URC Form

Title Page

OUTPATIENT URC

1 INTAKE

1a. CLIENT PHOTO ID SHEET
1b. PARTICIPANT ORIENTATION
1c. SWITS INTAKE ENCOUNTER NOTE (IN FILE from SWITS)
IS THE NOTE IN SWITS AND IN FILE?
1d. ADMISSION AGREEMENT
1e. ATTENDANCE POLICY
1f. FINANCIAL AGREEMENT
1g. PARTICIPANT IDENTIFICATION (TELEHEALTH CONSENT)
1h. HIV MINIMIZING RISK GUIDE
1i. COVID19 POLICY
1j. PARTICIPANT RIGHTS / GRIEVANCE
1k. CLIENT HANDBOOK ACKNOWLEDGEMENT
1l. COMMUNITY RESOURCE GUIDE ACKNOWLEDGMENT
1m. PRIVACY PRACTICES ACKNOWLEDGMENT
1n. BQuIP (If not, reason why you jumped to ASAM in a progress note) or (N/A if it was before 12/19/22 requirement date)
1o. PRE-ADMIT ASSESSMENT (BIO-PSYCH)
1p. MODIFIED MINI SCREEN
1q. SNAPS ASSESSMENT (N/A if ASI was in use at time)
1r. GLOBAL GOALS TREATMENT (N/A if ASI was in use at time)
1s. ACES ASSESSMENT (N/A if ASI was in use at time)
1t. PTSD CHECKLIST (N/A if ASI was in use at time)
1u. SUBSTANCE ABUSE PROBLEM (SAP) CHECKLIST (N/A if ASI was in use at time)
1v. RISK BEHAVIOR QUESTIONNAIRE (N/A if ASI was in use at time)
1w. HOMELESS/HOUSING QUESTIONNAIRE (N/A if ASI was in use at time)

2a. (PRE-ASSESSMENT RESULTS FORM) LPHA/Therapist & MD DIAGNOSIS (needed 30 days from admission)
- Yes
- No
- Out for Signature within 30 days of Admit
Does Therapist & Doctor have: Name, Signatures, and Dates?
When does the Therapist & MD need to sign by? (Type the due date in MM/DD/YYYY format, 30 days from the Admit Date).
2b. ASAM ASSESSMENT (completed in 30 days or 60 days if client is under 21 or homeless)
Is the client under age 21 or homeless?
When does client under age 21 or homeless have to have it completed by? (Write the date in MM/DD/YYYY format, 60 days from the admit date).
When does client have to have it completed by? (Type the due date in MM/DD/YYYY format, 30 days from the admit date).
2c. CONTINUED SERIVICE JUSTIFICATION (CJS) at 5-6 months
2d. MONTHLY MEDICAL VERIFICATION (If client is Pregnant or post-partum up to 6 weeks in Perinatal Program, they need this. If not clients would be NNA payor and click N/A).
Is the client NNA in the Perinatal Program?
2e. THIRD PARTY PAYER ROI
2f. THIRD PARTY VERIFICATION (FRONT & BACK OF CARD)
2g. TTR ADMISSION RECEIPT (IF SELF-PAY OR CSP)
2h. SWITS INTAKE (IN FILE from SWITS)
Is the SWITS INTAKE IN SWITS?
2i. MEDI-CAL ROI

3a. EMERGENCY CONTACT ROI
3b. SONOMA COUNTY BEHAVIORAL HEALTH/SWITS ROI
3c. SONOMA COUNTY PUBLIC HEALTH MEDICAL ROI
3d. CPS ROI
3e. SCHEDULING PURPOSE ROI
3f. UA MILLENNIUM HEALTH ROI
3g. COVID PRIMARY HEALTH ROI
3h. CRIMINAL JUSTICE ROI (NEEDS TO SAY "SONOMA COUNTY PROBATION" IN THE AGENCY LINE IF NOT IT'S A NO).
3i. WRS (Women Recovery Services) ROI *PERINATAL PROGRAM only
3j. HIPAA NOTICE ACKNOWLEDGMENT
3k. ADMIN & OVERSIGHT ACKNOWLEDGMENT
3l. SATISFACTION SURVEY (CONSENT FOLLOW-UP TX)
3m. AGENCY MAILING LIST

4a. PHYSICAL EXAM (needed 30 days from admission)
Is the Physical Exam Placed in The Problem List, as a goal to complete?
4b. HEALTH QUESTIONNAIRE
- Yes
- No
- Out for Signature within 30 days of Admit
Does Doctor have: Name, Signature, and Date?
4c. MAT REFERRAL FORM
If client declined, is it properly filled out stating "Client Declined" with client signature and date & staff signature and date?
4d. TOBACCO USE ASSESSMENT
If client doesn't smoke, is it circled all with 1's or 0's placed in each row and at the back all 0's with trigger being "Client stated they don't smoke."

5a. UA LOG (Perinatal Program is using. It will be implemented for rest of Outpatient soon Put N/A for Regular Outpatient for now)
5b. UA RESULTS (Results logged on the UA Log and Results printed and placed behind the UA log)

6a. PROBLEM LIST (needed 30 days from admission)
- Yes
- SWITS
- FILE
- No
6b. TREATMENT PLAN (needed 30 days from admission) (Not needed anymore but some still have them before requirement changed).

7a. PROGRESS NOTES (Are the individual notes: describing the service provided and how interventions addressed client's behavioral health needs/Data, Assessment, and Plan, proper spelling and grammar).
7b. GROUP NOTES (Are the group notes: describing the service provided and how interventions addressed client's behavioral health needs/Data, Assessment, and Plan, proper spelling and grammar).

8a. COMMUNICATION WITH P.O./CPS LOG (Need monthly contact with P.O. or CPS for clients that have a P.O. or CPS worker referral. ALL clients should still have a log in file if needed). Put N/A until we implement.
8b. CPS REFERRAL (Need if CPS client especially CPS Perinatal clients)

9a. EXIT/DISCHARGE PLAN (N/A if client is active and not discharged).
9b. DISCHARGE SUMMARY (N/A if client is active and not discharged).
9c. SWITS DISCHARGE FORM (N/A if client is active and not discharged).
9d. DISCHARGE/TRANSFER ASAM (N/A if client is active and not discharged by transfer).
9e. DISCHARGE/TRANSFER LPHA THERAPIST DIAGNOSIS (N/A if client is active and not discharged by transfer).