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
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
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
Jail Transition Services Report Form
Juvenile Court Treatment Program Reporting Template
Mobile Crisis Block Grant Stimulus Report Template
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)
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)
Program Integrity
Exclusion Attestation Statement
Quality Management
Quality Management Annual Review
Recovery Navigator Program
Quarterly Data Collection Tool
Recovery Navigator Program Quarterly Report
Single Bed Certification
Substance Abuse Block Grant (SABG)
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
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
Supplemental Data Daily Submission Notification