Please enter Appointments attended or missed/Services Provided
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.
If Other (Specify) funding source, it must be entered within each appointment. Click No on previous question.
900 character limit (about 9 lines)
Enter Seven Challenges Journal the youth is working on that you wish to share with the team.
Enter Initial or Change in Level of Care
Enter Residential Range of Dates (span must be at least 2 days)
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).
Enter funding source for this service.
Enter Residential Range of Dates
Enter type of Service to be Provided
Enter Service to be Provided
Were referrals made from your agency to an external provider? (enter up to 3)
1a. Please Enter the Date referred
1b. Name of the Agency or Organization that an external referral was made to
1d. Please describe other services
2a. Please Enter the Date referred
2b. Name of the Agency or Organization that an external referral was made to
2d. Please describe Other Services
3a. Please enter the Date referred
3b. Name of the Agency or Organization that an external referral was made to
3d. Please describe Other Services
Please enter Drug Screen results.
Enter Date of Drug Screening
Enter Drug Test Result
If applicable,enter Discharge information
Enter Excused Drop, or Other Drop Notes
Drop schedule changed, or used Normal Schedule based on Phase in program.
875 character limit
about 8 lines
Change future drop schedule if necessary
If next court hearing date not based on phase, enter exception here
If next court hearing date not based on phase, enter exception here.
In case TP does not enter correct hearing date
In case TP enters wrong id
This field is not part of the form submission.
* indicates a required field