Forms and Reports

Below are forms and reports to be completed and submitted by North Sound BH-ASO providers to meet contract requirements.

Provider Inventory

Please use the template below when notifying North Sound of any changes in service reductions, terminations and/or changes in service delivery.  Send completed spreadsheet to: deliverables@nsbhaso.org

North Sound Region Provider Inventory Template

Current Statewide Provider Inventory

Children’s Long-Term Inpatient Program (CLIP)

CLIP Application Form (PDF | Word)

Case Consultation Request

Credentialing

Credentialing Application Form, Agency

Credentialing Application Form, Facility/Site

Ownership and Disclosure Form

Quality Management

Quality Management Plan

Quality Management Annual Review

Crisis

Washington State Court Forms

Acknowledgement from Agency/Care Coordinator Assignment of CR/LR/AOT Receipt and Acceptance

CR/LR/AOT Individual Treatment Plan Legal Cover Sheet

Less Restrictive Provider Agreement (Electronic | Manual)

Client Crisis Prevention Safety Plan

Clinical Crisis Recommendations (Electronic | Manual)

Crisis Alert (Electronic | Manual)

Affidavit for Detention (Electronic | Manual)

DCR Contact Sheet, Page 1 (Electronic | Manual), DCR Contact Sheet, Page 2 (Electronic | Manual)

Outreach Safety Screening for Dispatch

Crisis Intervention Voluntary Contact Sheet (Electronic | Manual)

ED Medical Clearance Attestation for Dispatch Form 

Crisis Stabilization Funding Reporting Form

Unavailable Detention Facilities Report Form

Critical Incident

Critical Incident Reporting Form

Housing and Recovery through Peer Services (HARPS)

HARPS Participant Log

HARPS SUD Participant Log

HARPS Quarterly Report

HARPS Weekly Report

PSH Fidelity Self-Assessment Score Sheet

Joel's Law

All current forms and Joel Law Petition instructions can be found at:
Washington State Court Forms

Mental Health Block Grant (MHBG)

MHBG Progress Report Form

FBG Annual Progress Report

MHBG Expenditure Report

Program Integrity

Compliance Training Attestation Form

Exclusion Attestation Form

Program Integrity Plan

Substance Abuse Block Grant (SABG)

SABG Capacity Management Report Form

Opioid Outreach Monthly Reporting Form

Opioid Outreach (Youth) Reporting Form

PPW Housing Support Services Monthly Report

SABG Annual Progress Report

FBG Annual Progress Report

SABG Flex Fund Reimbursement Form (When completed send to fiscal@nsbhaso.org)

SABG Project Plan Template

Single Bed Certification

Eastern State Hospital

Western State Hospital

Trueblood

Trueblood Monthly Reporting Form

Utilization Management

Emergent Admission Notification Form

Psychiatric Inpatient Prior Authorization

Stabilization Service in a Triage Facility Guest Data (Electronic | Manual)

Other

CLAS Standards CLC Assessment Tool

Compensation Schedule

DBHR Quarterly Peer Pathfinder Report

Delegation Pre-Assessment Tool

E&T Discharge Planner Report

Engagement Specialist Quarterly Report

Juvenile Treatment Court Reporting Template

NCCC Residential Program Checklist

North Sound BH-ASO Compliance Plan

North Sound BH-ASO Invoice

Peer Bridger Participant Log

Schedule of Services