Clinical forms, ready to build in Kipu

A form completed when a client chooses to leave treatment before the treatment team recommends. It documents the client's stated reason, the risks and alternatives explained, safety steps taken, and the client's acknowledgment or refusal to sign.

Chart tab: Consents · Form type: consent_form

Sections: Departure Information · Clinical Recommendation · Risks Explained · Alternatives Offered · Safety at Departure · Client Acknowledgment · Staff Signatures

The closing clinical document for an episode of care: discharge type and reason, summary of the treatment course, progress on each problem, ASAM ratings and diagnoses at discharge, medications, and the continuing care plan with confirmed appointments. Completed at every discharge, planned or unplanned.

Chart tab: Discharge · Form type: evaluation

Sections: Discharge Information · Treatment Course · Status at Discharge · Medications · Continuing Care Plan · Client Participation · Records and Notifications · Signatures

A one-page worksheet that summarizes risk in each of the six ASAM dimensions, justifies each rating, and records the recommended and actual level of care. Used at admission, at each continued-stay review and at transition or discharge.

Chart tab: Assessments · Form type: evaluation

Sections: Review Information · D1 - Intoxication / withdrawal · D2 - Biomedical conditions · D3 - Emotional, behavioral or cognitive conditions · D4 - Readiness to change · D5 - Relapse / continued use potential · D6 - Recovery / living environment · Level of Care Recommendation

A full intake assessment of substance use, treatment history, medical and psychiatric history, psychosocial functioning and mental status for adults entering SUD or co-occurring treatment. Completed by the assigned counselor or clinician at admission and used as the foundation for the ASAM summary, diagnosis and initial treatment plan.

Chart tab: Assessments · Form type: evaluation

Sections: Assessment Information · Substance Use History · Treatment History · Medical and Psychiatric History · Psychosocial History · Mental Status Observations · Clinical Summary and Recommendations

A note for each case management contact: who was contacted and how, which needs were addressed, what was done, referrals made, outcome and follow-up tasks. Used for direct client contacts, collateral contacts and care coordination.

Chart tab: Progress Notes · Form type: evaluation

Sections: Contact Details · Needs Addressed · Services Provided · Referrals · Outcome and Follow-Up

Documentation for a counseling or education group: shared group information (topic, goal, interventions, facilitators) plus each attending client's individual response and plan. Completed by the facilitator after every group session.

Chart tab: Group Sessions · Form type: evaluation

Sections: Group Information · Group Goal and Interventions · Attendance Roster · Individual Client Documentation · Signature

A progress note for each individual counseling or therapy session. Captures session time and modality, client presentation and risk, which treatment plan problems and ASAM dimensions were addressed, interventions used, client response, and the medical necessity for continued services.

Chart tab: Progress Notes · Form type: evaluation

Sections: Session Details · Client Presentation and Risk · Session Content · Medical Necessity · Plan · Signature

The client's informed consent to outpatient or intensive outpatient SUD treatment. Covers what services involve, client rights, confidentiality and its limits, program expectations, telehealth, financial responsibility, the grievance process and the right to withdraw consent. Signed at admission before services begin.

Chart tab: Consents · Form type: consent_form

Sections: About Your Treatment · Your Rights · Confidentiality and Its Limits · Program Expectations · Telehealth · Financial Responsibility · Complaints and Grievances · Voluntary Consent

A collaborative safety plan written with the client in their own words after a positive suicide risk screen or at any point risk is identified. It lists the client's warning signs, coping steps, people and places to reach out to, professional and crisis contacts, and steps to limit access to lethal means.

Chart tab: Assessments · Form type: evaluation

Sections: Plan Information · Step 1 - Signs That a Crisis May Be Starting · Step 2 - Things I Can Do on My Own · Step 3 - People and Places That Help Me Feel Better · Step 4 - People I Can Ask for Help · Step 5 - Professionals and Crisis Lines · Step 6 - Making My Surroundings Safer · What Matters Most to Me · Review and Signatures

A short check completed at the start of each telehealth session to confirm the client's identity, physical location, privacy, emergency contact and a disconnection plan. Used for any video or audio-only service.

Chart tab: Progress Notes · Form type: evaluation

Sections: Session · Identity Verification · Client Location · Emergency Planning · Clinician and Technology · Signature

The first individualized treatment plan, built with the client from the biopsychosocial and ASAM summary. Each problem is tied to an ASAM dimension and broken into a goal, measurable objectives and specific interventions. Completed within your program's required timeframe after admission.

Chart tab: Treatment Plans · Form type: evaluation

Sections: Plan Information · Strengths, Needs and Barriers · Problem 1 · Problem 2 · Problem 3 · Problem 4 · Services and Frequency · Discharge Planning · Signatures

A structured review of progress on each treatment plan problem, updated ASAM risk ratings, plan changes and continued-stay justification. Completed at your program's scheduled review interval and whenever there is a significant change, a level of care change, or a client request.

Chart tab: Treatment Plans · Form type: evaluation

Sections: Review Information · Progress on Problems and Objectives · Updated ASAM Ratings · Plan Changes · Continued Stay and Level of Care · Client Input and Signatures

The nurse's admission assessment for residential and withdrawal management clients: vital signs, substance use and withdrawal status, systems review, medications brought in, fall and safety risk, and the initial nursing plan. Completed on arrival, before the client is cleared to the milieu.

Chart tab: Medical · Form type: evaluation

Sections: Arrival and Vital Signs · Substance Use and Withdrawal Status · Health History and Systems Review · Medications and Allergies · Safety and Fall Risk · Nutrition and Sleep · Nursing Impression and Plan

A repeatable nursing entry for each scheduled or as-needed withdrawal check: vital signs, CIWA-Ar or COWS score, PRN medication given, reassessment, and escalation to the provider. Used at the frequency ordered by the medical provider until withdrawal monitoring is discontinued.

Chart tab: Medical · Form type: evaluation

Sections: Monitoring Check · Vital Signs · Withdrawal Score · Interventions · Reassessment · Escalation · Nurse Note and Shift Log