Admission Application: Intensive Residential Rehabilitation / Community Residence / Supportive Living COVER PAGE
|
|
- Elwin Bishop
- 5 years ago
- Views:
Transcription
1 COVER PAGE Please check which level of care to which the applicant is applying. Complete referral packages* should be faxed to (716) or scanned and ed to Thank you. Intensive Residential Rehabilitation (Women) Intensive Residential Rehabilitation (Men) Madonna House Turning Point House 5586 Niagara St. Ext Sandrock Rd. Lockport, NY Eden, NY Applicants may be single women, pregnant women, or women with children preschool-age or younger Community Residential Erie County Casa Di Vita (Women) Cazenovia Manor (Men) Unity House (Homeless men) 200 Albany St. 486 N. Legion Dr. 923 Sycamore St. Buffalo, NY Buffalo, NY Buffalo, NY Verification of homelessness required Niagara County Somerset House (Women) Sundram Manor (Men) 7397 Lake Rd. 431 Memorial Pkwy Appleton, NY Niagara Falls, NY Liberty Hall PO Box 1500 Batavia, NY Please send applications for Liberty Hall directly to the program s address or fax, which is (585) Applications for Liberty Hall should not be sent to the address or fax number listed at the top of this page. Supportive Living (Erie County) Apartments located in Buffalo and surrounding areas Supportive Living (Niagara County) Apartments located in Niagara Falls and Lockport. Limited beds are available in both counties for parents with children preschool-age or younger *Complete referral packages must include the following: Application Psycho-social assessment Treatment plan Verification of homelessness (required for Unity House applicants) Confirmations from Social Services or Social Security Mental health evaluation, if applicable Consent forms (Social Service, referring agency, LOCADTR etc.) Medical history, physical, medical clearance for communicable diseases, and lab work with a PPD test and verification 1
2 INTRODUCTION Thank you for your interest in Cazenovia Recovery Systems. We look forward to assisting you in your continued recovery. You should be proud that you are open to receiving treatment. Please answer the questions below to the best of your ability. We understand this application asks many questions of you. This is done so that we can provide you with the best treatment possible so that you can build a future, achieve your dreams, and reach your goals. During your stay with us, we hope to provide you with services and treatment that are supportive and encouraging. We will assist you in finding resources for which you qualify to help make your recovery a positive journey toward your future. APPLICANT INFORMATION Name: Phone: Street address (prior to treatment, if applicable): City: County: State: Zip: What are the reasons why the applicant cannot return to the above address? Is the applicant homeless or at risk for homelessness? If yes, please explain: D.O.B. S.S.N. Medicaid Number: VETERAN STATUS Is the applicant a Veteran? If yes, please answer the following: Branch: Discharge Type: Years of Service: Did the applicant serve in the reserves? If yes, were they deployed? Does the applicant receive VA funding? If yes, how much per month? 2
3 SUBSTANCE HISTORY Does the applicant have a substance disorder diagnosis? If yes, list DSM / ICD Code: Code Description Substance Type Onset Frequency Route of Ingestion Date of Last Use TREATMENT HISTORY (e.g. Detox, Outpatient, Inpatient, Community Residence, etc.): Facility Name Type Dates Successful Completion 3
4 MENTAL HEALTH Does the applicant have a mental health diagnosis? If yes, please explain below: Diagnosed by: Date of diagnosis: Is the applicant currently receiving mental health treatment? If yes, who is the provider? Does the applicant have previous mental health treatment, including hospitalization? If yes, please answer the following: Events leading to mental health treatment Program Dates / Length of Stay Does the applicant have a history of suicide attempts? If yes, please explain below: 4
5 MEDICAL Does the applicant have a Primary Physician? If yes, please provide the following: Name of Physician Address Phone No. Conditions being treated Date of last physical exam / lab / blood work: Date of last TB test: List any physical disabilities or limitations: Is the applicant currently being treated for any communicable disease? If yes, explain below: Does the applicant have any previous head injuries? If yes, please explain circumstances: Has the applicant ever been linked with a Health Home? If yes, provide the following: Name of Health Home Health Home City Dates of Enrollment If the applicant is female, is she pregnant? N/A If yes, please answer the following: When is her due date? Is she receiving prenatal care? If she is receiving prenatal care, where? MEDICATION Current Medication Dosage Prescribing Doctor Reason for Medication Is the applicant prescribed any Medication-Assisted Treatment medications? If yes, please complete the following: Current Medication Dosage Prescribing Doctor Phone Number 5
