SECTION 1 CLIENT ENTRY INTO SYSTEM Procedure 115 …….. Capacity Report Form
Screening
120 ……. DADS Referral for Services 120 A …. DADS Referral for Services Guide
121 ……. Welcome to Treatment Referral
121 A …. Welcome to Treatment Dropdown Guide
Placement
130 ……. Concurrent Methadone and Residential Treatment 135 ……. Client Placement Decisions
135 A ….. ASAM Crosswalk
135 B ….. Placement Conversion List
136 ……. Dual Diagnosis Eligibility Criteria
137 ……. Resolving Disputes About Client Placement Decisions/Referrals 138 ……. Warrants
143 ……. In-Custody Placements
144 ……. In-Custody Clients who No-Show to Res Tx or THU 145 ……. Residential Placement and Wait List
145 A ….. Residential Wait List Client Instructions
147 ……. THU Advisement Treatment and Services Procedure 150 ……. AB 109
152 ……. Criminal Justice Services
152 A ….. Criminal Justice Case Management Referral Protocol 153 ……. MH Full Service Partnership Clients
154 ……. Parolee Re-Entry Grant 155 ……. Veterans Grant
156 ……. Homeless Grant
156 A …. Res Homeless Grant Attachment 156 B …. OP Homeless Grant Attachment 157 ……. CalEMA Grant
158 ……. Addiction Medicine Therapy (AMT) Medical Hold 160 ……. VHP Referrals
165 ……. Priority Admissions 166 ……. Prop-36 Eligibility
SECTION 2 CLIENT MOVEMENT THROUGH THE SYSTEM Referrals, Transfers, and Upgrades
Procedure 200 ……. Level of Care and Lateral Transfers
205 ……. Continuum of Care Referral Summary Form 205 A …. COC Dropdown Menu Guide
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210 ……. Transitional Housing Unit (THU) Referral and Placement 211 ……. Transitional Housing Unit (THU) Disposition
212 ……. THU Request for Extension 220 ……. Psychiatric Consultation Referral 240 ……. BASN Referrals
245 ……. CDCI Referrals
SECTION 3 CLINICAL
Clinical Standards Procedure 300 …….. Clinical Guidelines
300 A ….. Clinical Guidelines Table
302 ……. Intensive Outpatient Services 303 ……. Treatment Assessment
304 ……. Discharge Planning and Summary 305 ……. Treatment Plans
306 ……. Request for Temporary Reduction of Caseload Size 307 ……. Request for Residential Extension
307 A …. Request for Res Ext Guidelines Special Issues
308 ……. Unamenable
309 ……. Managing Client Alcohol/Drug Use during Treatment 309 A ….. Managing Client Use System Guideline
311 ……. Managing Client Threats of Violence Protocol 312 ……. Managing Client Violence
312 A ….. Managing Client ViolenceSystem Guideline
313 ……. Managing Client Suicide Potential Protocol 313 A …. Suicide Potential Guidelines
314 ……. Child Abuse and Neglect Reporting
315 ……. Managing Client Sexual Conduct at Treatment Facilities 316 ……. THU Violence Protocol
316 A ….. Managing Client Violence in the THU System Guidelines
318 ……. Provider Clinical Appeals Process 319 ……. Dual Relationships
Special Populations
330 ……. Treatment for Pregnant Women Medical
335 ……. TB Screening
336 ……. Suspected Active TB Disease
338 ……. AMT Take-Home: Security THU & Res (part 1)
338 ……. AMT Take-Home: Lost Stolen THU & Res (part 2)
340 ……. Clients with Prescription Medication
345 ……. Medical Marijuana Charting
350 ……. Progress Notes
360 ……. Group Agreement Policy 360 A ….. Group Agreement Example
SECTION 4 COMMUNICATION Confidentiality
Procedure 400 ……. Authorization Form for the Release of Confidential Client Info 404 ……. Criminal Justice Consent
405 ……. System Authorization Form for the Release of Confidential Client Info 406 ……. Fax and Email Transmission of Confidential Client Information
407 ……. Confidentiality – Leaving messages for potential clients/clients 408 ……. Parole Authorization Policy
409 ……. AB 109 Authorization Policy
Communication Inside and Outside the System 410 ……. Treatment Status Report
410 A….. Treatment Status Report Form Instructions
410 B….. Treatment Status Report FAQs
415 ……. Transitional Housing Unit Client Status Report Form 420 ……. Communication: Transitional Housing Unit Providers and
Outpatient Providers 425 ……. System Feedback Form
430 ……. Contract Agency Accident/Incident Report 435 ……. County Agency Accident/Incident Report 440 ……. Temporary Agency Closures
SECTION 5 CLIENT EXIT FROM THE SYSTEM Procedure 500 ……. Grievance Process
510 ……. THU Housing Exit Plan 520 ……. Timeline for Chart Closures
