Forms and Reports

Below are forms and reports to be completed and submitted by North Sound BH-ASO providers to meet contract requirements.


Children’s Long-Term Inpatient Program (CLIP)

CLIP Application Form (Electronic | Manual)


Credentialing

Credentialing Application Form

Ownership and Disclosure Form


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 (Whatcom County)


Critical Incident

Critical Incident Reporting Form


Housing and Recovery through Peer Services (HARPS)

HARPS Participant Log

HARPS Commerce Subsidy 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)

MHBG Progress Report Form

MHBG Expenditure Report


Program Integrity

Compliance Training Attestation Form

Exclusion Attestation Form


Substance Abuse Block Grant (SABG)

SABG Capacity Management Report Form

Opioid Outreach Monthly Reporting Form

PPW Housing Support Services Monthly Report

SABG Annual Progress Report


Single Bed Certification

Eastern State Hospital

Western State Hospital


Utilization Management

Emergent Admission Notification Form

Psychiatric Inpatient Prior Authorization

Stabilization Service in a Triage Facility Guest Data (Electronic | Manual)


Other

Peer Bridger Participant Log

E&T Complex Discharger Report

Snohomish County Juvenile Drug Court Reporting Form Quarterly

Criminal Justice Treatment Account (CJTA) Annual Plan

CLAS Standards CLC Assessment Tool

North Sound BH-ASO Compliance Plan

Delegation Pre-Assessment Tool

NCCC Residential Program Checklist

Schedule of Services

North Sound BH-ASO Invoice

Compensation Schedule

 

Suspect Fraud?

800.684.3555

Anonymously report suspected fraud, waste, or abuse to the North Sound BH-ASO Compliance Officer by using the Compliance Hotline.

Learn More

Dissatisfied with service?

888.336.6164

or visit the Ombuds website for assistance in filing a complaint or appealing a denial of service.

Learn More