Marc Center Employees Only

Marc Center BHS Forms

Section	Form Number	Title	Revision Date
Administration - ADM
	BHS - ADM-002	BUDGETING ASSISTANCE AGREEMENT	5/2007
	BHS - ADM-003	CLIENT CHECK REQUEST	5/2007
	BHS - ADM-004	PURCHASE REQUEST	5/2007
	BHS - ADM-005	BASHAS’ CREDIT CARD SIGN-OUT SHEET	5/2007
	BHS - ADM-006	WAL-MART CARD SIGN-OUT SHEET	5/2007
	BHS - ADM-008	PURCHASE REQUEST - OPC	5/2007
	BHS - ADM-009	FAX COVER SHEET	5/2007

Case File Record - CFR
	BHS - CFR-002	INTAKE PACKET REQUIREMENTS	5/2007
	BHS - CFR-003	INTAKE PACKET REVIEW FORM	5/2007
	BHS - CFR-004	INTAKE SUMMARY	5/2007
	BHS - CFR-005	CASE MANAGEMENT DOCUMENTAION	5/2007
	BHS - CFR-006	MONTHLY PROGRESS SUMMARY	5/2007
	BHS - CFR-007	PSYCHIATRIC PROGRESS NOTE	5/2007
	BHS - CFR-008	DAILY PROGRESS NOTE AND ENCOUNTER FORM	5/2007
	BHS - CFR-009	INDIVIDUAL DAILY UTILIZATION LOG	5/2007
	BHS - CFR-010	WEEKLY UTILIZATION SUMMARY	5/2007
	BHS-CFR-011	ENGAGEMENT FORM – VILLAGE PROGRAM	5/2007
	BHS - CFR-012	ISP MEETING NOTICE	5/2007
	BHS - CFR-100	ADHS/DBHS ASSESSMENT	1/1/2006
	BHS - CFR-100 SP	ADHS/DBHS ASSESSMENT	1/1/2006
	BHS - CFR-101	ISP SERVICE PLAN	5/2007
	BHS - CFR-102	VO EA1013 ASSESSMENT	1/16/2007
	BHS - CFR-103	LIVING SKILLS SCALE	5/2007
	BHS - CFR-104	CULTURAL PREFERENCES	5/2007
	BHS - CFR-106	INDIVIDUAL STRENGTHS & NEEDS PREFERENCES SUMMARY	5/2007
	BHS - CFR-107	FUNCTIONAL ASSESSMENT MEASURES BY SELF REPORT	5/2007
	BHS - CFR-202	ISP STAFFING FORM	5/2007
	BHS - CFR-403	DISCHARGE SUMMARY	5/2007
	BHS - CFR-404	DISCHARGE SUMMARY – RECOVERY SUPPORT SERVICES	5/2007
	BHS - CFR-405	OUTCOME RATING SCALE & PROGRESS NOTE	5/2007
	BHS - CFR-405 SP	OUTCOME RATING SCALE & PROGRESS NOTE	5/2007
	BHS - CFR-407	CHART REVIEW BY NON-CLINICAL TEAM MEMBER	5/2007

Curriculums - CUR
	BHS - CUR-100	BHS ORIENTATION	5/2007
	BHS - CUR-101	TREATMENT PLANNING FOR PERSON-CENTERED CARE	5/2007
	BHS - CUR-103	ASSESSMENT PROCESS & CLINICAL LIAISON ROLE	5/2007
	BHS - CUR-104	SERVICES PLANNING & STRENGTHS IDENTIFICATION	5/2007
	BHS - CUR-105	COORDINATION OF CARE	5/2007
	BHS - CUR-105b	COORDINATION OF CARE ON SCREEN	5/2007
	BHS - CUR-106a	CO-OCCURRING PSYCHIATRIC & SUBSTANCE DISORDERS	5/2007
	BHS - CUR-106b	CO-OCCURING DISORDERS DUAL DIAGNOSIS	5/2007
	BHS - CUR-107	SETTING & ACHIEVING GOALS	5/2007
	BHS - CUR-108	REHABILITATIVE SERVICES	5/2007
	BHS - CUR-108b	RECOVERY	5/2007
	BHS - CUR-109	IMPLEMENTING EVIDENCE BASED PRACTICES & ATTAINING NETWORK SUFFICIENCY	5/2007
	BHS - CUR-110	DOCUMENTATION	5/2007
	BHS - CUR-111	CLIENT ILLNESS & INJURY	5/2007
	BHS - CUR-113	SIGNS & SYMPTOMS	5/2007
