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

Intensive Behavioral Health Resource Team (IBHRT)

Intensive Behavioral Health Screening Form

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

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

Community Behavioral Health Rental Assistance Program (CBRA)

CBRA Guidelines (PDF)

Letter of Interest (Word)

Letter of Interest Form (Word)

Commerce Department TRAP Site

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

Crisis Stabilization Diversion Pilot Template

Mobile Crisis Block Grant Stimulus Report Template

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)

FBG Annual Progress Report

MHBG Expenditure Report

Peer Bridger Participant Log

Peer Bridger Participant Treatment Engagement Report

Peer Pathfinder Jail Transition Report

Program Integrity

Exclusion Attestation Statement

Exclusion Attestation Form

Program Integrity Plan

Recovery Navigator Program

Quarterly Data Collection Tool

Service Transactions Log

Recovery Navigator Program Quarterly Report

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

FBG Annual Progress Report

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

Single Bed Certification

Eastern State Hospital

Western State Hospital

Trueblood

Trueblood Monthly Reporting Form

Trueblood Misdemeanor Diversion Fund Report

Utilization Management

Emergent Admission Notification Form

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

Co-Responder Quarterly Reporting Form

DBHR Quarterly Peer Pathfinder Report

Delegation Pre-Assessment Tool

E&T Complex Discharger Report

Engagement Specialist Quarterly Report

Fee for Service Outpatient Rates

Jail Transition Services Report Form

Juvenile Court Treatment Program Reporting Template

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