20-3D

Treatment Program Clinical File ID Sheet

Name: _________________________________________________ Number: _______________________________

Admission Date: _________________________________________ Primary Counselor: _______________________

Date of Birth: ___________________________ Age: ____ Gender: _____ Race: __________Marital Status: __________

Referral Source: ______________________________ Reason for Referral: ___________________________________

Inmate's Last Address: _______________________________________ Telephone Number: ______________________

Emergency Contact: _________________________________________ Telephone Number: ______________________

Clinical Record Checklist

SECTION ONE SCREENING Initial

TCUDS V __________
State Specific Forms __________

SECTION TWO INTAKE Initial

Initial Treatment Plan __________

RDAP Client Rights and Limits of Confidentiality Handout __________
RDAP Informed Consent for Treatment Services __________
Confidentiality Waiver and Notice __________
Authorization for Release of Confidential Information __________
RDAP Agreement Form __________
TCU CTS, MOT, PSY, SOC (Intake) __________
State Specific Forms

SECTION THREE TREATMENT Initial

Psychosocial Assessment __________

Resident Goals and Objectives __________
Master Treatment Plan __________
RDAP Treatment Plan Update/Revision Form __________
Milestone Checklists __________
TCU ENG (Mid-Term) __________
State Specific Forms

SECTION FOUR PROGRESS NOTES Initial

RDAP Weekly/Daily Group Progress Note __________

RDAP Individual Contact Note __________
State Specific Forms

SECTION FIVE DISCHARGE Initial

RDAP Treatment Discharge Summary __________

TCU CTS, PSY, SOC, MOT, ENG __________
State Specific Forms

SECTION SIX MISCELLANEOUS

Proprietary Information – Not for Distribution – Copyrighted – Property of CCA 6/10/15