Table of Contents
(Each Section listed Top to bottom)
Section 1
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Table of Contents
Section 2
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Discharge Summary/Transition Plan at closure (Blue Form)
Individual Progress Notes, Group Progress Notes, Case Management Notes, CPST
and Psychiatric Clinical Individual Notes, Notes to file, (Urine Screening Results on
yellow paper if applicable)
Reopen Forms. (Copy of all forms filed in chronological order)
Status Change Form
Section 3
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Initial Transition Planning Worksheet
Treatment plan
Care Management Assessment
Care Management Plan
Personal Safety Plan (If PSP is not needed indicate this on form / When needed a Copy Must Be
Place In the file and in a Folder in File Room or secure area where staff has access to the plan)
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Continued Stay Level of Care
Ohio Behavior Health Transfer Form (Yellow Form)
Section 4
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NCA (National Council on Alcohol / Alcohol Screening Test)
MAST (Michigan Alcohol Screening Test)
DAST (Drug Abuse Screening Test),
Other Pertinent Screening Tools (South Oaks Gambling Screening, etc.)
CIWA – Ar (Clinical Institute Withdrawal Assessment of Alcohol Revised Scale) Other
Pertinent Withdrawal Assessment tools (COWS) Clinical Opiate Withdrawal Scale
Client Referral Form
Mental Health Referral Form
Transitional Summary Form
Adult Diagnostic Assessment (Level of Care Form, Recommendations for Treatment
Form, and Diagnostic Criteria Forms are included in the assessment packet)
SNAP Form
Lethality Assessment (If Applicable)
Section 5
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All Correspondence Received or Sent (Filed in Chronological Order / Most Recent on
Top)
Releases of Information(Legal and non-legal releases forms provided)
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Table of Contents
(Each Section listed Top to bottom)
Section 6
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Macsis Ohio Behavioral Health Admission Form (Green Sheet)
Client Orientation Check List
Notice of Privacy Practices (2 Pages)
Consent for Alcohol / Drug Treatment / Services
Program Rules and Expectations
Written Summary of Federal Confidentiality Laws & Regulations for Clients in
Alcohol and/or Drug Programs
Authorization for Disclosure of Confidential Information About Persons Receiving
Services From Pike County Recovery Council
Macsis Residency Verification Form
Pike County Recovery Council Financial Agreement
Consent for the Release of Confidential Financial Information
Medicaid Verification Forms (Obtain from Verification Site)
Initial Intake Data Sheet
Macsis Ohio Behavioral Health Discharge Form (Blue Sheet)
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