For better or worse, standardized forms are the grease that makes the operational machinery run smoothly. Many of the following forms were graciously furnished by Open Door Community Health Centers, providing health care and education to residents of Humboldt and Del Norte Counties in California, as well as several of IBHP’s other grantees.
- A treasure trove of forms created by the New York State Clinical Records Initiative
- Activities of Daily Living Scale – courtesy of Mendocino Community Health Clinic
- Adult History Form – courtesy of Family Health Centers of San Diego
- Adult Wellbeing Screening Form – compliments of MaineHealth
- Annual Patient Health Screening – courtesy of Mendocino Community Health Clinic
- AUDIT Screener for Alcohol Use
- Behavioral Consultant Note and Psychiatric Consultant Note (both courtesy of Golden Valley Health Centers) can be found on the last four pages of Golden Valley Health Centers’ Manual for Behavioral Health Services.
- Behavioral Health Assessment Form
- Behavioral Health Consultant Referral and Feedback
- Behavioral Health Consultant Tracking Form
- Behavioral Health Consultation Referral
- Behavioral Health Patient Request for Review
- Behavioral Health Peer Review Form – courtesy of the Molokai’l Community Health Center
- Behavioral Health Services Chart Review Sheet – courtesy of Hubert H. Humphrey Comprehensive Health Center
- Behavioral Health Symptom Progress Report
- Brief Behavioral Screening Questionnaire
- Brown Bag Medication Review Form
- Case Management Phone Log
- Case Management Progress Notes
- Case Management Psychosocial Assessment
- Case Management Referral Form
- Client consent to participate in exercise program – courtesy of Horizon House
- Core Behavioral Health Consultant Knowledge and Skills Assessment courtesy of the Southcentral Foundation
- Family Health Intake Form, English and Spanish – courtesy of SAC Norton Clinic (Loma Linda University)
- Family Health Survey – courtesy of SAC Norton Clinic (Loma Linda University)
- Health Home Patient Information-Sharing Consent form – courtesy of the New York State Dept. of Health
- Health-Related Quality of Life (English) – courtesy of Clinic Ole’
- Health-Related Quality of Life (Spanish) – courtesy of Clinic Ole
- Introducing the Care Team and the Integration Model (to be given to the patients), developed by the AIMS Center
- Justification For Mental Health Services
- Mood Questionnaire – courtesy of Mendocino Community Health Clinic
- Napa County Health Care Universal Referral Form – courtesy of the Napa Integration Health Care Project
- Napa Medication Reconciliation Form – courtesy of the Napa Integrated Health Care Project
- New Patient History Questionnaire
- Patient Contract Refusal Form
- Patient Stress Questionnaire in English and Spanish, compliments of the Center for Integrated Primary Care, University of Massachusetts Medical School
- Physician clearance for clients engaging in exercise program – courtesy of Horizon House
- Primary Care Medication Form – courtesy of the Napa Integrated Health Care Project
- Referral Form (from Alcohol and Drug Services) – courtesy of the Napa Integration Health Care Project
- Referral to Behavioral Health from Medical – compliments of Sierra Family Medical Center
- Referral to Medical From Behavioral Health – compliments of Sierra Family Medical Center
- Reimbursement Tracking Sheet for Primary Care Mental Health – compliments of MaineHealth
- Release of Information form – courtesy of Horizon House, Inc. and Delaware Valley Community Health, Inc.
- Risk Assessment Form
- Risk Assessment Screening Tool
- Specialty Behavioral Health Goal Contract
- Specialty Behavioral Health Intake Form
- Specialty Mental Health Tracking Form
- Staying Healthy Assessment – distributed by the California Department of Health Services
- Treatment Plan Form
- Universal consent form – courtesy of the National Council for Behavioral Health and the Rhode Island Behavioral Health
