Assessment Document Checklist
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INTAKE & ASSESSMENT CHECKLIST Consumer:
Date of Assessment:
Today’s Date Assessor Check as completed
Assessor: For Office Use Only
Update
INTAKE PAPERWORK Orientation Checklist Complete Referral form Consent to treatment Grievance Policy Rights and Responsibilities Release of Information Transportation form Consent to Photograph Intake Survey
ASSESSMENT DOCUMENTS Biopsychosocial CAFAS Developmental Assessment Treatment plan and Signature page
Check Missing Documents Intake Paperwork Orientation Checklist Complete Referral form Consent to treatment Grievance Policy Rights and Responsibilities Release of Information Transportation form Consent to Photograph Intake Survey Assessment Forms Biopsychosocial CAFAS Developmental Assessment Treatment plan and Signature page MICP Assignments Dr’s Appt Dr’s Name Nurse Appt Case Staffing Tx Plan delivered Case Staffed Collateral Documentation Medical Records School Records Psych Evals List Other Documents :
Service Order I understand that the above documents are missing & are my responsibility to correct. Assessor Signature:
ASSIGNMENTS Dr’s Appt Scheduled Dr’s Name Nurse Appt Scheduled Case Staffed Tx Plan delivered
N/A
Yes date
No why?
N/A N/A N/A
Yes date Yes date Yes date
No why? No why? No why?
COLLATERAL DOCUMENTATION Psych Evals req/rcv Medical Records req/rcv School Records req/rcv
N/A N/A N/A
Yes date Yes date Yes date
No why? No why? No why?
List additional documents below
Accepted by: ___________________________________________________________________ Print name: ________________________________ Date: ___________________________
INTAKE & ASSESSMENT CHECKLIST Consumer:
Date of Assessment:
Assessor:
Accepted by: ___________________________________________________________________ Print name: ________________________________ Date: ___________________________
Date of Assessment:
Today’s Date Assessor Check as completed
Assessor: For Office Use Only
Update
INTAKE PAPERWORK Orientation Checklist Complete Referral form Consent to treatment Grievance Policy Rights and Responsibilities Release of Information Transportation form Consent to Photograph Intake Survey
ASSESSMENT DOCUMENTS Biopsychosocial CAFAS Developmental Assessment Treatment plan and Signature page
Check Missing Documents Intake Paperwork Orientation Checklist Complete Referral form Consent to treatment Grievance Policy Rights and Responsibilities Release of Information Transportation form Consent to Photograph Intake Survey Assessment Forms Biopsychosocial CAFAS Developmental Assessment Treatment plan and Signature page MICP Assignments Dr’s Appt Dr’s Name Nurse Appt Case Staffing Tx Plan delivered Case Staffed Collateral Documentation Medical Records School Records Psych Evals List Other Documents :
Service Order I understand that the above documents are missing & are my responsibility to correct. Assessor Signature:
ASSIGNMENTS Dr’s Appt Scheduled Dr’s Name Nurse Appt Scheduled Case Staffed Tx Plan delivered
N/A
Yes date
No why?
N/A N/A N/A
Yes date Yes date Yes date
No why? No why? No why?
COLLATERAL DOCUMENTATION Psych Evals req/rcv Medical Records req/rcv School Records req/rcv
N/A N/A N/A
Yes date Yes date Yes date
No why? No why? No why?
List additional documents below
Accepted by: ___________________________________________________________________ Print name: ________________________________ Date: ___________________________
INTAKE & ASSESSMENT CHECKLIST Consumer:
Date of Assessment:
Assessor:
Accepted by: ___________________________________________________________________ Print name: ________________________________ Date: ___________________________
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