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Body
Payment Reform Reminder and Updates
County and Contract Forms and Resource Library
- Chart Review Protocol
- JV220 Application (typically for SSA or Probation Staff to complete)
- JV220A
- JV220B
- CYS General APT 2024 Hard Copy
- CYS APT 2024 Hard Copy Modules 1-3
- CYS APT 2024 Hard Copy County Program Practice Modules 4-10
- CYS APT 2024 Hard Copy Contract Program Practice Modules 11-15
Sample County and Contract Provider's Documentation
Sample County EHR 7 Domain Assessments
- County EHR Central Client 1 - 7 Domain Assessment
- County EHR Central Client 1 - ICC-IHBS Care Plan Progress Note
- County EHR Central Client 1 - Problem List Update
- County EHR Regional Client 2 - 7 Domain Assessment
- County EHR Regional Client 2 - ICC-IHBS Care Plan Progress Note
- County EHR Regional Client 2 - Problem List Update
- County EHR Regional Client 2 - Certified Peer Support Specialist Plan of Care Progress Note
- County EHR Central Client 3 - 7 Domain Assessment (CEGU)
- County EHR Central Client 3 - 7 Domain Re-Assessment (CEGU)
- County EHR Central Client 3 - ICC-IHBS Care Plan Progress Note
- County EHR Central Client 3 - ICC-IHBS Care Plan Progress Note Re-Assessment
- County EHR Central Client 3 - Problem List Update
- County EHR Regional Client 4 - 7 Domain Assessment (Juvenile Justice)
- County EHR Regional Client 4 - ICC-IHBS Care Plan Progress Note
- County EHR Regional Client 4 - Problem List Update
- County EHR Regional Client 4 - Certified Peer Support Specialist Plan of Care Progress Note
Sample Contract Provider's 7 Domain Assessments
- Central Contract Provider Client 1 - 7 Domain Assessment (Child Welfare)
- Central Contract Provider Client 1 - ICC-IHBS Care Plan Progress Note
- Central Contract Provider Client 1 - Problem List Update (Child Welfare)
- Regional Contract Provider Client 2 - 7 Domain Assessment
- Regional Contract Provider Client 2 ICC-IHBS Care Plan Progress Note
- Regional Contract Provider Client 2 Certified Peer Support Specialist Plan of Care Progress Note
- Regional Contract Provider Client 2 - Problem List Update
- Regional Contract Provider Client 3 - 7 Domain Assessment (TAY & Juvenile Justice)
- Regional Contract Provider Client 3 - ICC-IHBS Care Plan Progress Note
- Regional Contract Provider Partners Client 3 Certified Peer Support Specialist Plan of Care Progress Note
- Regional Contract Provider Client 3 - Problem List Update (TAY & Juvenile Justice)
Blank Forms
- County (Downtime Form) and Contract Provider Blank 7 Domain Assessment Form
- County (Downtime Form) and Contract Provider Blank Problem List
- County (Downtime Form) and Contract Provider Blank TCM Care Plan Progress Note
- County (Downtime Form) and Contract Provider ICC Care Plan and IHBS Authorization Form Progress Note
- County (Downtime Form) and Contract Provider Blank Encounter Document and Progress Note Form
Sample County Progress Notes
EHR Chart 1 Progress Notes
- County EHR Client 1 Intake Note
- County EHR Client 1 - Domain 7 Assessment Write-Up (no client present)
- County EHR Client 1 Comprehensive Multidisciplinary Evaluation by MHW
- County EHR Client 1 Comprehensive Multidisciplinary Evaluation by Therapist
- County EHR Client 1 External Record Review Assessment Note
- County EHR Client 1 Bief Emotional/Behavioral Assessment
- County EHR Client 1 Individual Therapy Note
- County EHR Client 1 ICC 90 Day CFT Review Note
- County EHR Client 1 IHBS Note
- County EHR Client 1 IHBS Collateral Note
- County EHR Client 1 Community Based WRAP Service
EHR Chart 2 Progress Notes
- County EHR Client 2 Intake Note
- County EHR Client 2 Assessment External Record Review Note
- County EHR Client 2 Assessment Psych_Testing_w-add-on
- County EHR Client 2 Telephone Assessment
- County EHR Client 2 Domain 7 Assessment Write-Up (no client present)
- County EHR Client 2 Individual Therapy Note with Interpretation Psychiatric Results
- County EHR Client 2 Individual Therapy (EMDR) Note
- County EHR Client 2 Family Therapy Note
- County EHR Client 2 ICC Note
