Form Ta 20 822 4 PDF Details

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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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In an effort to complete this PDF form, ensure you enter the required details in each field:

1. You'll want to complete the riasi pdf accurately, so take care while working with the sections containing all these blanks:

Stage # 1 for filling in DPP

2. Once this part is filled out, go to type in the applicable information in all these - Counselor assessment on a scale, the likelihood that the patient, Recommendations, Preadmission Assessment, Brief Intervention, No further assessment needed, Summary of Feedback given to the, Referral to different type or, Clinical Staff Members Signature, Date, By my signature I acknowledge that, Patients Signature, and Date.

DPP conclusion process shown (step 2)

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