Form Ta 20 822 4 PDF Details

In the landscape of chemical dependence treatment and management, the TA-20 822-4 form emerges as a critical instrument designed to facilitate a structured and efficient screening process for individuals suspected of substance abuse issues. Operating within the framework of outpatient services, this form ensures a comprehensive assessment of the patient, capturing essential data including the patient's identity, screening date, and the duration, along with the source of referral which may vary from self-referral to different agencies including probation, parole, and Department of Social Services/Child Protective Services (DSS/CPS), among others. Crucially, it upholds the principle of informed consent, mandating a confirmation of the patient's signed consent for the release of information. The strategic use of varied screening tools such as ASSIST, CAGEAID, and AUDIT, among others, underpins its adaptability to different patient needs and situations. This form not only assists in determining the likelihood of a substance abuse problem via a scored outcome but also compels a counselor’s assessment, enriching the decision-making process regarding the necessary recommendations for further assessments, brief interventions, or referrals to other care levels. The inclusion of a summary of feedback offered to the patient regarding the screening results, alongside signatures from both clinical staff and the patient, encapsulates a transparency and shared understanding vital for effective intervention strategies. This article aims to illuminate the multifaceted roles and implications of the TA-20 822-4 form, highlighting its significance in advancing patient-centered care in the domain of chemical dependence treatment.

QuestionAnswer
Form NameForm Ta 20 822 4
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesoasas ta 20 822 4, RIASI, DWI, CRAFFT

Form Preview Example

PART 822 CHEMICAL DEPENDENCE OUTPATIENT SERVICES

SCREENING FORM

Patient Name:

Patient ID #:

Date of Screening:

 

 

 

Duration of Screening:

 

 

 

 

 

 

 

 

Referral Source:

Self

Probation/Parole

DSS/CPS DWI/DPP

Other treatment provider

Other

Name/Title:

Agency:

Address:

Phone #:

Signed consent(s) for release? Yes No

Screening Tool:

ASSIST

CAGEAID

DPP/DWI

RIASI

AUDIT

CRAFFT (adolescents)

GAIN Quick

Simple Screen

CAGE

DAST

MAST

Other

Results of Screening:

Score from Screening Tool:

1.From results of Screening Tool, on a scale of 1 – 10 (with 1 being not likely and 10 being highly likely) how would

you rate the likelihood that the patient has a Substance Abuse Problem?

2.Counselor assessment, on a scale of 1 – 10 (with 1 being not likely and 10 being highly likely) how would you rate

the likelihood that the patient has a Substance Abuse Problem?

Recommendations:

 

Pre-admission Assessment

 

 

 

Brief Intervention

 

No further assessment needed

 

 

 

Referral to different type or level of care; referral information

Summary of Feedback given to the Patient Based on the Results of the Screening:

Clinical Staff Member’s Signature

Date

By my signature I acknowledge that the results and recommendations of this screening have been shared with me:

Patient’s Signature

TA-20 822-4 (07/11)

Date

How to Edit Form Ta 20 822 4 Online for Free

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Stage # 1 for filling in DPP

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DPP conclusion process shown (step 2)

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