6 LEGAL Is the applicant mandated to this level of care? If yes, by whom: Please provide any legal entities with which the applicant has involvement: Entity (Drug Court*, Probation, etc.) Jurisdiction Contact Person Contact Number If you are a Drug Court making this referral, please include the applicant s NYS ID and a criminal justice release with the completed application. Does the applicant have any pending court appearances? If yes, please describe below: Date Time Location Reason for Appearance Does the applicant have outstanding warrants? Unknown Does the applicant have a history of assault? Unknown Has the applicant accidentally or intentionally set fires? Unknown Has the applicant been arrested for or convicted of arson? Unknown Has the applicant ever been convicted of any crimes? If yes, provide nature of arrests: Has the applicant ever been incarcerated? Unknown Does the applicant have any history of rape, sexual abuse, or violent crimes against a person? If yes, please explain below: Does the applicant have an order of protection? Unknown 6
7 FINANCIAL Does the applicant currently receive Social Service benefits? If yes, please provide: From which county? Current monthly amount: Does the applicant currently receive SSI / SSD benefits? If yes, please provide: Self-Payee Rep Payee Payee Name: Phone No.: Payee Address: Current monthly income received from SSI / SSD: Has the applicant ever been sanctioned/refused Social Services or Social Security benefits? If yes, please explain: Does the applicant have any other sources of income? If yes, please explain: EDUCATION Proof of income must be submitted with the application. What is the highest grade level the applicant has completed? High School Diploma GED Some college College degree Please list any diplomas, degrees, certificates, and licenses below: FAMILY What is the applicant s marital status? Single Married Divorced Estranged Widowed Does the applicant have any children? If yes, do they have custody? If yes, how old are the children? If the applicant is applying to Madonna House or Supportive Living, do they hope to have children reside with them while in the program? N/A 7
8 SIGNATURES By signing below, you (the applicant) agree to and understand the following: 1. If you are receiving SSI/SSD or other forms of income, a sliding fee scale and financial agreement will be developed and agreed upon prior to your admission. 2. Cazenovia Recovery strives to house individuals who have prior histories of homelessness. If this applies to you, you may be asked to verify your homelessness status. 3. To ensure the safety of all applicants, current residents, and staff, you may be asked to consent to a criminal background check. 4. Cazenovia Recovery Systems cares about the health of each and every one of our residents. To ensure that our programs are healthy places to live, all of our facilities are no smoking. Applicants with nicotine dependence will be provided with smoking cessation information, treatments and groups. 5. For applicants applying to Madonna House: Mothers in recovery may need time to adjust to the program and to establish parenting skills they may need to develop. Because of this, children who are eligible for admission may not be admitted at the same time as their mother. Applicant s Signature: Date: Printed Name: Referring Staff s Signature: Date: Printed Name: Referring Agency Name: Contact Phone: 8
NEW LIFE FOR YOUTH ENROLLMENT APPLICATION
FACILITY 2 FACILITY 1 NEW LIFE FOR YOUTH ENROLLMENT APPLICATION GENERAL INFORMATION FIRST NAME LAST NAME MIDDLE CURRENT EMAIL PHONE GENDER (Circle) M F DATE OF BIRTH ARE YOU A U.S. CITIZEN? Y N IF YES,
More informationHARMONY HAUS SOBER LIVING MEMBER APPLICATION HARMONY HAUS, LLC.
HARMONY HAUS SOBER LIVING MEMBER APPLICATION HARMONY HAUS, LLC. BACKGROUND CHECK INFORMATION FULL NAME: NICKNAME OR ALIAS: PHONE: EMAIL: MARITAL STATUS: DATE OF BIRTH: DL/ID# EXPIRATION DATE STATE ISSUED
More informationNew Beginnings Long-Term Treatment Program
New Beginnings Long-Term Treatment Program To be eligible for the New Beginnings Program, you must: A. Be a resident of Kalamazoo County. B. Be a male with a history of alcohol or drug abuse. C. Be homeless
More informationTransitional Age Youth Housing Application 3530 Wilshire Blvd. 4 th Floor Los Angeles, CA (213)
THP Transitional Age Youth Housing Application 3530 Wilshire Blvd. 4 th Floor Los Angeles, CA 90010 (213) 351-0100 THP-Plus (Ages 18-21) (Ages 18-24) General Information Name: Date: / / Address: City:
More informationApplication for Residential Services
Check for which program applying for: Macleigh/VA Beach Kilmarnock/Rappahanock Colonial Beach/Colonial Beach Lynchburg Garber Morris/Varina Bonnie/Stuarts Draft Saratoga/Winchester Tate/Ashland Mary Beth
More informationLifeway Child/Adolescent Information Form
Date / / Lifeway Child/Adolescent Information Form Patient Name: First MI Last Date of Birth: / / Gender: M F Marital Status: M S D Address: City State: Zip: Primary Contact Phone: Secondary Contact Phone:
More informationJAIL TECHNICIAN. Some form of picture identification, such as a driver's license, will be required at examinations.
