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
Children’s Long-Term Inpatient Program (CLIP)
CLIP Application Form (PDF | Word)
Credentialing
Credentialing Application Form
Quality Management
Quality Management Annual Review
Crisis
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 (Whatcom County)
Critical Incident
Critical Incident Reporting Form
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
Compliance Training Attestation Form
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
SABG Flex Fund Reimbursement Form (When completed send to fiscal@nsbhaso.org)
Single Bed Certification
Trueblood
Trueblood Monthly Reporting Form
Utilization Management
Emergent Admission Notification Form
Psychiatric Inpatient Prior Authorization
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
Juvenile Court Treatment Program Reporting Template
NCCC Residential Program Checklist
North Sound BH-ASO Compliance Plan