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Health Services


Forms

The Department's Forms Library lists all official Department forms as well as some informational documents and links to other departments' forms that may be needed by DJJ employees.  If a form listed is associated with a DJJ policy or procedure a link to that policy/procedure is provided. 

Specific questions about the form or a related policy/procedure should be directed to staff in the office with ownership of the policy listed below.  If you have trouble accessing the documents you can contact the Department's Forms Coordinator for assistance.


Form Policy Form Number Effective Date Subject Office
Acknowledgement of Receipt of Clinical Psychotropic Progress Note
PDF
HS 001
08/01/2007
Health Services Health Services
Additional Reviews to Comprehensive Physical Assessment
PDF
HS 052
07/01/2009
Health Services Health Services
Affidavit of Diligent Effort
PDF
HS 056
01/01/2012
Health Services Health Services
American Academy of Pediatrics PPPEval Form
PDF
02/22/2012
Health Services Health Services
Assessment of Suicide Risk
PDF
MHSA 004
08/01/2006
Mental Health and Substance Abuse Health Services
Authority for Evaluation and Treatment
PDF
HS 002
02/01/2010
Health Services Health Services
Chronic Physical Health Conditions Roster
HS 004
10/01/2006
Health Services Health Services
Clinical Psychotropic Progress Note
PDF
HS 006
10/01/2014
Health Services Health Services
Close Supervision-Visual Checks Log
PDF
MHSA 020
08/01/2006
Mental Health and Substance Abuse Health Services
Comprehensive Physical Assessment
PDF
HS-007
10/29/2006
Health Services Health Services
Controlled Medication Inventory Record
PDF
HS 008
04/01/2010
Health Services Health Services
Counseling/Therapy Progress Notes
PDF
MHSA 018
08/01/2006
Mental Health and Substance Abuse Health Services
Crisis Assessment
PDF
MHSA 023
09/01/2010
Mental Health and Substance Abuse Health Services
Custody of Individual Health Care Record
PDF
HS 005
10/01/2006
Health Services Health Services
Detention Suicide Risk Parent/Guardian Notification
PDF
MHSA 009
08/01/2007
Mental Health and Substance Abuse Health Services
Documentation of Non-Licensed Mental Health Clinical Staff Person’s Training in Assessment of Suicide Risk
PDF
MHSA 022
10/01/2007
Mental Health and Substance Abuse Health Services
Episodic Care (First Aid/Emergency) Care Log
PDF
HS 009
10/01/2006
Health Services Health Services
Facility Entry Physical Health Screening and Body Diagrams
PDF
HS 010
05/01/2007
Health Services Health Services
Female Body Diagram
PDF
HS 048
05/01/2007
Health Services Health Services
Follow-Up Assessment of Suicide Risk
PDF
MHSA 005
08/01/2006
Mental Health and Substance Abuse Health Services
Guidelines for Obtaining Parental Signature on the AET
HS 011
10/01/2006
Health Services Health Services
Health Discharge Summary - Transfer Note
PDF
HS 012
10/01/2006
Health Services Health Services
Health Education Record
PDF
HS 013
10/01/2006
Health Services Health Services
Health Related History - New Short Form
PDF
HS 014
01/20/2011
Health Services Health Services
Health Status Checklist
PDF
MHSA 008
08/01/2006
Mental Health and Substance Abuse Health Services
Human Immunodeficiency Virus Youth Consent Form
PDF
HS 015
04/01/2010
Health Services Health Services
Immunization Tracking Record
PDF
HS 016
10/01/2006
Health Services Health Services
Individual Health Care Record Checklist and Internal Quality Control
PDF
HS 017
01/01/2006
Health Services Health Services
Individualized Mental Health/Substance Abuse Treatment Plan
PDF
MHSA 016
10/01/2014
Mental Health and Substance Abuse Health Services
Individualized Mental Health/Substance Abuse Treatment Plan Review
PDF
MHSA 017
10/01/2014
Mental Health and Substance Abuse Health Services
Infectious and Communicable Disease Form
PDF
HS 018
10/01/2006
Health Services Health Services
Initial Mental Health/Substance Abuse Treatment Plan
PDF
MHSA 015
10/01/2014
Mental Health and Substance Abuse Health Services