JAIL TECHNICIAN APPLICATION REQUEST AND RELEASE I, (print your name), hereby state that I wish to apply for employment at the Peoria County Sheriff's Office. I understand that as part of the application
More informationDetention/Hold Have the parents been notified? Yes - No By Whom Time: Officer/s Involved: Reason(s) for placement/offense: Person transporting:
Admission Form Date: PORT Group Homes Name: Last First Middle Date of birth Social Security number Admitted by order of : of on (Social Worker, Probation Officer, Judge) (County) (Date) Picture Taken:
More informationCertified Peer Recovery Mentor
Michigan Certification Board for Addiction Professionals CERTIFICATION MANUAL For Certified Peer Recovery Mentor (Michigan Only, non-ic&rc reciprocal) CPRM-M Directions for Submitting Application Completion
More informationBergen County Housing, Health and Human Services Center 120 South River Street, Hackensack, NJ 07601
Bergen County Housing, Health and Human Services Center 120 South River Street, Hackensack, NJ 07601 Housing Authority of Bergen County - Christ Church CDC - Care Plus NJ, Inc. Next Step intake worksheet
More informationVIDA Application. [ ] Yes [ ] No
Please complete this entire form. The information is for VIDA s use and will not be shared with any other agency without your consent. It is needed to determine your qualifications and to help us understand
More informationHelp Me Budget; Client Enrollment Form * Required
Help Me Budget; Client Enrollment Form * Required 1. Client's last name: * 2. Client's first name * 3. Client's current address * 4. Date of birth * 5. Social Security number * 6. Client ID number Leave
More informationTRAINING WORKBOOK Pilot Session 2
Rhode Island Behavioral Health On-Line Data (BHOLD) Service TRAINING WORKBOOK Pilot Session 2 Version 1.0 September 2009 1-888-600-4777 ribholdsupport@kitsolutions.net KIT Solutions, LLC 5700 Corporate
More informationCalOMS Tx Data Dictionary
The California Outcomes Measurement System Treatment (CalOMS Tx) File Version 2.0 File Version 2.1 (LGBT) California Department of Health Care Services January 2014 Document History Date Brief Description
More informationREFERRAL PROCEDURE for the PEOPLE 1st PROGRAMME (P.I.P.)
REFERRAL PROCEDURE for the PEOPLE 1st PROGRAMME (P.I.P.) 'Supporting People with an Intellectual Disability in relationships, protective education and sexuality People 1 st Programme is registered for
More informationCLINTON COUNSELING CENTER STUDENT SOCIAL MEDICAL QUESTIONNAIRE
CLINTON COUNSELING CENTER STUDENT SOCIAL MEDICAL QUESTIONNAIRE Please respond to ALL questions/information. There are multiple two sided pages. Check to be sure you have completed them all. Provide the
More informationLIFEWAY PREMARITAL INFORMATION FORM LIFEWAY REFERRAL INFORMATION
LIFEWAY PREMARITAL INFORMATION FORM Date: / / Name: First MI Last Date of Birth: / / Gender: M F Marital Status: Single Engaged Divorced Address: City State: Zip: Primary Contact Phone: Secondary Contact
More informationAdmission, Discharge, Update Client Data and Associated Forms
Admission, Discharge, Update Client Data and Associated Forms Table of Contents Introduction... 2 When to Update Client Data... 2 Admission Form... 2 Discharge Form...10 Update Client Data Form...11 CSI
More informationGuidelines for Completing the Residential Claim Form
Guidelines for Completing the Residential Claim Form 1. Bill only residential services on the Residential Claim Form. 2. To avoid denial of claims: Use the correct form. Complete and mail the form only
More informationCONTACT INFORMATION. NAME: Last First Middle Initial. HOME ADDRESS (Please do not use P.O. boxes or P.O. ZIP codes as destination of correspondence):
CONTACT INFORMATION NAME: Last First Middle Initial Gender: Male Female Date of Birth: HOME ADDRESS (Please do not use P.O. boxes or P.O. ZIP codes as destination of correspondence): Address City State
More informationICADV LEGAL SERVICES REFERRAL FORM
ICADV LEGAL SERVICES REFERRAL FORM REV. 10/01/16 Referred by: Organization: Phone Number: Email: Circle appropriate title: IMPD Coordinator / Family Advocate / Extended Support Advocate / Other DATE: Updated
More informationSLATER HIGH SCHOOL A+ STUDENT HANDBOOK SLATER HIGH SCHOOL HOME OF THE WILDCATS
SLATER HIGH SCHOOL A+ STUDENT HANDBOOK SLATER HIGH SCHOOL HOME OF THE WILDCATS Purpose of the A+ Student Handbook The purpose of this manual is to provide a clear understanding of the various aspects of