	BHS - CUR-114	ILLNESS MANAGMENT RECOVERY	5/2007
	BHS - CUR-115	SUPPORTIVE HOUSING & RESIDENTIAL PROGRAMS	5/2007
	BHS - CUR-116	Cultural Competency	5/2007
	BHS - CUR-117	Psychotropic Medications	5/2007
	BHS - CUR-117c	Addiction and Contemporary Culture	5/2007
	BHS - CUR-118	ASSISTANCE IN THE SELF-ADMINISTRATION OF MEDICATION	5/2007
	BHS - CUR-119	SCREENING EVALUATION & COURT ORDERED TREATMENT	5/2007
	BHS - CUR-121	CUSTOMER SERVICE	5/2007
	BHS - CUR-122	CORPORATE COMPLIANCE ANNUAL EMPLOYEE TRAINING	5/2007
	BHS - CUR-123	ACA CODE FOR ADMINISTRATIVE STAFF	5/2007
	BHS - CUR-124b	HIPAA SECURITY TRAINING	5/2007
	BHS - CUR-124c	INFORMATION SHARING	5/2007
	BHS - CUR-126	HEALTH SAFETY IAR	5/2007
	BHS - CUR-127	HEALTH & SAFETY	5/2007
	BHS - CUR-129	CHILDREN'S SYSTEM PRINCIPLES	5/2007
	BHS - CUR-130	REHABILITAION SERVICES II	5/2007
	BHS - CUR-131	MINDFULNESS & PSYCHOTHERAPY	5/2007
	BHS - CUR-132	JK PRINCIPLES	5/2007
	BHS - CUR-133	STRUCTURE PROCESS OUTCOME	5/2007
	BHS - CUR-134	SUPERVISION DDD	5/2007
	BHS - CUR-135	INTEGRATING	5/2007
	BHS - CUR- 136	PSYCHIATRIC REHABILITATION SKILLS IN PRACTICE 2	5/2007
	BHS - CUR- 137	GOALS, OBJECTIVES, AND METHODS	5/2007
	BHS - CUR- 140	HEALTHY RELATIONSHIP SKILLS	5/2007
	BHS - CUR- 141	CODEPENDENCY	5/2007
	BHS - CUR- 142a	SUICIDE AWARENESS & PREVENTION (part 1)	5/2007
	BHS - CUR- 142b	SUICIDE AWARENESS & PREVENTION (part 2)	5/2007
	BHS - CUR- 143	GRIEF & LOSS	5/2007
	BHS - CUR- 150	TRAUMA & PTSD	5/2007
	BHS - CUR- 151	LIFE STYLE CHANGES	5/2007
	BHS - CUR- 152	DOMESTIC VIOLENCE	5/2007
	BHS - CUR- 160	PROBLEM SOLVING SKILLS	5/2007
	BHS - CUR- 161	STRESS MANAGMENT	5/2007
	BHS - CUR- 162	PHYSICAL & EMOTIONAL SELF-CARE	5/2007
	BHS - CUR-163	COMMUNICATION SKILLS	5/2007
	BHS - CUR-164	RESISTING PRESSURES TO DRINK & USE	5/2007
	BHS - CUR-165	COPING WITH DEPRESSION AND ANXIETY	5/2007
	BHS - CUR-166	COPING WITH ANGER & RESENTMENT	5/2007
	BHS - CUR-167	FAMILY DYNAMICS	5/2007
	BHS - CUR-170	THE PROCESS OF RECOVERY	5/2007
	BHS - CUR-171	RECOVERY PROGRAMS & RESOURCES	5/2007
	BHS - CUR-172	THE PROCESS OF RELAPSE	5/2007
	BHS - CUR-173	RELAPSE PREVENTION (part 1)	5/2007
	BHS - CUR-174	RELAPSE PREVENTION (part 2)	5/2007
	BHS - CUR-201	SPECIAL ASSISTANCE FOR SMI	5/2007
	BHS - CUR-202	BIPOLAR DISCORDER	5/2007
	BHS - CUR-203	PARENT MANAGEMENT TRAINING	5/2007
	BHS - CUR-204	SELF-ESTEEN & POSITIVE PSYCHOLOGY	5/2007
	BHS - CUR- 205	MOVIES, MENTAL ILLNESS	5/2007
	BHS - CUR- 206	MOTIVATIONAL INTERVIEWING A	5/2007
Handouts - HD
	BHS - HD- 105a	Setting and Achieving Goals	5/2007
