Today's Date(Required) MM slash DD slash YYYY Consumer Name(Required) First Last Consumer Status:(Required) Adult (18 and Over) Adolescent (17 and under) Level of Care:(Required) IOP OP Residential Unsure Are court documents required for this consumer?:(Required) Yes, provided Yes, not provided No, not required Consumer Documents:(Required)Yes, in chart and completedYes, in chart, but incompleteNo, missingExpiredN/AConsent for TreatmentConsent for TelehealthEmergency Contact(s)HIPAAAttendance PolicyFinancial FormElectronic ConsentConsumer Handbook/Orientation AcknowledgementOverdose PlanSigned Clear WaiverConsumer Documents:(Required)Yes, in chart and completedYes, in chart, but incompleteNo, missingExpiredN/ATransportation: VanTransportation: UberROI: OptumROI: Mental HealthDate SUD Consent Signed (If missing use date 2001-01-01 or (Not in this program use 2002-02-02):(Required) Additional Screenings:(Required)Yes, in chart and completedYes, in chart, but incompleteNo, missingExpiredN/AFamily & Recovery Environment AssessmentAlcoholism ScreeningTobacco/Nicotine:TB:HIV Education:Gambling:TB Assessment:Completed Screenings:(Required)Yes, in chart and completedYes, in chart, but incompleteNo, missingExpiredN/ASuicideNutritionPain ManagementComments:Initial Date of SUD Referral (If not receiving these services use 2001-01-01 as the date):(Required) Completed ASAM- Chemical Dependancy Assessment:(Required) Yes No Missing N/A Date of ASAM (If missing, use the date 2001-01-01):(Required) Level of care at intake:(Required) IOP OP Unable to tell Completed ASI/POSIT- Bio, Psycho, Social Assessment:(Required) Yes, completed ASI (18 and older) Yes, completed, POSIT (17 and under) Incomplete, ASI(18 and older) Incomplete, POSIT (17 and under) Missing N/A Date of ASI (If missing, use the date 2001-01-01):(Required) Initial UA Results:(Required) Yes No/Missing N/A Completed Initial Individual Treatment Plan:(Required) Yes No/Missing Not due yet N/A Incomplete Date of Initial Individual Treatment Plan(If missing, use the date 2001-01-01):(Required) Has the consumer been in services days 30 days or longer?(Required) Yes No N/A How many treatment plans does the consumer currently have in the chart?(Required) Date of current treatment plan (If missing, use the date 2001-01-01):(Required) Has the consumer been discharged?(Required) Yes No Unable to tell Has a discharge summary been completed?(Required) Yes No If discharged, what's the date of discharge? (If discharge summery is missing, use 2001-01-01):(Required) Comments about SUD Services:(Required)