2. Youth First Initial*
3. Youth Last Initial*
4. Youth Court ID*
6. Treatment Provider Agency Name*
   -- Select One --A Renewed MindCHOICESNew ConceptsUnisonZepfLucas County Juvenile Court
7. Treatment Provider Employee name*
8. Is Youth on this week's Docket?*

   1. Yes
   2. No
9. Current Hearing Date*
   Current Hearing Date
11. Enter Services Provided - Appointments

    1. Yes
    2. No

    Please enter Appointments attended or missed/Services Provided
12. New: Does this youth's funding source apply to all Services?*

    1. Yes
    2. 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.
13. Youth's Main Funding Source*
    -- Select One --MedicaidInsuranceIndigent Driver FundsJDC/RF Funds State FundsSelf PayUnknownNone

    If Other (Specify) funding source, it must be entered within each appointment. Click No on previous question.
15. Treatment Provider Notes
    900 character limit (about 9 lines)
17. Seven Challenges Journal
    -- Select One --NoneJournal 1 part 1Journal 1 part 2Journal 2Journal 3Journal 4Journal 5Journal 6Journal 7 part 1Journal 7 part 2

    Enter Seven Challenges Journal the youth is working on that you wish to share with the team.
18. Change Level of Care?*

    1. Yes
    2. No

    Enter Initial or Change in Level of Care
19. Effective / Active Date*
    Effective / Active Date
20. Level of Care
    -- Select One --Intensive OutpatientNon Intensive OutpatientIndividual TreatmentExtended CareAftercareResidentialDischarged/Terminated
22. Group or Individual Service*

    1. Group
    2. Individual
    3. Both Group & Individual
    4. Other (Parent, Caregiver, Family/Support People)
    5. Residential Group Date Range
    6. None
23. Funding Source /Participants:

    1. Enter Specific Funding Source?
    2. Client
    3. Parent
    4. Caregiver
    5. Other
24. Date of Service*
    Date of Service
25. 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)
27. Attendance*

    1. Attended
    2. Excused
    3. Not Excused
28. Service to be Provided*
    -- Select One --7 ChallengesNo Services ProvidedACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy/Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT (Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther 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).
30. Other Service (Specify)
31. Funding Source*
    -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther SpecifyUnknownNone

    Enter funding source for this service.
32. Other Specify Funding Source
34. Another Appointment /Service?*

    1. Yes
    2. No
36. 2. Group or Individual Service*

    1. Group
    2. Individual
    3. Both Group & Individual
    4. Other (Parent, Caregiver, Family/Support People)
    5. Residential Group Date Range
37. Funding Source /Participants:

    1. Enter Specific Funding Source?
    2. Client
    3. Parent
    4. Caregiver
    5. Other
38. Date of Service*
    Date of Service
39. Residential Group Dates*
    Residential Group Dates Start Date

    —

    Residential Group Dates End Date
    Enter Residential Range of Dates
41. Attendance*

    1. Attended
    2. Excused
    3. Not Excused
42. Service to be Provided*
    -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

    Enter type of Service to be Provided
44. Other Service (Specify)
45. Funding Source*
    -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone

    Enter funding source for this service.
46. Other Specify Funding Source
48. Another Appointment /Service?*

    1. Yes
    2. No
50. 3. Group or Individual Service*

    1. Group
    2. Individual
    3. Both Group & Individual
    4. Other
    5. Residential Group Date Range
51. Funding Source /Participants:

    1. Enter Specific Funding Source?
    2. Client
    3. Parent
    4. Caregiver
    5. Other
52. Date of Service*
    Date of Service
53. Residential Group Dates*
    Residential Group Dates Start Date

    —

    Residential Group Dates End Date
    Enter Residential Range of Dates
55. Attendance*

    1. Attended
    2. Excused
    3. Not Excused
56. Service to be Provided
    -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolexcent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

    Enter type of Service to be Provided
58. Other Service (Specify)
59. Funding Source*
    -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone
60. Other Specify Funding Source
62. Another Appointment /Service?*

    1. Yes
    2. No
64. 4. Group or Individual Service*

    1. Group
    2. Individual
    3. Both Group & Individual
    4. Other
    5. Residential Group Date Range
65. Funding Source /Participants:

    1. Enter Specific Funding Source?
    2. Client
    3. Parent
    4. Caregiver
    5. Other
66. Date of Service*
    Date of Service
67. Residential Group Dates*
    Residential Group Dates Start Date