More informationVision Services Application Overview
The Georgia Lions Lighthouse is a 501(c)3 nonprofit. Our mission is to provide vision and hearing services through education, detection, prevention, and treatment. The services we provide are made possible
More informationTexas Department of Family and Protective Services. Residential Child Care Contractors
Texas Department of Family and Protective Services Residential Child Care Contractors Child Placement Vacancy Database User Guide Only Providers with a Department of Family and Protective Services (DFPS)
More informationASCENSION PARISH SHERIFF S OFFICE Employment Application NO FACSIMILE TRANSMITTALS WILL BE ACCEPTED
ASCENSION PARISH SHERIFF S OFFICE Employment Application NO FACSIMILE TRANSMITTALS WILL BE ACCEPTED Position(s) applying for (number in order of priority): Clerical Corrections E-911 Dispatch Patrol Other
More informationCertification Guidelines: Credential Standards and Requirements Table
Certification Guidelines: Credential Standards and Requirements Table Certified Recovery Peer Specialist (CRPS) Define Yourself as a Professional through Certification. 1715 S. Gadsden St. Tallahassee,
More informationDOMESTIC ABUSE DEATH REVIEW TEAM Fatality Review Data Collection Form. Unknown
DOMESTIC ABUSE DEATH REVIEW TEAM Fatality Review Data Collection Form Case ID#: Date Reviewed: Reviewed By: Chart Includes: Coroner Court Records Newspaper Death Certificate DOC MH/SA LE Local # Family
More informationVictim Assistance & Restorative Justice Program s Registrant/Victim Input at Offender Intake Form
Victim Assistance & Restorative Justice Program s Registrant/Victim Input at Offender Intake Form The Minnesota Department of Corrections goal is to promote safety in the lives of victims and others who
More informationLinda M. Mixon, LCSW Counseling Services
Date of First Appointment: How did you learn about this practice? Client Information: First Name: Middle Initial Last Name Date of Birth (MM/DD/YYYY Age Social Security # Ethnicity: Gender: [ ] Male [
More informationPersonal. Name Last: First: Middle: City: State: Zip: Contact numbers Home ( ) - Work ( ) - Other ( ) - Cell ( ) -
Black Hawk Police Department Background Questionnaire Personal Name Last: First: Middle: Other names you have been known by: Address where you reside Street: Apt/unit/PO Box: City: State: Zip: Mailing
More informationTRANSFER APPLICATION FOR GEORGIA CERTIFICATION Georgia Certified Alcohol and Drug Counselor Levels I, II and III
TRANSFER APPLICATION FOR GEORGIA CERTIFICATION Georgia Certified Alcohol and Drug Counselor Levels I, II and III Our goal is to provide competency-based certification that will assure quality care for
More informationPatient Registration
Patient Registration Adding a Patient Adding a new patient through SequelMed can be accomplished through just a few steps: Defining the Patient Attaching a Plan (optional) Attaching Documents (optional)
More informationFeel free to contact us with any questions, concerns or thoughts you may have. Peace and wellbeing to you. Name: First Middle Last.
Personal Inventory We realize that you are just beginning to express interest in learning about our way of life. We hope that the information provided in this website will answer some of your questions,
More informationBringing it Home: Tools, Knowledge and Approaches You Can Use Cheryl Miles January 24, 2017
Bringing it Home: Tools, Knowledge and Approaches You Can Use Cheryl Miles January 24, 2017 The Smith Family SLIDE: 2 Mrs. Smith, 56, Spouse Incarcerated Situation Grandmother/mother Lives in a rural community
More informationInsyst MHS Mini Manual
Alameda County Behavioral Health Care Services Insyst MHS Mini Manual BHCS Information System Support Services Phone: (510) 567-8181 FAX: (510) 567-8161 E-Mail: ISHelpDesk@acbhcs.org BHCS Web Site: ACBHCS.ORG/PROVIDERS
More informationLIFEWAY PREMARITAL INFORMATION FORM LIFEWAY REFERRAL INFORMATION
LIFEWAY PREMARITAL INFORMATION FORM Name: First MI Last Date of Birth: / / Gender: M F Marital Status: Single Engaged Divorced Address: City State: Zip: Primary Contact Phone: Secondary Contact Phone:
More informationNORTHERN CALIFORNIA EMS,
NORTHERN CALIFORNIA EMS, INC. 930 Executive Way Suite 150, Redding, CA 96002-0635 Phone: (530) 229-3979 Fax: (530) 229-3984 Need It Fast? Apply Online at: www.norcalems.org AEMT RECERTIFICATION APPLICATION