- County EHR Client 2 ICC 90 Day IS Review Note
- County EHR Client 2 IHBS Note
- County EHR Client 2 Certified Peer Support Specialist Progress Note
EHR Chart 3 Progress Notes
- County EHR Client 3 Intake Note
- County EHR Client 3 Assessment Note with Oral Translation
- County EHR Client 3 Assessment External Record Review Note
- County EHR Client 3 Assessment Psychological Testing with add-on code note
- County EHR Client 3 Domain 7 Assessment Write-Up (no client present)
- County EHR Client 3 Individual Therapy Note
- County EHR Client 3 Individual Therapy with Interactive Complexity Note
- County EHR Client 3 Crisis Psychotherapy Note
- County EHR Client 3 ICC 90 Day CFT Review Note
- County EHR Client 3 IHBS Note
- County EHR Client 3 Med Team Conference Note
- County EHR Client 3 Plan Development Consult Note
EHR Chart 4 Progress Notes
- County EHR Client 4 Intake Note
- County EHR Client 4 Individual Therapy Note
- County EHR Client 4 Family Therapy Note
- County EHR Client 4 ICC 90 Day IS Review Note
- County EHR Client 4 IHBS Note
- County EHR Client 4 Certified Peer Support Specialist Progress Note
Sample Contract Progress Notes (Paper format)
Chart 1 Progress Notes
- Client 1 Contract Provider (Central) Intake Note
- Client 1 Contract Provider (Central) Brief_Emotional/Behavioral Assessment (Screening tool)
- Client 1 Contract Provider (Central) Comprehensive Multidisciplinary Evaluation by MHW (more than 1 provider)
- Client 1 Contract Provider (Central) Comprehensive Multidisciplinary Evaluation by Therapist (more than 1 provider)
- Client 1 Contract Provider (Central) Assessment Interpretation of External Records Review
- Client 1 Contract Provider (Central) 7 Domain Assessment Write-up (no client present)
- Client 1 Contract Provider (Central) Individual Therapy Progress Note
- Client 1 Contract Provider (Central) ICC 90 day CFT review Progress Note
- Client 1 Contract Provider (Central) IHBS WRAP Progress Note
- Client 1 Contract Provider (Central) IHBS Collateral Progress Note
- Client 1 Contract Provider (Central) Community Based Wraparound Service Progress Note
Chart 2 Progress Notes
- Client 2 Contract Provider (Regional) Intake Note
- Client 2 Contract Provider (Regional) Assessment External Record Review
- Client 2 Contract Provider (Regional) Assessment Psychological Testing with add-on code
- Client 2 Contract Provider (Regional) Telephone Assessment Note
- Client 2 Contract Provider (Regional) 7 Domain Assessment Write-up (no client present)
- Client 2 Contract Provider (Regional) Individual Therapy Progress Note
- Client 2 Contract Provider (Regional) Individual Therapy EMDR Progress Note
- Client 2 Contract Provider (Regional) Family Therapy Progress Note
- Client 2 Contract Provider (Regional) ICC Progress Note
- Client 2 Contract Provider (Regional) ICC 90 day I.S. review Progress Note
- Client 2 Contract Provider (Regional) IHBS Progress Note
- Client 2 Contract Provider (Regional) Certified Peer Support Specialist Progress Note
Chart 3 Progress Notes
- Client 3 Contract Provider (Regional) Intake Note
- Client 3 Contract Provider (Regional) Individual Therapy Progress Note
- Client 3 Contract Provider (Regional) Family Therapy Progress Note
- Client 3 Contract Provider (Regional) ICC 90 day I.S. review Progress Note
- Client 3 Contract Provider (Regional) IHBS Progress Note
- Client 3 Contract Provider (Regional) Certified Peer Support Specialist Progress Note
Sample Contract STRTP Assessment & Progress Notes (Paper format)
- Contract STRTP Sample Assessment Intake Note
- Contract STRTP Sample Assessment Write-Up Note by LPHA using 70899-418 (no client present)
- Contract STRTP Sample Assessment Evaluation
- Contract STRTP Sample Individual Therapy Note
- Contract STRTP Sample Crisis Psychotherapy Note
- Contract STRTP Sample Collateral Rehab Note
- Contract STRTP Sample IHBS Note
- Contract STRTP Sample IHBS 2nd Note
- Contract STRTP ICC CFT Note
- Contract STRTP Care Management Progress Note for MD
- Contract STRTP Oral Medication Administration, Direct Observation, 15 min.
- Contract STRTP Problem List Update