    —

    Residential Group Dates End Date
    Enter Residential Range of Dates
69. Attendance

    1. Attended
    2. Excused
    3. Not Excused
70. Service to be Provided*
    -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

    Enter type of Service to be Provided
72. Other Service (Specify)
73. Funding Source
    -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone
74. Other Specify Funding Source
76. Another Appointment /Service?*

    1. Yes
    2. No
78. 5. Group or Individual Service*

    1. Group
    2. Individual
    3. Both Group & Individual
    4. Other
    5. Residential Group Date Range
79. Funding Source /Participants:

    1. Enter Specific Funding Source?
    2. Client
    3. Parent
    4. Caregiver
    5. Other
80. Date of Service*
    Date of Service
81. Residential Group Dates*
    Residential Group Dates Start Date

    —

    Residential Group Dates End Date
83. Attendance

    1. Attended
    2. Excused
    3. Not Excused
84. Service to be Provided*
    -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesRestitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

    Enter type of Service to be Provided
86. Other Service (Specify)
87. Funding Source*
    -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone
88. Other Specify Funding Source
90. Another Appointment /Service?*

    1. Yes
    2. No
92. 6. Group or Individual Service*

    1. Group
    2. Individual
    3. Both Group & Individual
    4. Other
    5. Residential Group Date Range
93. Funding Source /Participants:

    1. Enter Specific Funding Source?
    2. Client
    3. Parent
    4. Caregiver
    5. Other
94. Date of Service*
    Date of Service
95. Residential Group Dates*
    Residential Group Dates Start Date

    —

    Residential Group Dates End Date
97. Attendance

    1. Attended
    2. Excused
    3. Not Excused
98. Service to be Provided*
    -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

    Enter type of Service to be Provided
100. Other Service (Specify)
101. Funding Source*
     -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone
102. Other Specify Funding Source
104. Another Appointment /Service?*

     1. Yes
     2. No
106. 7. Group or Individual Service*

     1. Group
     2. Individual
     3. Both Group & Individual
     4. Other
     5. Residential Group Date Range
107. Funding Source /Participants:

     1. Enter Specific Funding Source?
     2. Client
     3. Parent
     4. Caregiver
     5. Other
108. Date of Service*
     Date of Service
109. Residential Group Dates*
     Residential Group Dates Start Date

     —

     Residential Group Dates End Date
111. Attendance

     1. Attended
     2. Excused
     3. Not Excused
112. Service to be Provided*
     -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

     Enter type of Service to be Provided
114. Other Service (Specify)
115. Funding Source*
     -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone
116. Other Specify Funding Source
118. Another Appointment /Service?*

     1. Yes
     2. No
120. 8. Group or Individual Service*

     1. Group
     2. Individual
     3. Both Group & Individual
     4. Other
     5. Residential Group Date Range
121. Funding Source /Participants:

     1. Enter Specific Funding Source?
     2. Client
     3. Parent
     4. Caregiver
     5. Other
122. Date of Service*
     Date of Service
123. Residential Group Dates*
     Residential Group Dates Start Date

     —

     Residential Group Dates End Date
125. Attendance

     1. Attended
     2. Excused
     3. Not Excused
126. Service to be Provided*
     -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

     Enter Service to be Provided
128. Other Service (Specify)
129. Funding Source*
     -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone
130. Other Specify Funding Source
132. Another Appointment /Service?*

     1. Yes
     2. No
134. 9. Group or Individual Service*

     1. Group
     2. Individual
     3. Both Group & Individual
     4. Other
     5. Residential Group Date Range
135. Funding Source /Participants:

     1. Enter Specific Funding Source?
     2. Client
     3. Parent
     4. Caregiver
     5. Other
136. Date of Service*
     Date of Service
137. Residential Group Dates*
     Residential Group Dates Start Date

     —

     Residential Group Dates End Date
139. Attendance

     1. Attended
     2. Excused
     3. Not Excused
140. Service to be Provided*
     -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

     Enter Service to be Provided
142. Other Service (Specify)
143. Funding Source*
     -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone
144. Other Specify Funding Source
146. Another Appointment /Service?*

