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COSIG CONFERENCE BROCHURE.pdf - Drexel University College ...

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12. What is the diagnosis: |___|<br />

1 – Substance use/abuse only<br />

2 – Mental health only<br />

3 – Both substance use and mental health<br />

4 – Neither<br />

13. Is there evidence that the diagnosis was substantiated: |___|<br />

1 – Yes<br />

2 – No<br />

14. Is there evidence of an integrated treatment plan: |___|<br />

1 – Yes<br />

2 – No<br />

3 – No treatment plan<br />

15. Is stage of change reflected in treatment plan: |___|<br />

1 – Yes<br />

2 – No<br />

3 – No treatment plan<br />

16. Is stage of change reflected in progress notes: |___|<br />

1 – Yes<br />

2 – No<br />

3 – No progress notes<br />

17. Is there evidence of communication with provider of physical health care if<br />

physical health care need identified:<br />

|___|<br />

1 – Yes<br />

2 – No<br />

3 – No health care need identified<br />

Comments:<br />

Thank you.<br />

Please mail completed forms to:<br />

Hornby Zeller Associates<br />

100 Commercial Street., Suite 300<br />

Portland, ME 04101

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