SECTION 1 CLIENT ENTRY INTO SYSTEM Procedure 115.. Capacity Report Form Screening 120. DADS Referral for Services 120 A. DADS Referral for Services Guide 121. Welcome to Treatment Referral 121 A. Welcome to Treatment Dropdown Guide Placement 130. Concurrent Methadone and Residential Treatment 135. Client Placement Decisions 135 A.. ASAM Crosswalk 135 B.. Placement Conversion List 136. Dual Diagnosis Eligibility Criteria 137. Resolving Disputes About Client Placement Decisions/Referrals 138. Warrants 143. In-Custody Placements 144. In-Custody Clients who No-Show to Res Tx or THU 145. Residential Placement and Wait List 145 A.. Residential Wait List Client Instructions 147. THU Advisement Treatment and Services Procedure 150. AB 109 152. Criminal Justice Services 152 A.. Criminal Justice Case Management Referral Protocol 153. MH Full Service Partnership Clients 154. Parolee Re-Entry Grant 155. Veterans Grant 156. Homeless Grant 156 A. Res Homeless Grant Attachment 156 B. OP Homeless Grant Attachment 157. CalEMA Grant 158. Addiction Medicine Therapy (AMT) Medical Hold 160. VHP Referrals 165. Priority Admissions 166. Prop-36 Eligibility SECTION 2 CLIENT MOVEMENT THROUGH THE SYSTEM Referrals, Transfers, and Upgrades Procedure 200. Level of Care and Lateral Transfers 205. Continuum of Care Referral Summary Form 205 A. COC Dropdown Menu Guide i
210. Transitional Housing Unit (THU) Referral and Placement 211. Transitional Housing Unit (THU) Disposition 212. THU Request for Extension 220. Psychiatric Consultation Referral 240. BASN Referrals 245. CDCI Referrals SECTION 3 CLINICAL Clinical Standards Procedure 300.. Clinical Guidelines 300 A.. Clinical Guidelines Table 302. Intensive Outpatient Services 303. Treatment Assessment 304. Discharge Planning and Summary 305. Treatment Plans 306. Request for Temporary Reduction of Caseload Size 307. Request for Residential Extension 307 A. Request for Res Ext Guidelines Special Issues 308. Unamenable 309. Managing Client Alcohol/Drug Use during Treatment 309 A.. Managing Client Use System Guideline 311. Managing Client Threats of Violence Protocol 312. Managing Client Violence 312 A.. Managing Client Violence System Guideline 313. Managing Client Suicide Potential Protocol 313 A. Suicide Potential Guidelines 314. Child Abuse and Neglect Reporting 315. Managing Client Sexual Conduct at Treatment Facilities 316. THU Violence Protocol 316 A.. Managing Client Violence in the THU System Guidelines 318. Provider Clinical Appeals Process 319. Dual Relationships Special Populations 330. Treatment for Pregnant Women Medical 335. TB Screening 336. Suspected Active TB Disease 338. AMT Take-Home: Security THU & Res (part 1) 338. AMT Take-Home: Lost Stolen THU & Res (part 2) 340. Clients with Prescription Medication 341. In-Custody Clients Referred with Medications ii
345. Medical Marijuana Charting 350. Progress Notes 360. Group Agreement Policy 360 A.. Group Agreement Example SECTION 4 COMMUNICATION Confidentiality Procedure 400. Authorization Form for the Release of Confidential Client Info 404. Criminal Justice Consent 405. System Authorization Form for the Release of Confidential Client Info 406. Fax and Email Transmission of Confidential Client Information 407. Confidentiality Leaving messages for potential clients/clients 408. Parole Authorization Policy 409. AB 109 Authorization Policy Communication Inside and Outside the System 410. Treatment Status Report 410 A.. Treatment Status Report Form Instructions 410 B.. Treatment Status Report FAQs 415. Transitional Housing Unit Client Status Report Form 420. Communication: Transitional Housing Unit Providers and Outpatient Providers 425. System Feedback Form 430. Contract Agency Accident/Incident Report 435. County Agency Accident/Incident Report 440. Temporary Agency Closures SECTION 5 CLIENT EXIT FROM THE SYSTEM Procedure 500. Grievance Process 510. THU Housing Exit Plan 520. Timeline for Chart Closures SECTION 6 QUALITY IMPROVEMENT/ASSURANCE Procedure 610. UNI/Care Data Entry 615. UNI/Care User Account and Provider Maintenance 650. Learning Organization SECTION 7 CONTINUOUS RECOVERY MODEL Procedure 700. Continuous Recovery Model (CRM) 701. CRM Client Returns to TX iii