More informationOlympia Family Medicine 5949 Harbour Park Drive Midlothian, VA 23112
Olympia Family Medicine 5949 Harbour Park Drive Midlothian, VA 23112 Patient Registration Date Name DOB Age SSN Sex: M F Address City State Zip Code Home Phone # Cell Phone # Work Phone Occupation Employer
More informationEXAMPLE 2-JOINT PRIVACY AND SECURITY CHECKLIST
Purpose: The purpose of this Checklist is to evaluate your proposal to use or disclose Protected Health Information ( PHI ) for the purpose indicated below and allow the University Privacy Office and Office
More informationApply for WIC & Dual Participation
This module applies to the following security roles: Receptionist Clerk RN/RD Breastfeeding Peer Counselor Kansas Department of Health and Environment Bureau of Family Health Nutrition and WIC Services
More informationClientConnect CANS User Manual DCF Area Offices Probation Parole
ClientConnect CANS User Manual DCF Area Offices Probation Parole 2 Revised 10/18/11 This page was intentionally left blank. 3 Revised 10/18/11 Table of Contents Introduction... 5 Overview... 6 ClientConnect
More informationNetsmart Sandbox Tour Guide Script
Netsmart Sandbox Tour Guide Script March 2012 This document is to be used in conjunction with the Netsmart Sandbox environment as a guide. Following the steps included in this guide will allow you to get
More informationCity and County of San Francisco
City and County of San Francisco Avatar CalPM User Guide ***see page 70*** May 2010 CBHS 1 Table of Contents Avatar Glossary...2 Avatar Desktop...3 Logging On To Avatar...14 Navigating in Avatar...19 Creating
More informationMontclair Public Schools. STUDENT REGISTRATION PORTAL INSTRUCTIONS
Montclair Public Schools STUDENT REGISTRATION PORTAL INSTRUCTIONS This registration portal is used to collect basic information about your child before you come to Central Office for grades K 8, or Montclair
More informationHomeless Management Information System (HMIS)
Mid-America Regional Council 600 Broadway, Suite 200 Kansas City, Missouri 64105 (816)474-4240 Kcmetrohmis.org Homeless Management Information System (HMIS) Data Quality Plan Kansas City Metro-Jackson,
More informationSoonerCare Provider Information
ATTACHMENT B-2006 SoonerCare Provider Program Information PLEASE READ THE DIRECTIONS CAREFULLY All providers must complete the Uniform Credentialing Application. It must be 100% complete, including required
More informationREQUIREMENT CHECKLIST FOR ATHLETIC TRAINER REGISTRATION/REACTIVATION
WEST VIRGINIA BOARD OF PHYSICAL THERAPY 2 Players Club Drive, Suite 102 Charleston, West Virginia 25311 Telephone: (304) 558-0367 Fax: (304) 558-0369 Email: wvbopt@wv.gov Website: www.wvbopt.com REQUIREMENT
More informationAGENCY VIEW USER MANUAL
OKLAHOMA HEALTH CARE AUTHORITY HEALTH CARE AUTHORITY ONLINE ENROLLMENT AGENCY VIEW USER MANUAL Table of Contents 1.0 Introduction and Purpose of Manual... 3 2.0 Logging on to the System... 4 2.1 Logon...
More informationEdition. MONTEREY COUNTY BEHAVIORAL HEALTH MD User Guide
Edition 1 MONTEREY COUNTY BEHAVIORAL HEALTH MD User Guide i Table of Content OderConnect/InfoScriber Registration CH1 Pg.2 Sign In to MyAvatar CH2..Pg.10 Sync OrderConnect Password CH3.Pg.14 Client Look
More informationDomestic Violence Client Intake Form
Domestic Violence Client Intake Form Date: Client ID: Client Name: DOB: Petitioner s Place of Birth Race Address: City State Zip Tel. No. Alt. No. Name/Relation of Contact Person Does the person who you
More informationEARLY CARE AND EDUCATION PROVIDER S MEETING
EARLY CARE AND EDUCATION PROVIDER S MEETING March 2016 Agenda Quality Counts Family Portal: Redetermination Contracts: Deadlines VPK Provider Payments QUALITY COUNTS MIAMI DADE COUNTY S QUALITY RATING
More informationHMIS Guide to the CSV APR HMIS End User Resource
2018 HMIS Guide to the CSV APR HMIS End User Resource This guide demonstrates how to run the CSV-APR Export and upload it into SAGE. This guide also reviews the data quality errors, which are identified
More informationPLEASE INDICATE HOW YOU HEARD ABOUT THIS POSTION: PLEASE INDICATE THE POSITION FOR WHICH YOU ARE APPLYING:
INSTRUCTIONS TO HUMAN RESOURCES: Detach this form before processing application. The Unified Police Department is proud to be an Equal Employment Opportunity Employer committed to a diverse workforce.
