Organizational Forms

Patient Rights Posting

Patient Rights Signature Sheet

Client Requests for Special Accommodations

Personnel Manual Forms

Employment Application

Employee Orientation Checklist

Employee Performance Evaluation

Purchase Authorization Form

Notice of Disciplinary Action

Security and Confidentiality Agreement

Hepatitis A Exposure Notice

Hepatitis B Vaccination Consent Form

Hepatitis B Vaccine Verification Form

Hepatitis B Vaccine Declination Form

Tuberculin (TB) Skin Test Record Form

Tuberculosis (TB) Risk Assessment

Tuberculosis (TB) Chest X-Ray Requisition

Manual Timesheet

Mileage & Expense Reimbursement

Leave of Absence Request

Employee Emergency One-Sheet

Employee Satisfaction Survey

PICC Line Competency Checklist

Job Descriptions

Chief Executive Officer

Chief Financial Officer

Chief Medical Officer

Clinical Services Director

Vice President of Residential Operations

Chief Compliance Officer

Human Resources Coordinator

Medical Director

Discharge Planner

Facility Administrator

Access Center Director

Access Center Navigator

Marketing Account Manager

Nursing Staff

Nursing Director

Recovery Coach

Peer Support Specialist

Shift Lead

Therapist

Utilization Review Director

Utilization Review Specialist

Billing Specialist

Digital Media Specialist

Media Production Assistant

Administrative Secretary

Sober Living House Manager

Intensive Health Job Descriptions

IH Office Coordinator

Transportation Staff (IH)

Billing Specialist (IH)

Lab Technician (IH)

Outpatient Nursing Staff (IH)

Engagement Specialist (IH)

Receptionist (IH)

Medical Provider – Physician (IH)

Medical Provider – Non-Physician (IH)

Therapist (IH)

Peer Support Specialist (IH)


Residential Operations Forms

Risk Management

Covid-19 Protocols

Covid-19 Patient Disclaimer

Covid-19  Patient Acknowledgment of Positive Case

Risk Management Log

Hepatitis A Exposure Educational Material

Emergencies

Monthly Drill Sheet

Emergency Drill Documentation

Emergency and Quick Reference Numbers

Contents of First-Aid Kit

Contents of Spill Kit

Quality Improvement

Client Progress for Utilization Review

Quality Assurance Quarterly Evaluation

Incident Report (Form)

Witness Report Form

Chart Audit Worksheet

Facility Operations

Client Admission Inventory

Admission Checklist

Nursing Assessment

Chore List

Deep Cleaning Saturday Assignment List

10-Foot Rule Redirection

Residential Rules

Residential Schedule

Patient Grievance Form

Security and Confidentiality Agreement for Volunteers

Treatment Plan

Treatment Plan Review

Physician Orders

Reminder

Reflection

Reflection Choices

Treatment Planning

Commitment to Improve

Group Note

Progress Note

Staff Note

Recovery Coach Admission Training Worksheet

Memorandum of Understanding

Discharge Planning Note

Discharge Checklist

Discharge Appointment

MAR

Clinical Opiate Withdrawal Scale (COWS)

CIWA

Detox Note

Mental Status Exam

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

Community Sheet

Community Wrap-Up Sheet

FAX Cover Sheet

Welcome Sign

Guest Confidentiality Agreement

Guest Guidelines for Visitation

“Client Update” Letter Template

Rounds Sheet (7am-7pm)

Rounds Sheet (7am-3pm)

Rounds Sheet (3pm-11pm)

Rounds Sheet (7pm-7am)

Rounds Sheet (11pm-7am)

Phone Time Sign-Up Sheet

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.

Records

Biopsychosocial Assessment

Summary of Multidemensional Assessment

Discharge Summary Continuing Care Plan

Fee Agreement

Third-Party Payer Acknowledgment

Confirmation of Assessment

Consent to Assessment and Treatment

Discharge Summary/Continuing Care Plan

Discharge Against Medical Advice (AMA)

Against Medical Advice Information

Discharge AMA Confirmation

Medical Records Release (ROI)

Authorization for Release of General Information Only

Special Event Release of Information

Hepatitis A Exposure Notice

Hepatitis A Exposure Acknowledgment of Education and Prophylaxis Recommendation

Notice of Privacy Practices

Media Release Form

Patient Taxicab Fare Log

OSHA

OSHA Bloodborne Exposure One-Sheet

Bloodborne Pathogen Exposure Lab Req

Bloodborne Pathogens Exposure Control Plan

Physical Plant

Monthly Housekeeping and Safety Inspection Checklist

Surveys

Intake Survey

Survey – AMA

15-Day Survey

Discharge Survey

Post-Discharge Follow-Up Survey

Family Survey

Referral Source Satisfaction Survey Form

Community Resources Survey Form

Sober Living Home Program

(Policy/procedure: 4.2.3.j. Sober Living Home Program)

Sober Living Home Resident Application

Sober Living Home Standards & Contract

Sober Living Home Phases

Sober Living Home Chore Sheet

Sober Living Home Educational Group Schedule

Sober Living Home Pass Request


Marketing Forms

Stepworks Events Checklist and Guidelines


Intensive Health

Treatment Plan (Intensive Health)