WAITING LIST
MANAGEMENT
Month/Year:
Provider:
Section 1: Alcohol and Drug Treatment Services
Waiting List for Alcohol and Drug Diagnostic Assessment: Adult (unduplicated quantity)
Total Number of Clients Waiting for Diagnostic Assessment During the Month
Average Number of Calendar Days from date client first called for appointment to date of initial
Diagnostic Assessment appointment scheduled.
Adults: Alcohol and Drug Treatment:
How many clients were referred for TB services?
Level of Care
Level IA-Outpatient
Level IB-Intensive Outpatient Program
Total Number of
Clients Waiting for
Level of Care
# clients
# ave days
# clients
# ave days
# clients
# ave days
# clients
# ave days
# clients
# ave days
# clients
# ave days
Number of
Pregnant
Women
Waiting for
Level of Care
Number of
IVDU Clients
Waiting for
Level of Care
Level IC-Day Treatment
Level 2A-Non-Medical Community Residential
Level 3A-Ambulatory Detoxification
Level 3B-Observation Bed
Level3C-Sub-Acute Detoxification
Total
Referral of Parent, Guardian, or Custodian with Substance Abuse Disorder who have
Dependent Children at Risk of Neglect/Abuse
Total Number of Parents, Guardians, or Custodians with Substance Abuse Disorders Referred from a
Public Children Services Agency
Average Number of Calendar Days from date Parent, Guardian, or Custodian was referred for
appointment to date of initial Diagnostic Assessment appointment scheduled. Should be no more than
2 weeks.
Waiting List for Alcohol and Drug Diagnostic Assessment: Adolescent
(unduplicated quantity)
Total Number of Clients Waiting for Diagnostic Assessment During the Month
Average Number of Calendar Days from date client first called for appointment to date of initial
Diagnostic Assessment appointment scheduled.
Revised 5-12-15
Adolescents: Alcohol and Drug Treatment:
How many clients were referred for TB services?
Level of Care
Total Number of
Clients Waiting for
Level of Care
Level IA-Outpatient
Level IB-Intensive Outpatient Program
# clients
# ave days
# clients
# ave days
# clients
# ave days
# clients
# ave days
# clients
# ave days
Number of
Pregnant
Women
Waiting for
Level of Care
Number of
IVDU Clients
Waiting for
Level of Care
Level IC-Day Treatment
Level 2A-Non-Medical Community Residential
Level 3A-Ambulatory Detoxification
Level 3B-Observation Bed
Level3C-Sub-Acute Detoxification
Total
Pregnant Women (AoD services only)
Number
For pregnant clients, average number of calendar days from date initial contact was made to
date of initial assessment? Should be no more than 24 hours.
How many pregnant clients were admitted to the needed LOC within 24 hours of the initial
assessment?
How many clients received interim services? Should receive interim services within 48 hours.
IVDU Clients (AoD services only)
Number
For IVDU clients, average number of calendar days from date initial contact was made to date
of initial assessment? Should be no more than 24 hours.
How many IVDU clients were admitted to the needed LOC within 24 hours of the initial
assessment?
How many clients received interim services? Should receive interim services within 48 hours.
Has the agency reached 90% capacity this month? (mark ‘yes’ or ‘no’ in box to the right)
Section 2: Co-Occurring MH/AoD Services
Waiting List for Diagnostic Assessment: Adult Co-Occurring (unduplicated quantity)
Total Number of Clients Waiting for Diagnostic Assessment During the Month
Average Number of Calendar Days from date client first called for appointment to date of initial
Diagnostic Assessment appointment scheduled.
Revised 5-12-15
Adults: Co-Occurring Treatment Services:
How many clients were referred for TB services?
Level of Care
Total Number of
Clients Waiting
for Level of Care
Level IA-Outpatient
Level IB-Intensive Outpatient Program
Number of
Pregnant Women
Waiting for Level
of Care
Number of IVDU
Clients
Waiting for Level
of Care
# clients # ave days
# clients # ave days
Level IC-Day Treatment
Level 2A-Non-Medical Community Residential
Level 3A-Ambulatory Detoxification
# clients # ave days
# clients # ave days
Level 3B-Observation Bed
Level3C-Sub-Acute Detoxification
Total
# clients # ave days
# clients # ave days
Pregnant Women (Adult Co-Occurring Services Only)
Number
For pregnant clients, average number of calendar days from date initial contact was made to
date of initial assessment? Should be no more than 24 hours.
How many pregnant clients were admitted to the needed LOC within 24 hours of the initial
assessment?
How many clients received interim services? Should receive interim services within 48 hours.
IVDU Clients (Adult Co-Occurring Services Only)
Number
For IVDU clients, average number of calendar days from date initial contact was made to date
of initial assessment? Should be no more than 24 hours.