APPENDIX A PERFORMANCE MEASURES None with this Release APPENDIX B COUNSELOR RESOURCE MATERIALS Best Practices Clinical Abbreviations The Clinician s Guide (Toolkit) Dual Diagnosis Services Patient Placement Criteria Outline Medical Necessity Criteria, Santa Clara County, Dept of Mental Health APPENDIX C APPENDIX D TAB D1. TAB D2. THU STANDARDS FORMS Capacity Report Forms primarily used for client entry, referral, and transfer Case Management Questionaire Continuum of Care Referral Summary DADS Referral for Service DADS Referral for Service Guide Psychiatric Referral Client Information WTT Reassessment VHP Confidential Patient Information Form VHP Gateway Referral Form Authorization for the Release of Confidentiality Auth - 2-Party for the Release of Confidential Client Info Auth - 2-Party for the Release of Confidential Client Info-Span Auth - 2-Party for the Release of Confidential Client Info-Viet Auth AB 109 for the Release of Confidential Client Info Auth AB 109 for the Release of Confidential Client Info-Span Auth AMT Confidential Info Auth AMT Confidential Info Spanish Auth AMT Confidential Info Vietnamese Auth-Systems - for the Release of Confidential Client Info Auth-Systems - for the Release of Confidential Client Info-Span Auth-Systems - for the Release of Confidential Client Info-Viet Auth-CJS DADS Auth-CJS DADS-Span Auth-CJS DADS-Viet Auth-BASN CJS-DADS Auth-Dependency Court-DADS Auth-Moorpark Care Team iv
THU Forms THU/DA Certification/Advisement Form THU/DA Certification/Advisement- Spanish THU/DA Certification/Advisement- Vietnamese THU Client Disposition Form THU Exit Plan THU Request for an Extension Unicare Forms UNI/Care CalOMS Registration Form UNI/Care CalOMS Registration Data Definitions UNI/Care CalOMS Admission Form UNI/Care CalOMS Admission Form Data Definitions UNI/Care CalOMS Admit Questionnaire UNI/Care CalOMS Admit Questionnaire Data Definitions UNI/Care CalOMS Discharge Summary Form UNI/Care CalOMS Discharge Summary Data Definition UNI/Care CalOMS Discharge Questionnaire UNI/Care Services Rendered Form UNI/Care THU Admission/Discharge Form UNI/Care CalOMS CFCS-Detox Admit Form UNI/Care CalOMS CFCS-Detox Discharge Form UNI/Care Annual Update UNI/Care Oath of Confidentiality UNI/Care User Information Form UNI/Care Username Request Form UNI/Care User Responsibility Statement Instruction TAB D3. Forms primarily used for client treatment Clinical Protocol: Suicide Potential Scale Suicide Prevention Planning Form Continuum of Care Referral Summary Discharge Summary Codes Discharge Summary Form Progress Notes Form Progress Form Psycho-Ed (Structured- Discovery Group) Request for Residential Extension Form Treatment Assessment Form Treatment Assessment Spanish Treatment Assessment Viet Treatment Assessment Codes Treatment Plan Form A Treatment Plan Form B Treatment Plan Form - Counselor Version-Viet v
Treatment Status Report (TSR) TAB D4. Forms primarily used for reporting purposes Detox Status Report Form Detox Status Report Dropdown Guide Gateway Status Report Form Treatment Status Report (TSR) TSR Instructions Unamenable/Ineligible/Suspended Client Report Form Unamenable/Ineligible/Suspended Report Dropdown Guide Accident/Incident Report-Contract Agency Accident/Incident Report-County Agency System Feedback Form Temporary Closure Form THU Client Status Report (CSR) THU Exit Plan Patient Death Report Unusual Incident/Injury/Death Report TAB D5. TAB D6. Forms related to client outcomes measurement ORS / SRS Forms Forms related to Continuous Recovery Monitoring CRM Client Consent CRM Information Sheet (Handwritten) CRM Information Sheet (Fillable Form) CRM Call Record (Handwritten) CRM Call Record (Fillable Form) CRM Call Record (Excel Spreadsheet) CRM Immediate Needs Profile CRM Discharge Form / Referral to TX Form (Fillable Form) CRM Discharge Form / Referral to TX Form-Menu CRM Consent CRM Email Consent vi