	BHS - HD- 105b	Goal Planning Worksheet	5/2007
	BHS - HD- 109	EvidenceBasedPractice	5/2007
	BHS - HD- 117c	Addiction and Contemporary Culture	5/2007
	BHS - HD- 117c	Culture	5/2007
	BHS - HD- 140	Healthy Relatinship Skills	5/2007
	BHS - HD- 141	Codependency	5/2007
	BHS - HD- 142a	Suicide Awareness and Prevention (part1)	5/2007
	BHS - HD- 142b	Suicide Awarenedd and Prevention (part 2)	5/2007
	BHS - HD- 143	Grief and Loss	5/2007
	BHS - HD- 150	Trauma and PTSD	5/2007
	BHS - HD- 151	Life Style Changes	5/2007
	BHS - HD- 152	Domestic Violence	5/2007
	BHS - HD- 160	Problem Solving Skills	5/2007
	BHS - HD- 161	Stress Management	5/2007
	BHS - HD- 163	Communication Skills	5/2007
	BHS - HD- 164	Resisting Pressures to Drink and Use	5/2007
	BHS - HD- 165	Coping with Depression and Anxiety	5/2007
	BHS - HD- 166	Coping with Anger and Resentment	5/2007
	BHS - HD- 167	Family Dynamics	5/2007
	BHS - HD- 170	The Process of Recovery	5/2007
	BHS - HD- 171	Recovery Programs and Resources	5/2007
	BHS - HD- 171b	Common Recovery Programs and Resources	5/2007
	BHS - HD- 172	The Process of Relapse	5/2007
	BHS - HD- 173	Relapse Prevention (part 1)	5/2007
	BHS - HD- 174	Relapse Prevention (part 2)	5/2007
CONSENTS & RIGHTS – RI
	BHS -RI-003	AUTHORIZATION FOR RELEASE OF INFORMATION	5/2007
	BHS -RI-004	CONSENT FOR EVALUATION AND/OR TREATMENT	5/2007
	BHS -RI-004 SP	CONSENT FOR EVALUATION AND/OR TREATMENT	5/2007
	BHS -RI-005	RIGHTS OF PERSON SERVED	5/2007
	BHS -RI-005 SP	RIGHTS OF PERSON SERVED	5/2007
	BHS -RI-006	ACKNOWLEDGEMENT	5/2007
	BHS -RI-007	INFORMED CONSENT FOR PSYCHOTROPIC MEDICATIONS	5/2007
	BHS -RI-008	FAMILY INCLUSION FORM	5/2007
CONSENTS & RIGHTS – RI CONTINUED
	BHS -RI-009	CONFIDENTIALITY – DRUG & ALCOHOL ABUSE	5/2007
	BHS -RI-009 SP	CONFIDENTIALITY – DRUG & ALCOHOL ABUSE	5/2007
	BHS -RI-110	RECORDS RELEASE RESPONSE	5/2007
	BHS -RI-111	REQUIRED PHONE NUMBERS	5/2007
	BHS -RI-112	NOTICE OF LEGAL RIGHTS FOR PERSONS WITH SMI – ADHS FORM MH-211	9/1993
	BHS -RI-112 SP	NOTICE OF LEGAL RIGHTS FOR PERSONS WITH SMI – ADHS FORM MH-211	9/1993
	BHS -RI-113	NOTICE OF DISCRIMINATION PROHIBITED – ADHS FORM MH-209 (ENGLISH & SPANISH)	NO DATE
	BHS -RI-114	VO-NOTICE OF CONFIDENTIALITY – DRUG & ALCOHOL ABUSE (PM FORM 4.1.7)	3/29/2001
	BHS -RI-114 SP	NOTICE OF CONFIDENTIALITY – DRUG & ALCOHOL ABUSE	NO DATE
	BHS -RI-115	AUTHORIZATION TO PICK UP CHILD	5/2007
	BHS -RI-116	NOTICE OF INDIVIDUALS RECEIVING SUBSTANCE ABUSE SERVICES (PM ATTACHMENT 3.19.1)	9/03/2004
	BHS -RI-116 SP	NOTICE OF INDIVIDUALS RECEIVING SUBSTANCE ABUSE SERVICES (PM ATTACHMENT 3.19.1)	9/03/2004
