Quick Reference

Acronym and Abbreviation Reference Sheet

FAX Cover Sheet

Bloodborne Exposure One-Sheet

Bloodborne Pathogen Exposure Lab Req

Bloodborne Pathogens Exposure Control Plan

Emergency Drill Documentation

Clinical Opiate Withdrawal Scale (COWS)


Contents of First-Aid Kit

Contents of Spill Kit

Treatment Planning for Therapists

Folder Insert – Print a new copy


Incident Report Form

Witness Report Form

Medical Records Release (ROI)

Patient Grievance Form

Patient Request Form for Special Accommodations

Log of Patient Requests for Special Accommodations


Emergency and Quick Reference Numbers

Grievances and Other Complaints

Guest Confidentiality Agreement (Facility Sign-in Sheet)

Guest Guidelines for Visitation

Patient Rights Posting

Residential Schedule

Management Forms

Hepatitis B

All patient-care employees should have a completed Hepatitis B Immunity Status Verification Form completed at hire.  If receiving the vaccine, they should have the consent form and be given the VIS.  If not receiving the vaccine, regardless of the reason, they should complete the declination form.

Hepatitis B Immunity Status Verification Form

Hepatitis B Vaccination Consent Form

Hepatitis B CDC Vaccine Information Sheet (VIS)

Hepatitis B Vaccine Declination Form


Tuberculosis (TB) Annual Risk Assessment

Tuberculin (TB) Skin Test Record Form

Tuberculosis (TB) Chest X-Ray Requisition


Accounts Payable Process (effective 11/15/21)

Employee Orientation Checklist

Influenza Vaccine Information Sheet (VIS)

Leave of Absence Request

Manual Timesheet

PICC Line Competency Checklist

Security and Confidentiality Agreement for Volunteers

Residential Operations Forms

(If the EMR is temporarily unavailable, please scroll to the bottom of the page for paper chart templates.)


Admission Form Packet

Third-Party Payer Acknowledgement

COVID-19 Patient Acknowledgement of Positive Case in Facility

Admission Folder Packet

Daily Operations

Chore List – Bowling Green Female

Chore List – Bowling Green Male

Chore List – Crowne Pointe

Chore List – Nicholasville

Community Sheet

Community Wrap-Up Sheet

Deep Cleaning Saturday Assignment List (Co-ed Facilities)

Deep Cleaning Saturday Assignment List (Single-Sex Facilities)

Phone Time Sign-Up Sheet (weekday)

Phone Time Sign-Up Sheet (weekend)

Choices and Consequences

10-Foot Rule Redirection


Reflection Choices


Commitment to Improve


Discharge Checklist

Discharge Summary Continuing Care Plan

Patient Taxicab Fare Log

Infection Control

COVID-19 Positive Patient Information Sheet

Covid-19 Protocols

Hepatitis A Exposure Educational Material

Hepatitis A Exposure Notice

Hepatitis A Exposure Acknowledgment of Education and Prophylaxis Recommendation

Movie Assignments

Stepworks Movie Checklist

“28 Days” Movie Worksheet

“My Name is Bill W.” Movie Worksheet

“Clean and Sober” Movie Worksheet

“Flight” Movie Worksheet

“When a Man Loves a Woman” Movie Worksheet

Recovery Coach Resources

Rounds Sheet (7am-7pm)

Rounds Sheet (7am-3pm)

Rounds Sheet (3pm-11pm)

Rounds Sheet (7pm-7am)

Rounds Sheet (11pm-7am)

Recovery Coach Shift Duties

Weekdays 7 a.m.–3 p.m.

Weekdays 3 p.m.–11 p.m.

Weekdays 11 p.m.–7 a.m.

Weekends 7 a.m.–7 p.m.

Weekends 7 p.m.–7 a.m.


Survey – AMA

15-Day Survey

Discharge Survey

Post-Discharge Follow-Up Survey

Family Survey

Sober Living Program

New Resident Forms

Sober Living Agreement to Standards, Policies, and Testing

Sober Living Application

Sober Living Resident Lease Agreement

Sober Living Authorization to Destroy Resident Property

Current Resident Forms

Sober Living Chore Sheet

Sober Living Educational Group Schedule

Sober Living Home Phases

Sober Living House Lead Description

Sober Living Internet Usage Agreement

Sober Living Overnight Pass Request

Sober Living Payment Plan

Sober Living Recovery Focus Plan

Sober Living Recovery Meeting Attendance Form

Sober Living Sign-in and out Sheet

Sober Living Technology Device Agreement

Intensive Health

Client Outcome Measures

Residential Paper Chart Templates

Screening Assessment

Biopsychosocial Assessment

Admission Forms

Authorization for Release of General Information Only

Consent to Assessment and Treatment

Notice of Privacy Practices

Patient Rights Signature Sheet

Residential Rules

Notes and Assessments

Detox Note

Group Note


Mental Status Exam

Nursing Assessment

Physician Orders

Progress Note

Staff Note

Treatment Plan

Treatment Plan Review


Discharge Appointment

Discharge Planning Note

AMA Discharges

Discharge Against Medical Advice (AMA)

Against Medical Advice Information

Discharge AMA Confirmation

New Form/Sign or Update Requests