How many IVDU clients were admitted to the needed LOC within 24 hours of the initial
assessment?
How many clients received interim services? Should receive interim services within 48 hours.
Has the agency reached 90% capacity this month? (mark ‘yes’ or ‘no’ in box to the right)
Waiting List for Diagnostic Assessment: Adolescent Co-Occurring (unduplicated quantity)
Total Number of Clients Waiting for Diagnostic Assessment During the Month
Average Number of Calendar Days from date client first called for appointment to date of initial
Diagnostic Assessment appointment scheduled.
Revised 5-12-15
Adolescents: Co-Occurring Treatment Services:
How many clients were referred for TB services?
Level of Care
Total Number of
Clients Waiting
for Level of Care
Number of
Pregnant Women
Waiting for level
of care
Number of IVDU
Clients
Waiting for level
of care
# clients # ave days
Level IA-Outpatient
Level IB-Intensive Outpatient Program
# clients # ave days
Level IC-Day Treatment
Level 2A-Non-Medical Community Residential
Level 3A-Ambulatory Detoxification
# clients # ave days
# clients # ave days
Level 3B-Observation Bed
Level3C-Sub-Acute Detoxification
# clients # ave days
Total
Pregnant Women (Adolescent Co-Occurring Services Only)
Number
For pregnant clients, average number of calendar days from date initial contact was made to
date of initial assessment? Should be no more than 24 hours.
How many pregnant clients were admitted to the needed LOC within 24 hours of the initial
assessment?
How many clients received interim services? Should receive interim services within 48 hours.
IVDU Clients (Adolescent Co-Occurring Services Only)
Number
For IVDU clients, average number of calendar days from date initial contact was made to date
of initial assessment? Should be no more than 24 hours.
How many IVDU clients were admitted to the needed LOC within 24 hours of the initial
assessment?
How many clients received interim services? Should receive interim services within 48 hours.
Has the agency reached 90% capacity this month? (mark ‘yes’ or ‘no’ in box to the right)
Section 3: ACTT-IDDT Services
Waiting List for Diagnostic Assessment: Adult ACTT-IDDT (unduplicated quantity)
Total Number of Clients Waiting for Diagnostic Assessment (non-physician) during the month
Average Number of Calendar Days from date client first called for appointment to date of initial
Diagnostic Assessment appointment scheduled.
Revised 5-12-15
Section 4: Mental Health Treatment Services
Waiting List for Diagnostic Assessment: Adult Mental Health (unduplicated quantity)
Total Number of Clients Waiting for Diagnostic Assessment (non-physician) during the month
Average Number of Calendar Days from date client first called for appointment to date of initial
Diagnostic Assessment appointment scheduled.
Waiting List for Diagnostic Assessment: Child/Adolescent Mental Health
(unduplicated quantity)
Total Number of Clients Waiting for Diagnostic Assessment (non-physician) during the month
Average Number of Calendar Days from date client first called for appointment to date of initial
Diagnostic Assessment appointment scheduled.
Section 5: MST and WA Services
Waiting List for MST Assessment and WA SNCD (unduplicated quantity)
Total Number of Clients Waiting for Diagnostic Assessment (non-physician) or SNCD during the
month.
Average Number of Calendar Days from date client first called for appointment/date of referral to
date of initial Diagnostic Assessment or SNCD appointment scheduled.
Section 6: Agency Med/Som Services
Adult Waiting List for Initial Med/Som Service (unduplicated quantity)
Total Number of Adult Clients Waiting for an Initial Med/Som Appointment during the month.
Average Number of Calendar Days from date the referral for Med/Som service was made to the date
the initial Med/Som appointment was scheduled for.
Child/Adolescent Waiting List for Initial Med/Som Service (unduplicated quantity)
Total Number of Child/Adolescent Clients Waiting for an Initial Med/Som Appointment during the
month.
Average Number of Calendar Days from date the referral for Med/Som service was made to the date
the initial Med/Som appointment was scheduled for.
Revised 5-12-15
Section 7: Agency Community Psychiatric Supportive Treatment (CPST)
Services
Adult Waiting List for Initial CPST Service (unduplicated quantity)
Total Number of Adult Clients Waiting for an Initial CPST Appointment during the month.
Average Number of Calendar Days from date the referral for CPST service was made to the date the
initial CPST appointment was scheduled for.
Child/Adolescent Waiting List for Initial CPST Service (unduplicated quantity)
Total Number of Child/Adolescent Clients Waiting for an Initial CPST Appointment during the
month.
Average Number of Calendar Days from date the referral for CPST service was made to the date the
initial CPST appointment was scheduled for.
Additional Comments:
Prepared by:
Revised 5-12-15
Date: