Idea Transcript
Alcohol/Drug Assessment/Treatment Report Instructions Updated and Upgraded – This new and improved form makes paper-handling obsolete. Now, when you fill out this form online and transmit it – it will go safe and secure to the DOL Alcohol Treatment mailbox in Olympia. Most of the form is self-explanatory; however, I’ve gone through each section to make sure sections work. I will use a “Test License Number” to simulate each of the areas. You can also use the same test license number as well. The highlighted areas were used during testing of the form you can use the same test info to become familiar with the form if you like.
START HERE: https://fs11.formsite.com/ihill/dolform500010/index.html What you’re submitting? Assessment, Information school only, or Treatment only. Name, DOB, and LICENSE NUMBER: OConnell, Test, Record, 09/11/1953, OCONNTR473OJ I’ve selected “Assessment” so that section will come up and ask for a specific date: Type 04/01/2015 What were your findings: Substance use disorder Alcohol/drug information school is recommended (ASAM Level 0.5) It will ask “What were your findings” – If you select “Substance use disorder” another selection appears: Diagnosis – which you have to choose: Mild substance use disorder Moderate substance use disorder Severe substance use disorder Once a diagnosis is selected – “Level of treatment” appears, so select a level and move on: No treatment is recommended – Please justify in the “Comments” box below. (Reminder: By checking No Treatment Recommended, you are verifying that your client is in full sustained remission.)
ASAM Level I
ASAM Level II
ASAM Level III
Treatment report appears – when you select yes a date box appears: Yes No – If selected it will ask; “Why not?” – here you might put “never came back” etc. Date treatment began: Type 04/07/2015 Treatment program status, client is: Compliant Currently in treatment Completed Treatment completion date: Type 04/20/2015 Non-compliant Transfer/Additional treatment recommended Yes No
Comments Section: No need to put in anything but if needed, you have 375 characters to use. Your Information: the Counselors Name, the full 10-digit phone number; Use: Butch Cassidy, 360-902-3977 Are you a WA certified agency? Yes = DSHS agency certification number 96001300 DOH CDP credential number EF00131728 No = State where certified Arizona Certification number NOYNAC DNARG Your Agency name: Type: 8th Heaven Counseling Your Address: Type: 11 Pine Tree Drive Your City, State, Zip Code: Type: Bellevue, WA 98558 Today’s Date: Type: 04/28/2015 Your Email: Type: Your Email Here (No need to put our treatment email box here – it’s automatic!) (NOTE: Using a comma and no space allows you to send to multiple people – BUT NEVER TO THE INDIVIDUAL
After pressing the button, you’ll see the following screen to confirm you’re entry:
After reviewing your entries, click on the “Yes” block stating that the info is correct.
When ready to send to DOL Press “Submit”
If anything appears in red or is surrounded by a red border – there is an issue that should be corrected. Again, the program will automatically send a copy of this form to the DOL Treatment Mailbox. You’ll receive a confirm message (below) on your screen when the (no errors) submission is sent.
A PDF of your submission will also be sent to the email address you entered. Written By: Ed OConnell, Dept of Licensing, (360) 902-3977