The Twelve of Ohio, Inc.
CLIENT FILE CHECK LIST
SECTION 1: CLIENT INFORMATION
_____ Client File Check List
_____ Client picture (dated: ___/___/___ )
____ Birth Family Contact Form (Mass) (Toledo) (Elyria) _____ Police Reports
_____ Signed Client Rights _____ Court Papers (journal entry)
_____ Signed youth and family information _____ Social Security Card
_____ Medical Card _____ Birth Certificate
_____ Personal inventory / clothing receipts /Discharge inventory
_____ Consent for Release of Information (90 days) (Mass) (Toledo) (Elyria)
_____ All Satisfaction Surveys
SECTION 2: Mental Health Assess. /ISP/Quarterly Review/Discharge
_____ Application for Services – TX permission (Mass) (Toledo) (Elyria)
_____ ODP
_____ Discharge Summary
_____ Quarterly Progress Review Addendum
_____ Mental Health Assessment
_____ Letters of Invitation - directly under each corresponding ISP / Quarterly
SECTION 3: Progress Notes (only billable notes)
____ Progress Notes: Freemed /TX notes (only billable activity)
SECTION 4: Progress Notes (Non-billable notes)
____ Incident reports – (in chronological order with MUIs and progress notes)
____ Internal Disruption Staffing
____ Notice of Removal
____ Client weekly progress report (in chronological order with all progress notes)
____ Client Monthly Progress Report
____ Respite forms (Mass) (Toledo) (Elyria) (in chronological order progress notes)
____ Behavior management form
SECTION 5: EDUCATION RECORDS
_____ Grade Cards
_____ Individual Education Plan (IEP)
_____ Educational Assessments
SECTION 6: MEDICAL
_____ HIV/AIDS/Health Information Form (ten years and older)
_____ Medical exam ____ Dental exam (Form) _____ Vision screen (Optical Exam Form)
_____ Medical appointment Log _____ Medication Log
____ Permission to Administer Psychotropic Medication
____ Immunization Records
____ Comprehensive Medical Examination
SECTION 7: Diagnostic tools
____ Ohio Scales: Intake, every 6 months, discharge
____ Ansell Casey (14 years, intake, 6 months, discharge)
____ Kaufman (intake/ annual/discharge - required also for ODP outcomes report at intake and discharge)
____ DECA
SECTION 8:
_____ Referral/Intake Information
_____ Individual Child Care Agreement
_____ Case Plan
_____ Psychological Assessments (previous)
_____ Youth Placement Form (Mass) (Toledo) (Elyria)
_____ Unattended youth form
_____ Change of Status Forms
_____ Letters to service providers
_____ Two-week assessment of placement
Revised: 08/26/2015 - Note: Blue text has Forms available on website for download