More informationHMIS Emergency Shelter Projects
HMIS Emergency Shelter Projects Riverside County DPSS ASD HPU December 2016 Page 1 Table of Contents HMIS Introduction... 4 Universal Data Elements... 4 HMIS Workstation Security Procedures... 6 Data Timeliness
More informationWEST VIRGINIA BOARD OF PHYSICAL THERAPY 101 Dee Drive Charleston, West Virginia Telephone: (304) Fax: (304)
WEST VIRGINIA BOARD OF PHYSICAL THERAPY Charleston, West Virginia 25311 Telephone: (304) 558-0367 Fax: (304) 558-0369 ATHLETIC TRAINER REGISTRATION REACTIVATION INSTRUCTIONS $125.00 To reactivate your
More informationP A T I E N T C E N T E R E D M E D I C A L H O M E ( P C M H ) A T T E S T A T I O N O F F A C I L I T Y C O M P L I A N C E
P A T I E N T C E N T E R E D M E D I C A L H O M E ( P C M H ) A T T E S T A T I O N O F F A C I L I T Y C O M P L I A N C E State of Wyoming, Department of Health, Division of Healthcare Financing 2015
More informationANNE ARUNDEL COUNTY FIRE DEPARTMENT
ANNE ARUNDEL COUNTY FIRE DEPARTMENT FIREFIGHTER BACKGROUND BOOK APPLICANT: (PRINT NAME) Failure to bring this completed background book to your oral panel interview in the Office of Personnel will result
More informationCertified Behavioral Health Case Manager Supervisor (CBHCMS)
Certified Behavioral Health Case Manager Supervisor (CBHCMS) The Certified Behavioral Health Case Manager Supervisor (CBHCMS) program is for people who supervise individuals who provide direct mental health
More informationMERLIN Documentation Applicant Interface
MERLIN Documentation: Applicant Interface 1 MERLIN Documentation Applicant Interface Table of Contents Getting Started... 1 Creating a Merlin Account... 2 Starting an Application... 3 HSC General Information
More informationRyan White Eligibility Assessment User Guide / Help
Ryan White Eligibility Assessment User Guide / Help TABLE OF CONTENTS LOGIN OVERVIEW... 2 LOG OUT BAR... 2 ACCESSING RYAN WHITE... 3 RYAN WHITE ELIGIBILITY ASSESSMENT... 4 SAVED DRAFTS... 4 NEW ASSESSMENT...
More informationIntake Application Please complete all sections of this application and do not leave any blanks. Please print.
Return to CP Rochester 1000 Elmwood Ave. Suite 900 Rochester, NY 14620 585-295-1587 ext. 2281 Intake Application Please complete all sections of this application and do not leave any blanks. Please print.
More informationBehavioral Health e referral User Guide. Confidence comes with every card.
Behavioral Health e referral User Guide Confidence comes with every card. September 2017 Dear Blue Cross Blue Shield of Michigan and Blue Care Network health care provider: Welcome to e-referral (also
More informationMonthly Webinar June 2016 CRM and MFP ANE Checks, Re-Referrals, Timely Entry
Monthly Webinar June 2016 CRM and MFP ANE Checks, Re-Referrals, Timely Entry 2 When you sign into CRM, you land on your default dashboard. Select TC (New) and set it as your default dashboard Click Microsoft
More informationAUTHORIZATION TO RELEASE HEALTH INFORMATION
Request Completed Health Information Management AUTHORIZATION TO RELEASE HEALTH INFORMATION Completion of this form authorizes the use and/or disclosure (release) of individually identifiable health information,
More informationGovernors State University
MSW Advanced Field Application (2018-19) Last Name First Name Address Email Address Home phone Cell Phone The following questions are designed to help the Field Division faculty help you find the best
More informationSteffanie Hall, RHIA HIM Director/Privacy Officer 1201 West 12 th Emporia, Kansas ext
JOINT NOTICE OF PRIVACY PRACTICES NEWMAN REGIONAL HEALTH, NEWMAN REGIONAL HEALTH MEDICAL PARTNERS, HOSPICE, NEWMAN PHYSICAL THERAPY, COMMUNITY WELLNESS AND MEMBERS OF THE NEWMAN REGIONAL HEALTH ORGANIZED
More informationSTEP BY STEP HOW TO COMPLETE THE ELECTRONIC BGC FORM
Human Resources Background Check Program backgroundchecks.hr.ncsu.edu 2711 Sullivan Drive, Admin Services II Raleigh, NC 27695 background-checks@ncsu.edu STEP BY STEP HOW TO COMPLETE THE ELECTRONIC BGC
