In an effort to address substance abuse and its subsequent impact on individuals and families, a comprehensive assessment and referral system plays a crucial role in connecting those in need with appropriate treatment services. The DSHS 14-299 form, critical in this chain of assistance, serves as a pivotal documentation tool for the Alcoholism and Drug Addiction Treatment and Support Act (ADATSA) along with other adult assessment referrals. It meticulously records the identifying information of clients, crucial details of their scheduled assessment appointments, and specific instructions necessary for agencies and treatment centers involved. Boasting sections that cover everything from the client's personal and contact information to the specifics of their appointment at an assessment center, the form lays down a structured pathway for the referred individuals. It emphasizes the importance of adherence to appointments, warns of the consequences of treatment refusal, and provides a space for addressing any special needs or health problems the client might be facing. This documentation not only aids in the smooth transition of clients through the assessment process but also enforces accountability among service providers and recipients. Moreover, by catering to specific groups, such as pregnant women or individuals with children, and recognizing the urgency of their situation, the form underscores the tailored approach needed in dealing with diverse cases of substance use disorders.
| Question | Answer |
|---|---|
| Form Name | Form Dshs 14 299 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 14_299 adatsa adult assessment form |
ADATSA/ADULT ASSESSMENT REFERRAL
REFERRING CSO
DATE
SECTION A. IDENTIFYING INFORMATION
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CLIENT LAST NAME |
FIRST NAME |
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MIDDLE NAME |
2. DATE OF BIRTH |
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3. |
ACES CLIENT NUMBER |
4. GENDER |
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5. SOCIAL SECURITY NUMBER |
6. CLIENT TELEPHONE |
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Male |
Female |
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MESSAGE NUMBER |
7. LIMITED ENGLISH PROFICIENCY? |
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No |
Yes; Primary language: |
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8. |
STREET ADDRESS |
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CITY |
STATE |
ZIP CODE |
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SECTION B. ASSESSMENT APPOINTMENT INFORMATION |
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NAME OF ASSESSMENT CENTER/ENTITY |
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2. TELEPHONE NUMBER |
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3. |
STREET ADDRESS |
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CITY |
STATE |
ZIP CODE |
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4. |
APPOINTMENT DATE |
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5. APPOINTMENT TIME |
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PLEASE NOTE: Take this form (and any attachments) with you to your appointment. Failure to keep this appointment may result in denial, delay or termination of your benefits. Failure to accept a program of treatment as prescribed by the assessment center means you refuse treatment, which may result in denial, termination, and possible sanction. If you have questions about treatment requirements, please ask your CSO worker.
SECTION C. TO ASSESSMENT CENTER
1. |
DATE OF APPLICATION |
2. NAME OF REFERRING AGENCY, OTHER THAN CSO (I.E., HOSPITAL, |
3. AGENCY TELEPHONE NUMBER |
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JAIL, DETOX, ETC., IF APPLICABLE) |
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4. |
CLIENT TYPE (CHECK ALL THAT APPLY) |
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TANF |
PPW |
ADATSA |
SSI/ABD cash |
MCS |
Other: |
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5. |
PRIORITY GROUP: |
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Pregnant |
CPS Referral |
I.V. Drug |
HH/Children |
2082 |
Regular ADATSA (No Priority) |
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6.THE ABOVE NAMED CLIENT IS (Check appropriate box):
Applicant |
Current Recipient |
Transfer from another program |
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A. Client is Title XIX CNP eligible. PROVIDER ONE NUMBER: |
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TANF |
SSI |
ABD |
Other: |
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OR |
Attach printout of medical coverage. |
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B. Applying only for ADATSA Service
C. ABD cash eligibility established
D. MCS medical eligibility established
E. Other reasons this client is being referred?
7.
Other incapacity/health problems:
A. Other evaluation pending (indicate type and date scheduled):
B. Medical/psychological information attached. Screening information attached. C. Special needs for this client. Describe:
8. Comments/Other:
9. FINANCIAL WORKER/CASE MANAGER
TELEPHONE NUMBER
10. CASE WORKER
TELEPHONE NUMBER
COPIES TO: Client File; Client; Assessment Center
DSHS
INSTRUCTIONS
The initiating worker:
1.Enters the referring community Services Office (CSO) name and current date.
2.Completes Section A, including the client’s full name. The full middle name (not just initial) is requested.
3.Completes Section B when the assessment appointment is established.
4.Completes Section C:
A.Item 1 designates date the application was initiated.
B.Completes Items 2 and 3 by entering the name and telephone number of the agency or other entity that prompted the individual to seek chemical dependency services.
C.Item 4 designates client’s program type(s).
D.Completes Item 5 designating the client’s priority category by:
1)Checking “Pregnant” for anyone currently pregnant or up to two months postpartum;
2)Checking “CPS Referral” for anyone that is a direct referral for chemical dependency services from Children Protective Services;
3)Checking “I.V. Drug” for anyone that is an intravenous drug user;
4)Checking “HH/Children” for individuals with children in the home;
5)Checking “No Priority” for everyone not included in the first four priorities.
NOTE: If the client is pregnant, contact the local assessment center immediately for an assessment, as these individuals are fast tracked through the assessment process.
E.Completes either A, B, or C in Item 6, as appropriate. If Item A is checked, indicate Title XIX the Provider One number for medical coverage.
5.Completes Items 7 and 8 as needed. Checks Item 7C if the client has a special need.
6.Completes Items 9 and/or 10 with the names and telephone numbers of the referring financial and social workers.
DSHS