Forms and Reports

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

Community Behavioral Health Rental Assistance Program (CBRA)

Department of Health CBRA Website

Credentialing

Credentialing Application Form, Agency

Credentialing Application Form, Facility/Site

Ownership and Disclosure Form

Crisis

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

Affidavit for Detention (Electronic | Manual)

Client Crisis Prevention Safety Plan

Clinical Crisis Recommendations (Electronic | Manual)

Crisis Alert (Electronic | Manual)

Crisis Intervention Voluntary Contact Sheet (Electronic | Manual)

Crisis Stabilization Diversion Pilot Template

CR/LR/AOT Individual Treatment Plan Legal Cover Sheet

DCR Contact Sheet, Page 1 (Electronic | Manual)

DCR Contact Sheet, Page 2 (Electronic | Manual)

ED Medical Clearance Attestation for Dispatch Form 

Less Restrictive Provider Agreement (Electronic | Manual)

Outreach Safety Screening for Dispatch

Unavailable Detention Facilities Report Form

Washington State Court Forms

Critical Incident
Critical Incident Reporting Form

Intensive Behavioral Health Resource Team (IBHRT)

Children’s Long-Term Inpatient Program (CLIP) Application (electronic) 

Children’s Long-Term Inpatient Program (CLIP) Application (handwritten)

Intensive Behavioral Health Screening Form

Provider Deliverables

Co-Responder Quarterly Reporting Form

Crisis Stabilization Funding Reporting Form

E&T Complex Discharger Report

Jail Transition Services Report Form

Juvenile Court Treatment Program Reporting Template

Mobile Crisis Block Grant Stimulus Report Template

Peer Bridger Participant Log

Peer Bridger Participant Treatment Engagement Report

Peer Pathfinder Jail Transition Report

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

Washington State DOH Behavioral Health Agencies

Housing and Recovery through Peer Services (HARPS)

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)

FBG Annual Progress Report

MHBG Expenditure Report

Program Integrity

Exclusion Attestation Form

Exclusion Attestation Statement

Program Integrity Plan

Quality Management

Quality Management Annual Review

Quality Management Plan

Recovery Navigator Program

Quarterly Data Collection Tool

Recovery Navigator Program Quarterly Report

Service Transactions Log

Single Bed Certification

Eastern State Hospital

Western State Hospital

Substance Abuse Block Grant (SABG)

FBG Annual Progress Report

Opioid Outreach Monthly Reporting Form

Opioid Outreach (Youth) Reporting Form

PPW Housing Support Services Monthly Report

SABG Capacity Management Report Form

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

Trueblood

Trueblood Monthly Reporting Form (updated 3/18/2024)

Utilization Management

Psychiatric Inpatient Prior Authorization

Single Case Agreement Request Form

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

Engagement Specialist Quarterly Report

Fee for Service Outpatient Rates

NCCC Residential Program Checklist

North Sound BH-ASO Compliance Plan

North Sound BH-ASO Invoice

Schedule of Services

Supplemental Data Daily Submission Notification

Supplemental Data Monthly Certification Letter

Trauma Informed Counseling Youth/Children Report Template