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Regional CCS Forms


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 Orientation Packet / Provider Handbook. This packet contains information needed to become a provider of Comprehensive Community Services (CCS) in counties that are part of the Central Wisconsin Health Partnership (CWHP).
 
  • 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)
  • Comprehensive Assessment (updated 9-16-19)
  • Comprehensive Assessment with One Key Question domain (Waupaca County)
  • Assessment Summary  (updated 10-19-19)
            -  Life Satisfaction Scale - optional
            -  Assessment Addendum - optional
            Additional Resources:
            -  Evidence-Based AODA Screen Tools
​            -  Medicaid Mental Health and Substance Abuse Documentation Requirements
  • ​Recovery Plan  (updated 10-10-19)
            - 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

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

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Questions or suggestions?  Please contact Lori Martin, CWHP Regional CCS Coordinator: lori.martin@cwhpartnership.org