Department of Health: Comunity Based Case Management (CBCM)

North Shore Mental Health Forms

 Client Documentation

• NSMH CBCM Intake Assessment Form (UPDATED)
• Authorization to Release/Obtain Confidential Information
• Clients Right Acknowledgement (UPDATED)
• Consent to Treatment
• HIPPA Acknowledgement
• Client Insurance Information
• Individual Recovery Plan (pdf format)
• Individual Recovery Plan (word format)
• Progress Notes
• Discharge and Aftercare Plan (NEW)
• Transport Permission
• Childrens Crisis Plan  (New)
• Client Medication Log (New)

Billing Documentation

• CBCM Billing Clarifications Revised 4-05
• CBCM Billing Form Revised 9-06
• CBCM Psychiatric Billing Clarifications
• CBCM Psychiatric Billing Form

Administration Forms

• CBCM Form Checklist (New)
• NSMH Supervision Form (NEW)
• NSMH Supervision Form (NEW for MAC)
• Case Review Supervision Form
• Vacation / Leave of Absence Form
• Client Satisfaction and Accessibility Survey
• Time Sheet
• NSMH Fax Cover Sheet
• Psychosocial Rehabilitaton Referral Form
• Transition of Care (TOC) Aloha Quest (NEW)
• BHPP Inpatient Notification Aloha Quest (NEW)

Adult Mental Health Division Documentation and Various Forms

Utilization Management (UM) Forms/Assessment/Diagnostic Tools

• LOCUS Form
• REVISED Cage AID Form (NEW)
• MR Screening Form
• MR Screening Form Instructions
• Quality of Life Interview - Very brief
• Demographic - Admission
• Trauma Informed Care Initiative TIC-IT (NEW)

Miscellaneous     

• AMHD Eligible Dx Codes
• AMHD UNIVERSAL Referral Form (Updated 10-2011)
•      Attachment "A" Treatment Services (NEW)
•      Rep Payee Referral Attachment "B" (Updated 10-2011) 
•      Housing Attachment "C" (NEW)
•      HUD Housing Attachment "D" (NEW)
• AMHD Referral Form Instructions
• Authorization for Use/Disclosure DOH
• CBI/CRF FORM
• CBI/CRF INSTRUCTIONS 
• Consumer Update/Increased Units
• CRF- Agreement For Repayment 
• Hospital Recovery Plan Review
• InterimHousing
• Crisis Plan
• Advance Mental Health Directive
• Bureau of Prisons NCIC Clearance

Emergency/Crisis Forms

• Application for Emergency Exam and Treatment/Oral Ex Parte 
• Request for Emergency Rx Form-DHS1149 
• Physicians Statement of clients Inability to manage Finances   Form SSA-787 (Updated 10-2011)
• DHS-1147 LOC for Care Home Placement (Updated 10-2011)

Consumer Sentinel Event/Incident Documentation

• Sentinel Event Incident Form
• Sentinel Event Immediate Notification Form 
• Sentinel Event 10 Day Report Form
• Sentinel Event 30 Day Root Cause Analysis (New) 

Community Based CM Forms

• Adult Mental Health Division - Service Authorization Request 
• Club House Application
• Gateway Rep Payee Referral (NEW)
• Gateway Rep Payee Fund Request (NEW)
• Helping Hands Rep Payee Referral
• Helping Hands Referral Check Off Sheet (New 10-2011)
• Helping Hands Treatment Collaboration Sheet (New 10-2011)
• Rep Payee Referral Attachment (For HHH & Hale Ipu) (Updated 10-2011)
• Helping Hands Rep Payee Financial/Check Request (Updated 10-2011)
• Helping Hands Rep Payee Demographics Update (Updated 10-2011)
• Helping Hands Rep Payee Provider Satisfaction Survey (New 10-2011)
• Representative Payee's Report to SSA Document List (New 10-2011)
• Hale Ipu Rep Payee Referral
• Hale Ipu Rep Payee Check Request
• Consumer Budget Form for Rep Payee (For HHH & Hale Ipu)
• The BUS- Bus Pass Application
• Po'ailani Intake Screening  (Includes PHI, Physical & Psych Eval) (NEW)
• Helping Hands Emergency Assistance Fund Application (New)
• Helping Hands Emergency Fund Pre-Screening Tool (New)
• Community Clearinghouse Referral Form (New)
• Salvation Army Clothing Referral Form (New)
• Kumuhonua Transitional Housing App Instructions (NEW)
• Kumuhonua Transitional Housing Application (NEW)
• Mental Health Kokua Peer Coach Project Referral (NEW)
   

Miscellaneous Forms

• DOH Authorization for Use of Disclosure of Protected Health Information (BLANK FORM)
• DHS Consent to Release/Obtain MED-Quest Division (NEW) 

Steadfast Forms (SHDC)

• Referral Form
• Consent to Release Information
• Certificate of Criminal History Form
• Certification of Homelessness
• Certification of Severe & Persistent Mental Illness