CLINIC AUDIT TOOL

Step 1 of 3

Date(Required)

Reviewing Staff:(Required)

First Last

Signature:(Required)

Email:(Required)

Assigned Clinical Staff:(Required)

First Last

Referral Date:(Required)

If missing 11/11/1111

Consumer Name:(Required)

First Last

Consumer Type:(Required)

Proof of guardianship:(Required)

Is a PDF Intake Packet Included?(Required)

Was verbal consent documented for assessment, intake, and ongoing services?(Required)

Intake packet items:(Required)

Initial Assesment:(Required)

Date of Initial Assessment:(Required)

If missing 11/11/1111

More than one evaluation:(Required)

How many?(Required)

Does the consumer have a Treatment Plan:(Required)

Initial Tx:(Required)

If missing 11/11/1111

Initial Tx Plan Co-signed:(Required)

LCSW-C, LCPC, LGSW & LCSW-C, LGPC & LCPC, or Intern and LCSW-C or LCPC (Choose N/A if the consumer was not seen for at least 3 sessions)

Does the consumer have additional Treatment Plans:(Required)

Recent Initial Tx:(Required)

If missing 11/11/1111

Current Tx Plan Co-signed:(Required)

Contact Log Notes:(Required)

Has this consumer been discharged?(Required)

Outreach Letter:(Required)

Date of Discharge:(Required)