Step 1 of 3 33% Date(Required) MM slash DD slash YYYY Reviewing Staff:(Required) First Last Signature:(Required)Email:(Required) Assigned Clinical Staff:(Required) First Last Referral Date:(Required) MM slash DD slash YYYY If missing 11/11/1111Consumer Name:(Required) First Last Consumer Type:(Required)AdolescentAdultProof of guardianship:(Required)Court Order/Other Document (1)Missing (0)Natural Parent (N/A)Is a PDF Intake Packet Included?(Required)YesNoWas verbal consent documented for assessment, intake, and ongoing services?(Required)Yes, all services were consented to.No, only assessment and intake.No, only ongoing servicesMissingIntake packet items:(Required)Current (1)Incomplete (0)Missing (0)Expired (0)N/ACurrent Consent for TxEmergency Contact FormHIPAAProof of IdentificationAttendance PolicyDemographic/Financial FormMedical Screening FormElectronic ConsentUber ConsentTransportation ConsentROI: MedicalROI: PsychiatristROI: MH ProviderROI: PharmacyROI: EducationROI: SUD ProgamSummary of ConsentsInitial Assesment:(Required)YesNoN/ADate of Initial Assessment:(Required) MM slash DD slash YYYY If missing 11/11/1111More than one evaluation:(Required)YesNoHow many?(Required)Does the consumer have a Treatment Plan:(Required)YesNoN/AInitial Tx:(Required) MM slash DD slash YYYY If missing 11/11/1111Initial Tx Plan Co-signed:(Required)Yes (1)Incomplete (0)Missing (0)N/ALCSW-C, LCPC, LGSW & LCSW-C, LGPC & LCPC, or Intern and LCSW-C or LCPC (Choose N/A if the consumer was not seen for at least 3 sessions)Does the consumer have additional Treatment Plans:(Required)YesNoN/ARecent Initial Tx:(Required) MM slash DD slash YYYY If missing 11/11/1111Current Tx Plan Co-signed:(Required)YesIncompleteMissingContact Log Notes:(Required)Yes (1)No (0)N/AHas this consumer been discharged?(Required)Yes (1)N/AUnable to tell (0)Outreach Letter:(Required)Yes (1)No (0)N/ADate of Discharge:(Required) MM slash DD slash YYYY Completed discharge summary:(Required)Yes (1)No (0)Incomplete (0)Missing (0)Date of Summary:(Required) MM slash DD slash YYYY Has a discharge letter been sent?(Required)Yes (1)No (0)Date Sent:(Required) MM slash DD slash YYYY Discharged from Optum:(Required)Yes (1)No (0)Unable to tell (0)Date Discharged:(Required) MM slash DD slash YYYY Additional notes: