Datacorp - Client Login

CLIENT FOLLOW-UP FORM

INTRODUCTION

Client follow-up begins when the intake or baseline ASI is conducted.This is the time when the interviewer has the most information about the client, and it is at this time that the interviewer can most successfully lay the groundwork for client location and a successful follow-up.

Please stress several times during the intake that DATACORP will contact him/her 3 months after treatment ends and will offer him/her $10 for a completed interview. Encourage the client to let you know if they move at any time during treatment or during the three months following treatment. It is important that we be able to contact him/her later to see how they are doing.

Reassure the client that his or her confidentiality will be maintained and that DATACORP will not ask anyone except the client how they are doing. Any people DATACORP contacts are purely an effort to contact the client.

It is critical that all fields on this form be completed in order to increase the chance of following up with this client.Please stress how important follow-up is so we can learn how to improve the entire treatment experience.

A. Today's Date:

1. Please Enter Today's Date

Month	Day	Year

B. WAMHSAC Provider

2. What WAMHSAC Provider Are You From?

C. Client Information

Please fill out the client's information exactly as it is written on the ASI and WCIS forms.

3. Client ID Number:
4. Social Security Number (xxx-xx-xxxx):
5. Last Name:
6. First Name:
7. Middle Name:
8. Nickname:

9. Date of Birth:

Month	Day	Year

10. Gender: Male Female

11. Treatment Modality:

Outpatient	Intensive Outpatient (IOP)
Residential	Continuing Care
Discharged

D. Current Address

12. Street Address:
13. City:		14. State:
15. ZIP:

E. Permanent Address (If Different Than Current)

16. Street Address:
17. City:		18. State:
19. ZIP:

F. Contact Numbers

20. When is the best time to reach you by telephone? (example = 5:30 p.m.)

21.

Home Telephone: (xxx-xxx-xxxx)

N/A

22. Home Telephone is listed in the telephone book: Yes No

23. If yes, whose name is it listed under?

First Name

Last Name

24. Cell Telephone (xxx-xxx-xxxx): N/A

25. E-mail Address: N/A

26. Please list three places where you spend your free time. (When you are not at home or work).

G. Employment

27. Are you employed?Yes No If no, skip to EDUCATION

28. What shift do you work? 1st2nd 3rd Varies

29. Name of Employer:

30. Street Address:

31. City:

32. State:

33. ZIP:

34. Phone: Dept:

35. Job Title:

H. Education

36. Are you a student? Yes No If no, skip to LOCATORS

37. Do you go full time or part time? Please mark one: full time part time

38. School:

39. Major:

I. Locators

This section will provide the name and contact information of someone that has a telephone that knows how to get a hold of you when it is time for your interview

Contact 1

40. Name:

41. Street Address:

42. City:

43. State:

44. ZIP:

45. Telephone:

46. Relationship:

Contact 2

47. Name:

48. Street Address:

49. City: