Riverhaven Coordinating Agency
Capacity
Management Waiting List Form
PROGRAM:
_______________________________________ LICENSE
#: _________________________
For the period of
_____/_____/_____ through _____/_____/_____
Waiting List
Definition: Any person who has requested
service and cannot begin treatment or receive an assessment within 14 days due
to the lack of capacity at the program.
Total number of
clients on the Waiting List:
SARF _____
Outpatient _____
IOP _____
Of the clients listed above, number of priority clients on waiting list (must fill in – even if 0) _____
List all priority
clients on the Waiting List below.
(Coding system is at the program’s discretion and the ID used must not
violate client confidentiality.)
Priority codes: 1 = Pregnant
injection drug users
2 = Pregnant substance abusers
3 = Injecting drug users (history of IDU within the last 30 days)
4 = parents at risk of losing children
due to substance abuse
Waiting List ID# Date of Contact Priority Code Interim Services
Provided
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Due date: Data for
this report is to be collected at the end of each month and is due to RCA on
the first Monday following the reporting month unless the first Monday is a
holiday, in which case it would be due on the first Tuesday. Please e-mail all submissions to Darren
McAllister at dmcallister@babha.org
or fax to (989) 497-1348.
Signature of staff
person submitting form Date