Cornerstone Behavioral Healthcare

Clinical Forms

Reference

Form	Revision Date	Printable	Fillable
AC-OK Screening FAQs		Printable	N/A
Audit Corrections Fax Coversheet	09-24-20	Printable	N/A
CM Resources (Waterville Area)	10-20-16	Printable	N/A
DSM-5 Secured		Printable	N/A
DSM-5 Assessments		Printable	N/A
Fax Cover Sheet (Bangor)	06-01-15	Printable	N/A
Fax Cover Sheet (Waterville)	06-01-15	Printable	N/A
Local Area Resources (Bangor)	10-20-16	Printable	N/A
Modality Types	09-16-16	Printable	N/A
PHQ-9 Overview And Scoring		Printable	N/A
Psychiatric Advanced Directives Instructions	11-01-13	Printable	N/A
Resources	03-16-20	Printable	N/A
Risks and Benefits of Therapy	09-22-17	Printable	N/A
Stages of Change	03-01-03	Printable	N/A

Aroostook Case Management Packets

Form	Revision Date	Printable	Fillable
Annual Adult Packet	01-25-24	Printable	N/A
Annual Child Packet	01-25-24	Printable	N/A
Opening Adult Packet	01-25-24	Printable	N/A
Opening Child Packet	01-25-24	Printable	N/A

Bangor Case Management Packets

Form	Revision Date	Printable	Fillable
Annual Adult Packet	01-25-24	Printable	N/A
Annual Child Packet	01-25-24	Printable	N/A
Opening Adult Packet	01-25-24	Printable	N/A
Opening Child Packet	01-25-24	Printable	N/A

Washington Case Management Packets

Form	Revision Date	Printable	Fillable
Annual Adult Packet	01-25-24	Printable	N/A
Annual Child Packet	01-25-24	Printable	N/A
Opening Adult Packet	01-25-24	Printable	N/A
Opening Child Packet	01-25-24	Printable	N/A

Individual Case Management Forms

Form	Revision Date	Printable	Fillable
#1 CCDAR	06-07-23	Printable (PDF)	Printable (DOCX)
#2 Annual HIPAA Signature Page	12-07-22	Printable	N/A
#3 Client Signature Attestation	10-01-21	Printable	N/A
#4 Telehealth Agreement	10-01-21	Printable	N/A
#5 HIN Opt Back in & Opt Out Form	03-11-22	Printable	N/A
#5 HIN Opt In for Sensitive Health Info	03-11-22	Printable	N/A
#5 HIN Opt Out for General Medical Info	03-11-22	Printable	N/A
#5 HIN Opt Out for Sensitive Health Info	03-11-22	Printable	N/A
#6 Need for Change Employment	06-08-23	Printable	N/A
#6 Need for Change Education	06-08-23	Printable	N/A
#6 Need for Change Commitment to Change	06-08-23	Printable	N/A
#7 Housing Needs Assessment	10-01-21	Printable	N/A
#8 LOCUS Assessment	10-01-21	Printable	N/A
#9 Diagnosis Sheet (Conditional Provider)	11-11-22	Printable	N/A
#9 Diagnosis Sheet (Outside Provider)	12-27-22	Printable	N/A
#10 Adult ACOK	10-01-21	Printable	N/A
#11 Adolescent ACOK	10-01-21	Printable	N/A
#12 ISP Signature Page	06-07-23	Printable (PDF)	Fillable (DOCX)
#13 Crisis Safety Plan	01-24-24	Printable (PDF)	Printable (DOCX)
#14 PCP Letter	10-01-21	Printable	N/A
#15 Section 17	10-01-21	Printable	N/A
#16 CANS Assessment	10-01-21	Printable	N/A
A. DHHS Release	10-01-21	Printable	N/A
B. DHHS Authorized Rep Form	10-01-21	Printable	N/A
C. PNHD Release	10-01-21	Printable	N/A
D. PCHC Release	11-17-22	Printable	N/A
E. Northern Light Release	10-01-21	Printable	N/A
F. St. Joseph Release	10-01-21	Printable	N/A
G. CHCS Release	10-01-21	Printable	N/A
H. SSA Release	10-01-21	Printable	N/A
I. General Release	05-26-23	Printable (PDF)	Printable (DOCX)
J. Wabanaki Voc Rehab Release	02-22-22	Printable	N/A
K. IHS-Maliseet Behavioral Health Release	11-11-22	Printable	N/A
L. Katahdin Valley Health Release	10-01-21	Printable	N/A
M. AMHC Release	02-10-10	Printable	N/A
N. Houlton Regional Release	03-01-10	Printable	N/A
O. Houlton Pediatrics Release	03-01-10	Printable	N/A
P. Central Aroostook Psychiatric Release	10-01-21	Printable	N/A
Q. Calais Regional Hospital 2013-03	03-2013	Printable	N/A
R. PCP Release	05-27-22	Printable	N/A
S. IHS-Maliseet Health Care Release	11-11-22	Printable	N/A
T. IHS-Indian Township Health Release	11-11-22	Printable	N/A
U. IHS-Pleasant Point Health Release	11-11-22	Printable	N/A
V. St. Croix Regional Family Health Center Release	11-11-22	Printable	N/A
No Contact Letter	06-16-23	Printable	N/A
Peer Paperwork	10-01-21	Printable	N/A
Adult and Child Peer Note	08-08-23	Printable	N/A
Annual Peer Consent	10-01-21	Printable	N/A
Aroostook Paperwork List	11-08-22	Printable	N/A
Bangor Paperwork List	11-08-22	Printable	N/A
Washington Paperwork List	11-08-22	Printable	N/A