     1. Yes
     2. No
148. 10. Group or Individual Service*

     1. Group
     2. Individual
     3. Both Group & Individual
     4. Other
149. Funding Source /Participants:

     1. Enter Specific Funding Source?
     2. Client
     3. Parent
     4. Caregiver
     5. Other
150. Date of Service*
     Date of Service
151. Attendance

     1. Attended
     2. Excused
     3. Not Excused
153. Service to be Provided*
     -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

     Enter Service to be Provided
155. Other Service (Specify)
156. Funding Source*
     -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone
157. Other Specify Funding Source
159. Another Appointment /Service?*

     1. Yes
     2. No
161. 11. Group or Individual Service*

     1. Group
     2. Individual
     3. Both Group & Individual
     4. Other
162. Funding Source /Participants:

     1. Enter Specific Funding Source?
     2. Client
     3. Parent
     4. Caregiver
     5. Other
163. Date of Service*
     Date of Service
164. Attendance

     1. Attended
     2. Excused
     3. Not Excused
166. Service to be Provided*
     -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

     Enter Service to be Provided
168. Other Service (Specify)
169. Funding Source*
     -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone
170. Other Specify Funding Source
172. Another Appointment /Service?*

     1. Yes
     2. No
174. 12. Group or Individual Service*

     1. Group
     2. Individual
     3. Both Group & Individual
     4. Other
175. Funding Source /Participants:

     1. Enter Specific Funding Source?
     2. Client
     3. Parent
     4. Caregiver
     5. Other
176. Date of Service*
     Date of Service
177. Attendance

     1. Attended
     2. Excused
     3. Not Excused
179. Service to be Provided*
     -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

     Enter Service to be Provided
181. Other Service (Specify)
182. Funding Source*
     -- Select One --MedicaidIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone
183. Other Specify Funding Source
185. Another Appointment /Service?*

     1. Yes
     2. No
187. 13. Group or Individual Service*

     1. Group
     2. Individual
     3. Both Group & Individual
     4. Other
188. Funding Source /Participants:

     1. Enter Specific Funding Source?
     2. Client
     3. Parent
     4. Caregiver
     5. Other
189. Date of Service*
     Date of Service
190. Attendance

     1. Attended
     2. Excused
     3. Not Excused
192. Service to be Provided*
     -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

     Enter Service to be Provided
194. Other Service (Specify)
195. Funding Source*
     -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone
196. Other Specify Funding Source
198. Another Appointment /Service?*

     1. Yes
     2. No
200. 14. Group or Individual Service*

     1. Group
     2. Individual
     3. Both Group & Individual
     4. Other
201. Funding Source /Participants:

     1. Enter Specific Funding Source?
     2. Client
     3. Parent
     4. Caregiver
     5. Other
202. Date of Service*
     Date of Service
203. Attendance

     1. Attended
     2. Excused
     3. Not Excused
205. Service to be Provided*
     -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

     Enter Service to be Provided
207. Other Service (Specify)
208. Funding Source*
     -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone
209. Other Specify Funding Source
211. Another Appointment /Service?*

     1. Yes
     2. No
213. 15.Group or Individual Service*

     1. Group
     2. Individual
     3. Both Group & Individual
     4. Other
214. Funding Source /Participants:

     1. Enter Specific Funding Source?
     2. Client
     3. Parent
     4. Caregiver
     5. Other
215. Date of Service*
     Date of Service
216. Attendance

     1. Attended
     2. Excused
     3. Not Excused
218. Service to be Provided*
     -- Select One --7 ChallengesACC (Assertive Continuing Care)ACRA (Adolescent Community Reinforcement Approach)ART (Aggression Replacement Therapy)CBT / MET (Cognitive-Behavioral Therapy / Motivational Enhancement Therapy)Case ManagementCommunity Review BoardsContinuing Care (Other)CRAFT (Community Reinforcement and Family Training)Education ServicesFFT(Functional Family Therapy)Home VisitsMATRIXMRT (Moral Reconation Therapy)Mentoring ProgramParenting ProgramProsocial ActivitiesREBT (Rational Emotive Behavior Therapy)Restitution OrdersNo Services ProvidedSchool VisitsTFCBT (Trauma Focused Cognitive Behavioral Therapy) or other Trauma ServicesTransportationOther Service (Please Specify)

     Enter Service to be Provided
220. Other Service (Specify)
221. Funding Source*
     -- Select One --MedicaidInsuranceIndigent Driver FundsState FundsSelf PayJDC/RF FundsOther Grant FundsOther Federal FundsOther SpecifyUnknownNone
222. Other Specify Funding Source
224. External Agency Referral

     1. Yes
     2. No

     Were referrals made from your agency to an external provider? (enter up to 3)
226. Date of Referral
     Date of Referral
     1a. Please Enter the Date referred
227. Agency / Organization Referred To
     1b. Name of the Agency or Organization that an external referral was made to
229. Reoffered to this organization for the following services

     1. Substance Abuse Treatment
     2. Behavioral / Mental Health
     3. Education
     4. Employment
     5. Family Services
     6. Prosocial / Recreational
     7. Other Services
230. Other Services
     1d. Please describe other services
232. Date of Referral
     Date of Referral
     2a. Please Enter the Date referred
233. Agency / Organization Referred To
     2b. Name of the Agency or Organization that an external referral was made to
235. Services Provided by this Agency / Organization

     1. Substance Abuse Treatment
     2. Behavioral / Mental Health
     3. Education
     4. Employment
     5. Family Services
     6. Prosocial / Recreational
     7. Other Services
236. Other Services
     2d. Please describe Other Services
238. Date of Referral
     Date of Referral
     3a. Please enter the Date referred
239. Agency / Organization Referred To
     3b. Name of the Agency or Organization that an external referral was made to
241. Services Provided by this Agency / Organization

     1. Substance Abuse Treatment
     2. Behavioral / Mental Health
     3. Education
     4. Employment
     5. Family Services
     6. Prosocial / Recreational
     7. Other Services
242. Other Services
     3d. Please describe Other Services
244. Any Drug Screens?*

     1. Yes
     2. No

     Please enter Drug Screen results.
245. Drug Name*
     -- Select One --AlcoholMarijuanaHeroinCocaineOpiatesOxycodoneOther
246. Other Drug
     Please specify
248. Date of Screen*
     Date of Screen
     Enter Date of Drug Screening
249. Result of Screen*

     1. Negative
     2. Positive
     3. DNG
     4. Pending

     Enter Drug Test Result
250. Creatine?

     1. Normal
     2. Diluted
251. Another Test ?*

     1. Yes
     2. No
253. Drug Name
     -- Select One --AlcoholMarijuanaHeroinCocaineOpiatesOxycodoneOther
254. Other Drug
     Please specify
256. Date of Screen*
     Date of Screen
257. Result of Screen*

     1. Negative
     2. Positive
     3. DNG
     4. Pending
258. Creatine?

     1. Normal
     2. Diluted
259. Another Test?*

     1. Yes
     2. No
261. Drug Name
     -- Select One --AlcoholMarijuanaHeroinCocaineOpiatesOxycodoneOther
262. Other Drug
     Please specify
264. Date of Screen*
     Date of Screen
265. Result of Screen*

     1. Negative
     2. Positive
     3. DNG
     4. Pending
266. Creatine?

     1. Normal
     2. Diluted
267. Another Test?*

     1. Yes
     2. No
269. Drug Name
     -- Select One --AlcoholMarijuanaHeroinCocaineOpiatesOxycodoneOther
270. Other Drug
     Please specify
272. Date of Screen*
     Date of Screen
273. Result of Screen*

     1. Negative
     2. Positive
     3. DNG
     4. Pending
274. Creatine?

     1. Normal
     2. Diluted
275. Another Test?*

     1. Yes
     2. No
277. Drug Name
     -- Select One --AlcoholMarijuanaHeroinCocaineOpiatesOxycodoneOther
278. Other Drug
     Please specify
280. Date of Screen*
     Date of Screen
281. Result of Screen*

     1. Negative
     2. Positive
     3. DNG
     4. Pending
282. Creatine?

     1. Normal
     2. Diluted
284. Discharge Status
     -- Select One --Successfully completed, Discharged to communitySuccessfully completed, Referred to another providerUnsuccessful discharge, Voluntarily withdrew from programUnsuccessful discharge, Diverted to another substance abuse treatment programUnsuccessful discharge, Diverted to another mental health programUnsuccessful discharge, Disciplinary reasonsOther (Please Specify)

     If applicable,enter Discharge information
285. If Other, Please Specify
286. Date of Discharge
     Date of Discharge
288. End of Treatment Provider Info
Leave This Blank:


305. 1. Receive an email copy of this form.
306. Email address

     This field is not part of the form submission.

307. Submit

* indicates a required field