
Substance Abuse Treatment
Behavioral / Mental Health
Education
Employment
Family Services
Prosocial / Recreational
Other Services
Other Services
2d. Please describe Other Services
Date of Referral
Date of Referral
3a. Please enter the Date referred
Agency / Organization Referred To
3b. Name of the Agency or Organization that an external referral was made to
Services Provided by this Agency / Organization
Substance Abuse Treatment
Behavioral / Mental Health
Education
Employment
Family Services
Prosocial / Recreational
Other Services
Other Services
3d. Please describe Other Services
Any Drug Screens?
*
Yes
No
Please enter Drug Screen results.
Drug Name
*
-- Select One --
Alcohol
Marijuana
Heroin
Cocaine
Opiates
Oxycodone
Other
Other Drug
Please specify
Date of Screen
*
Date of Screen
Enter Date of Drug Screening
Result of Screen
*
Negative
Positive
DNG
Pending
Enter Drug Test Result
Creatine?
Normal
Diluted
Another Test ?
*
Yes
No
Drug Name
-- Select One --
Alcohol
Marijuana
Heroin
Cocaine
Opiates
Oxycodone
Other
Other Drug
Please specify
Date of Screen
*
Date of Screen
Result of Screen
*
Negative
Positive
DNG
Pending
Creatine?
Normal
Diluted
Another Test?
*
Yes
No
Drug Name
-- Select One --
Alcohol
Marijuana
Heroin
Cocaine
Opiates
Oxycodone
Other
Other Drug
Please specify
Date of Screen
*
Date of Screen
Result of Screen
*
Negative
Positive
DNG
Pending
Creatine?
Normal
Diluted
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Drug Name
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Date of Screen
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Date of Screen
Result of Screen
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DNG
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Creatine?
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Diluted
Another Test?
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Alcohol
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Date of Screen
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DNG
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Creatine?
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Discharge Status
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Successfully completed, Discharged to community
Successfully completed, Referred to another provider
Unsuccessful discharge, Voluntarily withdrew from program
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