SECTION 6 QUALITY IMPROVEMENT/ASSURANCE Procedure 610 ……. UNI/Care Data Entry
615 ……. UNI/Care User Account and Provider Maintenance 650 ……. Learning Organization
SECTION 7 CONTINUOUS RECOVERY MODEL Procedure 700 ……. Continuous Recovery Model (CRM)
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APPENDIX A PERFORMANCE MEASURES None with this Release
APPENDIX B COUNSELOR RESOURCE MATERIALS Best Practices
Clinical Abbreviations
The Clinician’s Guide (Toolkit)
Dual Diagnosis Services Patient Placement Criteria Outline
Medical Necessity Criteria, Santa Clara County, Dept of Mental Health APPENDIX C THU STANDARDS
APPENDIX D FORMS
TAB D1 ………. Capacity Report
TAB D2 ………. Forms primarily used for client entry, referral, and transfer Case Management Questionaire
Continuum of Care Referral Summary DADS Referral for Service
DADS Referral for Service – Guide Psychiatric Referral Client Information WTT Reassessment
VHP Confidential Patient Information Form VHP Gateway Referral Form
Authorization for the Release of Confidentiality
Auth - 2-Party for the Release of Confidential Client Info Auth - 2-Party for the Release of Confidential Client Info-Span Auth - 2-Party for the Release of Confidential Client Info-Viet Auth – AB 109 for the Release of Confidential Client Info Auth – AB 109 for the Release of Confidential Client Info-Span Auth – AMT Confidential Info
Auth – AMT Confidential Info Spanish Auth – AMT Confidential Info Vietnamese
Auth-Systems - for the Release of Confidential Client Info Auth-Systems - for the Release of Confidential Client Info-Span Auth-Systems - for the Release of Confidential Client Info-Viet Auth-CJS DADS
Auth-CJS DADS-Span Auth-CJS DADS-Viet Auth-BASN CJS-DADS
Auth-Dependency Court-DADS Auth-Moorpark Care Team
THU Forms
THU/DA Certification/Advisement Form
THU/DA Certification/Advisement- Spanish THU/DA Certification/Advisement- Vietnamese THU Client Disposition Form
THU Exit Plan
THU Request for an Extension Unicare Forms
UNI/Care CalOMS Registration Form
UNI/Care CalOMS Registration Data Definitions UNI/Care CalOMS Admission Form
UNI/Care CalOMS Admission Form Data Definitions UNI/Care CalOMS Admit Questionnaire
UNI/Care CalOMS Admit Questionnaire Data Definitions UNI/Care CalOMS Discharge Summary Form
UNI/Care CalOMS Discharge Summary Data Definition UNI/Care CalOMS Discharge Questionnaire
UNI/Care Services Rendered Form
UNI/Care THU Admission/Discharge Form UNI/Care CalOMS CFCS-Detox Admit Form UNI/Care CalOMS CFCS-Detox Discharge Form UNI/Care Annual Update
UNI/Care Oath of Confidentiality UNI/Care User Information Form UNI/Care Username Request Form
UNI/Care User Responsibility Statement Instruction TAB D3 ………. Forms primarily used for client treatment
Clinical Protocol: Suicide Potential Scale
Suicide Prevention Planning Form Continuum of Care Referral Summary
Discharge Summary Codes Discharge Summary Form Progress Notes Form
Progress Form Psycho-Ed (Structured- Discovery Group) Request for Residential Extension Form
Treatment Assessment Form Treatment Assessment – Spanish Treatment Assessment – Viet Treatment Assessment Codes Treatment Plan Form A Treatment Plan Form B
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Treatment Status Report (TSR)
TAB D4 ………. Forms primarily used for “reporting” purposes Detox Status Report Form
Detox Status Report Dropdown Guide Gateway Status Report Form
Treatment Status Report (TSR) TSR Instructions
Unamenable/Ineligible/Suspended Client Report Form Unamenable/Ineligible/Suspended Report Dropdown Guide
Accident/Incident Report-Contract Agency Accident/Incident Report-County Agency System Feedback Form
Temporary Closure Form
THU Client Status Report (CSR) THU Exit Plan
Patient Death Report
Unusual Incident/Injury/Death Report
TAB D5 ………. Forms related to client outcomes measurement ORS / SRS Forms
TAB D6 ………. Forms related to Continuous Recovery Monitoring CRM Client Consent
CRM Information Sheet (Handwritten) CRM Information Sheet (Fillable Form) CRM Call Record (Handwritten)
CRM Call Record (Fillable Form) CRM Call Record (Excel Spreadsheet) CRM Immediate Needs Profile
CRM Discharge Form / Referral to TX Form (Fillable Form) CRM Discharge Form / Referral to TX Form-Menu
CRM Consent CRM Email Consent
