Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

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. End of Treatment Provider Info
  104. Leave This Blank:

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