More information2017/2018 ABA Sessions
Our evidenced-based ABA programs are individualized for children ages 2-10 years old who have a developmental disability and need some extra 1:1 assistance in a variety of skill areas. Individualized programming
More informationPOLICY AND OPERATING PROCEDURE
TEXAS DEPARTMENT OF CRIMINAL JUSTICE PAROLE DIVISION NUMBER: PD/POP 3.10.3 DATE: 06/25/18 POLICY AND OPERATING PROCEDURE PAGE: 1 of 12 SUPERSEDES: 12/29/16 SUBJECT: INTERSTATE TRANSFER INVESTIGATIONS AUTHORITY:
More informationCYBER Overview Training for New Providers in the New Jersey Children s System of Care
CYBER Overview Training for New Providers in the New Jersey Children s System of Care Updated 6/4/2018 #01043 What is CYBER? A fully functional Electronic Health Records system, that is a tool for providers
More informationgfedc 5 Name: Case #: Case: Index 1. Review 2. Goal Review
Index 1. Review 2. Goal Review 1. Periodic Review: Review Review Date Start Time 3. Authorizations 4. Action Notice 5. Send Copy to. Signatures Use Current Date Significant Changes No significant changes
More informationInstitutional Review Board. Application for Research Using Humans
Institutional Review Board 4500 Riverwalk Parkway Riverside, CA 92515 IRB Research Application Phone 951.785.2099 Fax 951.785.2918 www.lasierra.edu/spa/human-subjects Institutional Review Board Application
More informationCase Evaluation Information EXPUNGEMENT
Case Evaluation Information EXPUNGEMENT (Note: LEAAC may use some of the demographic, personal, and subjective information provided in this form to aggregate into anonymous data pools for our internal
More informationCape Breton- Victoria Regional School Board
Cape Breton- Victoria Regional School Board APPLICATION PROCEDURE FOR SUBSTITUTE TEACHING Complete substitute application form and attach a photocopy of your valid Nova Scotia teaching license, along with
More informationCIVIL SERVICE OPPORTUNITIES
AN EQUAL OPPORTUNITY EMPLOYER CIVIL SERVICE OPPORTUNITIES COMPUTER SUPPORT SPECIALIST Examination # 19450 Training and Experience Test Qualifying PC Administered Test Applications will be accepted continuously
More informationEXAMPLE 3-JOINT PRIVACY AND SECURITY CHECKLIST
Purpose: The purpose of this Checklist is to evaluate your proposal to use or disclose Protected Health Information ( PHI ) for the purpose indicated below and allow the University Privacy Office and Office
More informationTips on Filling Out the Lifeline Care Plan Agreement Form
Tips on Filling Out the Lifeline Care Plan Agreement Form The following information is required for the processing of your Lifeline Application: Household Phone # - Include area code and phone number.
More informationSonoma County s System-wide Efforts to Improve the Broader Criminal Justice System
Sonoma County s System-wide Efforts to Improve the Broader Criminal Justice System Jennifer Murray, Deputy County Administrator Tom Schwedhelm, Santa Rosa Chief of Police Robert Ochs, Chief Probation Officer
More informationThe General Data Protection Regulation
PRIVACY NOTICE INFORMATION FOR (a) APPLICANTS TO AND USERS OF CHS COMMUNITY SUPPORT SERVICES; (b) OTHER STAKEHOLDERS CHS is committed to protecting your personal data. This privacy notice sets out how
More informationNote: The higher the resolution, the less top to bottom and side to side scrolling is required to see the entire screen. Consider using 1280 by 1024
1 2 Note: The higher the resolution, the less top to bottom and side to side scrolling is required to see the entire screen. Consider using 1280 by 1024 pixels if you can. 3 4 5 6 To obtain the HNFS System
More informationPLEASE INDICATE HOW YOU HEARD ABOUT THIS POSTION: PLEASE INDICATE THE POSITION FOR WHICH YOU ARE APPLYING:
INSTRUCTIONS TO HUMAN RESOURCES: Detach this form before processing application. The Unified Police Department is proud to be an Equal Employment Opportunity Employer committed to a diverse workforce.
