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November 2015 Drug Court Progess Report Services Provided

    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.

  1. 900 character limit (about 9 lines)

    Enter Initial or Change in Level of Care

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

  3. Enter Residential Range of Dates

  4. Enter Residential Range of Dates

  5. Enter Residential Range of Dates

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

  6. 1a. Please Enter the Date referred

  7. 1b. Name of the Agency or Organization that an external referral was made to

  8. 1d. Please describe other services

  9. 2a. Please Enter the Date referred

  10. 2b. Name of the Agency or Organization that an external referral was made to

  11. 2d. Please describe Other Services

  12. 3a. Please enter the Date referred

  13. 3b. Name of the Agency or Organization that an external referral was made to

  14. 3d. Please describe Other Services

    Please enter Drug Screen results.

  15. Please specify

  16. Enter Date of Drug Screening

    Enter Drug Test Result

  17. Please specify

  18. Please specify

  19. Please specify

  20. Please specify

  21. Leave This Blank:

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