Regional CCS Forms

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As part of our regional shared services, the CWHP has developed several regional CCS forms.  Individual CWHP counties may modify the forms to meet their specific needs. 

​The forms below are in "locked" status, allowing for the use to tab through and complete the "fillable" fields.  Click on the link that follows for the "unlocked" editable versions of the forms: Unlocked Forms.
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• CCS Consumer Handbook (updated 11/16/18) - a resource for Consumers who are referred to CCS. The document can be used "as is" or can be customized to the individual county's CCS program.
• CCS Provider Contract Addendum (6/29/21)  outlines regional expectations for contracting with CCS providers

 

• Internal File / Process Review Checklist (updated 1/11/18)

 

• Referral Form (updated 7-27-17)
• Application and Admission Agreement (updated 7-27-17)
• Physician Prescription (updated 1-11-18)
• Determination of Need (updated 9-16-19)
• Assessment Tools.  Following are 3 sets of CCS assessment tools that CWHP counties may chose to use and/or adapt:
  1. Narrative Assessment (6-30-21)
     • Companion Document (6-30-21)
  2. CCS Comprehensive Assessment Summary (June 2021)
  3. (original) Comprehensive Assessment (updated 9-16-19)
     • ​Assessment Summary  (updated 10-19-19)
     • Life Satisfaction Scale - optional
     • Assessment Addendum - optional

            Additional Assessment Resources:
                 -  Evidence-Based AODA Screen Tools
​                 -  Medicaid Mental Health and Substance Abuse Documentation Requirements

• ​Recovery Plan  (updated 2-4-21)

            - Recovery Plan Addendum - optional

• ​Recovery Plan Supplement - Goals 3 through 6
• Marquette County's Individual Service Plan for CLTS and CCS (please note: this plan has been approved for use by Marquette County; other counties interested in utilizing this tool would have to go through he CLTS approval process)
• CCS Discharge Summary (4-22-16)
• TARP Progress Note

Additional Optional Tools

• ​Sample Service Facilitator Checklist (30 day, 6 month, 1 year)
• Sample Standard Language for Recovery Plans
• Service Array Summary (updated 6-25-18)
• Service Facilitator Service Plan meeting note template
• TARP Note Review Guide

 

• Provider Rate Setting Tool

 

• Roles of CCS Staff Members

Please contact Lori Martin, Regional CCS Coordinator, for more information: 715-258-0877, or email: lori.martin@cwhpartnership.org