	BHS -RI-117	ADHS/DBHS NOTICE OF SMI GRIEVANCE AND APPEAL PROCEDURE (PM ATTACHMENT 5.5.1)	8/01/2004
	BHS -RI-117 SP	ADHS/DBHS NOTICE OF SMI GRIEVANCE AND APPEAL PROCEDURE (PM ATTACHMENT 5.5.1)	8/01/2004
	BHS -RI-118	NOTICE OF ACTION (PM FORM 5.1.1)	11/01/2005
	BHS -RI-118 SP	NOTICE OF ACTION (PM FORM 5.1.1)	11/01/2005
	BHS -RI-119	ADHS/DBHS APPEAL OR SMI GRIEVANCE FORM (PM FORM 5.3.1)	4/12/2005
	BHS -RI-119 SP	ADHS/DBHS APPEAL OR SMI GRIEVANCE FORM (PM FORM 5.3.1)	1/01/2004
	BHS -RI-120	NOTICE OF DECISION AND RIGHTS TO APPEAL (PM FORM 5.5.1)	6/03/2005
	BHS -RI-120 SP	NOTICE OF DECISION AND RIGHTS TO APPEAL (PM FORM 5.5.1)	6/03/2005
EMPLOYEE – EMP
	BHS -EMP-001	CLINICAL/ADMINISTRATIVE SUPERVISION	5/2007
	BHS -EMP-002	STAFF AVAILABILITY FORM	5/2007
	BHS -EMP-003	INSERVICE TRAINING RECORD	5/2007
	BHS -EMP-004	TRAINING CERTIFICATE	5/2007
	BHS -EMP-006	SKILLS & KNOWLEDGE COMPETENCIES CHECKLIST	5/2007
	BHS -EMP-009	REQUEST FOR COVERAGE	5/2007
	BHS -EMP-011	CLINICAL SUPERVISION COMMITMENT	5/2007
	BHS -EMP-012	NOTICE OF SUSPENSION UNTIL COMPLETION OF SUPERVISION HOURS	5/2007
	BHS -EMP-014	REQUEST FOR TEMPORARY STAFF	5/2007
	BHS -EMP-015	HOLIDAY REQUEST FOR IN HOME SUPPORTS	5/2007
	BHS -EMP-200	SITE STAFF ORIENTATION FORM – CONSUMER INFORMATION	5/2007
	BHS -EMP-201	SITE STAFF ORIENTATION FORM – SITE INFORMATION	5/2007
	BHS -EMP-202	SITE STAFF ORIENTATION FORM – BHS DEPARTMENTAL INFORMATION	5/2007
	BHS -EMP-203	SITE STAFF ORIENTATION FORM – PROGRAM INFORMATION	5/2007
INDIVDUAL INENIFYING INFORMATION - IN
	BHS-IN-001	INDIVIDUAL FACE SHEET	5/2007
	BHS -IN-002	REFERRAL PHONE LOG	5/2007

INCIDENT/ACCIDENT REPORTS - IAR
	BHS-IAR-001 A	INCIDENT/ACCIDENT REPORT FORM COVER PAGE	5/2007
	BHS-IAR-001 B	VO INCIDENT/ACCIDENT REPORT	2/10/2006
	BHS-IAR-002	IAR FAX COVER SHEET	5/2007
	BHS-IAR-003	VO MEDICATION INCIDENT REPORTING FORM – PM FORM 7.4.2	NO DATE
	BHS-IAR-004	VO ADVERSE REACTION REPORTING FORM – PM FORM 7.4.3	NO DATE
	BHS-IAR-006	PROTECTIVE SERVICES REPORT	5/2007
	BHS-IAR-009	INCIDENT DEBRIEFING FORM	5/2007
LEVEL II – L2
	BHS-L2-004	OUTING FORM	5/2007
	BHS-L2-005	PRELIMINARY FACILITY CHECKLIST	5/2007
	BHS-L2-007	PERSONAL BELONGINGS	5/2007
	BHS-L2-008	RESIDENTIAL CENSUS REPORT	5/2007
MEDICAL - MD
	BHS-MD-001	PCP COMMUNICATION FORM	5/2007
	BHS-MD-002	MEDICAL APPOINTMENT REPORT	5/2007
	BHS-MD-003	VITALS SHEET	5/2007
	BHS-MD-005	TELEPHONE CONTACT FORM	5/2007
MEDICATION – RX
	BHS-RX-001 AM	MEDICATION AM PRESCRIPTION	5/2007
	BHS-RX-001 PM	MEDICATION PM PRESCRIPTION	5/2007
	BHS-RX-002	MEDICATION PRN	5/2007
	BHS-RX-003