More informationGuidelines for Completing the Residential Claim Form
Guidelines for Completing the Residential Claim Form 1. Bill only residential services (Room and Board, Care and Supervision, and Bed Holds) on the Residential Claim Form. All other services (including
More informationMission Statement: Cuyahoga County Department of Justice Affairs
Cuyahoga County Department of Justice Affairs Mission Statement: Providing hope and opportunity for a safer community, ensuring justice, support and recovery for all citizens Cuyahoga County Department
More informationMedicare Health Risk Assessment Questionnaire
Medicare Health Risk Assessment Questionnaire Instructions: Please complete and return it in the self-addressed stamped envelope provided. If you have questions or need help completing the questionnaire,
More informationEXCEL HEALTHCARE STAFFING AND REFERRAL AGENCY
APPLICATION FOR EMPLOYMENT (Please Fill Out Completely) Date of Application Social Security Number / / Print Full Name Home Phone: Mobile: Email: Address City State Zip Code Position Applied For Documents
More informationLifeway Adult Information Form
Date / / Patient Name: First Lifeway Adult Information Form MI Last Date of Birth: / / Gender: M F Marital Status: M S D Address: City State: Zip: Primary Contact Phone: Secondary Contact Phone: Please
More informationRRR Checklist. RRR Checklist. 1.0 Overview. 1.1 View RRR Detail Listing
1.0 Overview Users are able to add commonly used forms to the RRR packet to encourage households to submit verification of their circumstances at the same time that they return their RRR packets. These
More informationINSPIRE. User Screen Guide: MST, Clinical
INSPIRE User Screen Guide: MST, Clinical The EPISCenter is a project of the Prevention Research Center, College of Health and Human Development, Penn State University, and is funded by the Pennsylvania
More informationA+ Program. Mehlville High School. Andy Ross A+ Schools Coordinator. Mehlville High School Lemay Ferry Road St. Louis, MO (314) 467.
Mehlville High School Andy Ross A+ Schools Coordinator Mehlville High School 3200 Lemay Ferry Road St. Louis, MO 63125 (314) 467.6000 Oakville High School Brian Brennan A+ Schools Coordinator Oakville
More informationCT BHP ProviderConnect User Manual Adult Group Home Reviews. ProviderConnect Adult Group Home User Manual
ProviderConnect Adult Group Home User Manual 1 Revised 5/26/2016 Table of Contents Introduction... 3 Accessing ProviderConnect... 5 ProviderConnect Basics... 7 ProviderConnect Functions... 9 Completing
More informationicare s Provider Portal Guide
icare s Provider Portal Guide 2 CONTENTS New Provider Registration... 4 New Registration...5 Login Page 9 Sign In 9 Forget Your Password...10 Provider Home Page 12 Track Request 12 Contact Us.. 14 Provider
More informationChoong Sil Tae Kwon-Do Federation Application for Certified Instructor Program
Choong Sil Tae Kwon-Do Federation Application for Certified Instructor Program To: Choong Sil Tae Kwon-Do Federation Headquarters: Cost [ ] Certified Instructor Program Level I - $0.00 [ ] Certified Instructor
More informationAPPLICATION FOR EMPLOYMENT
APPLICATION FOR EMPLOYMENT Full-Time Reserve/ Public Meters Police Officer Special Officer Safety Dispatcher Enforcement (Check one or more than one) 1) The forms shall be typewritten or printed in blue
More informationRio Salado College LAW ENFORCEMENT TECHNOLOGY CREDIT BY EXAMINATION
Rio Salado College LAW ENFORCEMENT TECHNOLOGY CREDIT BY EXAMINATION LAW ENFORCEMENT TECHNOLOGY CREDIT BY EXAMINATION Rio Salado College, a Maricopa County Community College in Tempe, Arizona, is proud
More informationNetsmart Sandbox Tour Guide Script
Netsmart Sandbox Tour Guide Script March 2012 This document is to be used in conjunction with the Netsmart Sandbox environment as a guide. Following the steps included in this guide will allow you to get
More informationC4Yourself External User Guide. External Page User Guide
External Page User Guide C-IV Page 1 2/29/2012 PURPOSE The purpose of this guide is to provide users with step-by-step instructions on completing an online Application and submitting the application through
More informationReinstatement Information Packet
Landon State Office Building 900 SW Jackson Street, Room 1031 Topeka, KS 66612-1228 Dr. Joel E Hornung, Chair Joseph House, Executive Director Board of Emergency Medical Services phone: 785-296-7296 fax:
More informationIMPORTANT INSTRUCTIONS:
IMPORTANT INSTRUCTIONS: PLEASE MAIL THIS FORM ALONG WITH YOUR AUTHORIZATION AGREEMENT BACK TO US AT: THE POLYCLINIC ATTN: EHR/MYCHART 1145 BROADWAY SEATTLE, WA 98122 PLEASE ALSO PROVIDE US WITH A PHONE
More informationTara A. Dullye, M.D., F.A.C.O.G. Obstetrics, Gynecology, & Infertility
Letter from the Doctor Tara A. Dullye, M.D., F.A.C.O.G. Obstetrics, Gynecology, & Infertility Margot Perot Women's and Children's Hospital 8160 Walnut Hill Lane, Suite 219 Dallas, TX 75231 Phone: (214)
More informationCPRC Renewal Changes
CPRC Renewal Changes Please Note: All CPRC renewals must have six (6) hours of continuing education in Ethical Responsibility, out of the required twenty (20) hours. As of January 1 st, 2017 ethical responsibilities
More information