Step 1 of 4 25% Date(Required) MM slash DD slash YYYY Reviewing Staff Name:(Required) First Last Signature:(Required)Assigned Staff Name:(Required) First Last Consumer Name:(Required) First Last Type of Consumer:(Required)AdolescentAdultUnable to tellReferral Date:(Required) MM slash DD slash YYYY Proof of Guardianship:(Required)MissingIncludedNot requiredWas an initial screening completed?(Required)YesMissingIncompleteDate of Initial Screening:(Required) MM slash DD slash YYYY 5 days from the referral date. 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 (Due annually):(Required)Current (1)Incomplete (0)Missing (0)Expired (0)N/AClient DemographicsSomatic HealthConsent for ServicesAgreement of InvolvementAdvance DirectiveClient RightsGrievance PolicyConfidentialityTransportation ConsentDischarge ProceduresEntitlement FormSummary of ConsentsInitial Assessment:(Required)IncludedIncompleteMissingDate of Assessment:(Required) MM slash DD slash YYYY DLA-20:(Required)IncludedIncompleteMissingN/AInitial IRP:(Required)IncludedIncompleteMissingDate of IRP:(Required) MM slash DD slash YYYY Have other IRPs been completed?(Required)YesNoUnable to tellHow many?(Required)Has this consumer been discharged?(Required)YesNoUnable to tellDate of Discharge:(Required) MM slash DD slash YYYY Completed discharge summary:(Required)YesNoIncompleteDate of Summary:(Required) MM slash DD slash YYYY Has a discharge letter been sent?(Required)YesNoDate Sent:(Required) MM slash DD slash YYYY Discharged from Optum:(Required)YesNoUnable to tellDate Discharged:(Required) MM slash DD slash YYYY Additional notes:Email:(Required)