Drug Court Progress Report Services Provided

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

292. School Attendance Issues ?

     1. Yes

293. Suspended, Expelled, Truancy Hearing
     -- Select One --SuspendedTruancy HearingExpelledOtherNone

295. School Attendance/Behavior Note

297. Drop_Notes

     Enter Excused Drop, or Other Drop Notes

299. Breathalyzer

     1. Yes

300. Breathalyzer Date
     Breathalyzer Date

302. Prior Court Orders

     1. Attend Sober Support Activities
     2. Community Service Hours
     3. Complete phase advancement paper
     4. House Arrest
     5. House Arrest w/Surveillance

303. Number of Community Service Hours assigned

304. Number of Sober Support Activities

306. Other Court Orders

308. Prior Drop Schedule

     1. Red
     2. Yellow
     3. Green

     Drop schedule changed, or used Normal Schedule based on Phase in program.

309. Case Manager Comments and Recommendations

     875 character limit about 8 lines

311. New Court Orders

     1. Administrative Review
     2. Attend Sober Support Activities
     3. Community Control Detention Reporting Center Level 2
     4. Community Control Level 3
     5. Community Control Level 4
     6. Community Control Level ?
     7. Community Service Hours
     8. Complete phase advancement paper
     9. Electronic Monitoring
     10. House Arrest
     11. House Arrest w/Surveillance
     12. Mentor to be assigned
     13. Move to Phase
     14. Present Relapse Prevention Plan
     15. SCRAM

312. Number of Sober Support Activities assigned

313. Phase to be moved to*

314. Number of Community Service Hours to assign

316. Other Court Orders

317. Daily Drop Schedule

     1. Turn On
     2. Turn Off
     3. Leave On
     4. NA

319. New Drop Schedule

     1. Use Normal Phase Definition
     2. Red
     3. Yellow
     4. Green

     Change future drop schedule if necessary

321. Change Next Court Hearing Date?

     1. Yes
     2. No

     If next court hearing date not based on phase, enter exception here

322. Date of Next Court Hearing
     Date of Next Court Hearing

     If next court hearing date not based on phase, enter exception here.

324. Today's Hearing Date*
     Today's Hearing Date

     In case TP does not enter correct hearing date

325. Enter Court Id*

     In case TP enters wrong id

Leave This Blank:


327. 1. Receive an email copy of this form.
328. Email address

     This field is not part of the form submission.

329. Submit

* indicates a required field