Client Related Forms2

Click Here For Printable Checklist

Referral Packet
☐ Referral letter from Dr. Krohn
☐ Referral/Application (completed by referring agent)
☐ Screening (completed by APS staff after receiving the referral info)

Welcome Packet
To be given to ALL clients to keep
Receipt of these documents to be kept in the client record
☐ Welcome letter from Dr. Krohn
☐ “My Rights” Handbook
☐ Program/Service Specific Handbook
☐ Program Description- Service Specific
☐ APS’ Privacy Practices
☐ Client Rights Policy
☐ Fee Policy
☐ Client Funds in Residential Services Policy
☐ Client Grievance Policy
☐ Suspension & Expulsion Policy
☐ Search and Seizure Policy
☐ Restrictive Interventions
☐ Protection of Client Possessions Policy

In-take Packet
To be maintained in ALL client records
☐ Face Sheet
☐ Referral
☐ Screening
☐ Consent for Treatment
☐ Decision to Enter Care (updated annually)
☐ Authorization for Medical Care (updated annually)
☐ Authorization to Disclose Health Info (updated annually)
☐ Privacy Practices receipt
☐ Client Rights (updated annually by reviewing entire welcome packet)
☐ Admission Assessment
☐Consent to be photographed

Program Specific Paperwork
For clients that take medications in our services
☐ Authorization for Over-The Counter (OTC) medications, if applicable
☐ Authorization to Self-Administer Medication, if applicable
☐ Medication Education

For clients in DHSR licensed services
☐ Receipt of No Smoking Notice

For Non-Residential Services
☐ Field Trip Permission Form
☐ Approved Therapeutic Leave

For Alamance House
☐ Affidavit of Student in Good Standing
☐ Approved Therapeutic Leave

For Therapeutic Foster Care
http://info.dhhs.state.nc.us/olm/forms/forms.aspx?dc=dss

Annual Consents
For all clients
☐ Decision to Enter Care (updated annually)
☐ Authorization for Medical Care (updated annually)
☐ Authorization to Disclose Health Info (updated annually)
☐ Client Rights (updated annually by reviewing entire welcome packet)

For clients that take medications in our services
☐ Authorization for Over-The Counter (OTC) medications, if applicable
(signed annually by the physician)
☐ Authorization to Self-Administer Medication, if applicable
(signed annually by the physician)
☐ Medication Education
(signed annually by the physician)

Discharge
For all clients
☐ Discharge Summary

 

Please use the comment box below to let me know how this works for your program. Thanks! Jenny


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