Licensed Mental Health Professionals and Licensed/Certified Substance Abuse Professionals Direct Supervision Log
PDF
MHSA 019
08/01/2006
Mental Health and Substance Abuse Health Services
Limited Consent for Evaluation and Treatment
PDF
HS 057
12/01/2013
Health Services Health Services
Male Body Diagram
PDF
HS 047
05/01/2007
Health Services Health Services
Medication Administration Record
PDF
HS 019
10/01/2006
Health Services Health Services
Mental Health Alert - Observation Log
PDF
MHSA 007
08/01/2006
Mental Health and Substance Abuse Health Services
Mental Health/Substance Abuse Referral Summary
PDF
MHSA 014
08/01/2006
Mental Health and Substance Abuse Health Services
Mental Health/Substance Abuse Treatment Discharge Summary
PDF
MHSA 011
10/01/2014
Mental Health and Substance Abuse Health Services
Oral Health Assessment Form
PDF
HS 050
02/01/2007
Health Services Health Services
Parental Notification of Health Related Care: General
PDF
HS 020
02/01/2010
Health Services Health Services
Parental Notification of Health Related Care: Medications
PDF
HS 021
02/01/2010
Health Services Health Services
Parental Notification of Health Related Care: Vaccinations/Immunizations
PDF
HS 022
02/01/2010
Health Services Health Services
Personal and Health Related Information
PDF
HS 023
10/01/2006
Health Services Health Services
Practitioners Orders
PDF
HS 024
10/06/2006
Health Services Health Services
Prescription Medication Verification Checklist
HS 025
10/01/2006
Health Services Health Services
Probation Medical and Mental Health Clearance Form
PDF
HS 051
07/01/2010
Health Services Health Services
Problem List
PDF
HS 026
10/01/2006
Health Services Health Services
Refusal of Treatment Form
HS 027
10/31/2006
Health Services Health Services
Report of On-Site Health Care by Non-Health Care Staff
PDF
HS 049
12/01/2006
Health Services Health Services
Request for Parent/Guardian Signature on the Authority for Evaluation and Treatment
HS 028
10/01/2006
Health Services Health Services
Sexually Transmitted Infections Screening Form
PDF
HS 029
01/20/2011
Health Services Health Services
Sick Call Index
PDF
HS 030
10/01/2006
Health Services Health Services
Sick Call Request
PDF
HS 032
02/01/2010
Health Services Health Services
Sick Call/Referral Log
PDF
HS 031
10/01/2006
Health Services Health Services
Suicide Precautions Observation Log
PDF
MHSA 006
10/01/2014
Mental Health and Substance Abuse Health Services
Suicide Risk Screening Instrument
PDF
MHSA 002
10/01/2014
Mental Health and Substance Abuse Health Services
Suicide Risk Screening Parent/Guardian Notification
PDF
MHSA 003
08/01/2006
Mental Health and Substance Abuse Health Services
Summary of Off-Site Care Consultation Report
PDF
HS 033
10/01/2006
Health Services Health Services
Treatment Flow Sheet: Asthma
HS 034
10/01/2006
Health Services Health Services
Treatment Flow Sheet: Diabetes
HS 035
10/01/2006
Health Services Health Services
Treatment Flow Sheet: General Medical
HS 036
10/01/2006
Health Services Health Services
Treatment Flow Sheet: Hypertension
HS 037
10/01/2006
Health Services Health Services
Treatment Flow Sheet: Seizure Disorder
HS 038
10/01/2006
Health Services Health Services
Treatment Flow Sheet: Tuberculosis / INH Therapy
HS 039
10/01/2006
Health Services Health Services
Treatment Plan: Asthma
HS 040
10/01/2006
Health Services Health Services
Treatment Plan: Diabetes
HS 041
10/01/2006
Health Services Health Services
Treatment Plan: General Medical
HS 042
10/01/2006
Health Services Health Services
Treatment Plan: Hypertension
HS 043
10/01/2006
Health Services Health Services
Treatment Plan: Seizure Disorder
HS 044
10/01/2006
Health Services Health Services
Treatment Plan: Tuberculosis / INH Therapy
HS 045
10/01/2006
Health Services Health Services
Tuberculosis Testing Log
HS 046
10/01/2006
Health Services Health Services
Youth Consent for Release of Substance Abuse Treatment Records
PDF
MHSA 013
08/01/2006
Mental Health and Substance Abuse Health Services
Youth Consent for Substance Abuse Treatment
PDF
MHSA 012
08/01/2006
Mental Health and Substance Abuse Health Services