Clinical Referral Forms

Form Revision Date Printable Fillable

Cornerstone Referral Script 09-24-20 Printable Fillable

Form	Revision Date	Printable	Fillable
Cornerstone Referral Script	09-24-20	Printable	Fillable

Outpatient & Substance Abuse Clinical Forms

Form	Revision Date	Printable	Fillable
Atrezzo Pre-Registration Form	02-24-23	Printable	N/A
Behavioral Healthcare Program Outpatient Treatment Report	01-10-20	Printable	N/A
CBH Case Management Signature Page (PIMSY users only)	08-19-20	Printable	N/A
Client Signature Attestation Form	09-24-20	Printable	N/A
Cornerstone Telehealth Services Policy and Signature Page	07-25-23	Printable	N/A
CR.1.B&C Client Right's Second Opinion Form	02-09-15	Printable	N/A
Critical Incident Reporting Adult (Print from Website)		Maine.gov
CSR Form Atrezzo (Therapy and Substance Abuse)	02-02-24	Printable (PDF)	Printable (DOCX)
*RETRO Eligibility Authorization Request	02-18-21	Printable	N/A
*Unit Request	09-24-20	Printable	Fillable
DHHS Agency Request to Terminate Form	09-24-20	Printable	N/A
DHHS Release Form	2020	Printable	N/A
Diagnosis Sheet	11-23-16	Printable	N/A
Direct-Entry Billing Ticket	09-24-20	Printable	N/A
Grievance Form	04-01-12	Printable	N/A
In-House Addendum to the Discharge	09-24-20	Printable	Fillable
In-House Addendum to the Treatment Plan	09-24-20	Printable	Fillable
In-House Adolescent AC-OK	09-24-20	Printable	Fillable
In-House Adult AC-OK	09-24-20	Printable	Fillable
In-House Annual HIPAA Signature Page	12-07-22	Printable	Fillable
In-House Annual Summary/Addendum to Initial Assessment	11-21-22	Printable	Fillable
In-House Consolidated Demographic	06-07-23	Printable (PDF)	Printable (DOCX)
In-House Client Transfer and Diagnosis Change Note	09-24-20	Printable	Fillable
In-House Clinical ITP Signature Page (PIMSY users only)	02-08-24	Printable (PDF)	Printable (DOCX)
In-House Crisis Safety Plan	01-24-24	Printable (PDF)	Printable (DOCX)
In-House Discharge Summary	09-22-23	Printable	Fillable
In-House Individual Treatment Plan	01-16-24	Printable	Fillable
In-House Initial Co-Occuring Assessment	01-31-24	Printable (PDF)	Printable (DOCX)
In-House Outpatient Therapy Progress Note	12-21-23	Printable	Fillable
In-House PCP Cover Letter	09-24-20	Printable	Fillable
In-House PCP Release	09-24-20	Printable	Fillable
In-House Release of Information	05-26-23	Printable (PDF)	Printable (DOCX)
In-House Treatment Plan Remained the Same	09-24-20	Printable	Fillable
Medicare/Mainecare Waiver	11-09-17	Printable	N/A
PHQ-9	02-20-17	Printable	N/A
PHQ-A	10-20-16	Printable	N/A
Pro Bono Request	05-29-19	Printable	N/A
Psychiatric Advanced Directives Form	2007	Printable	N/A

Additional Forms for Substance Abuse Treatment

Form	Revision Date	Printable	Fillable
In-House Substance Use Clinical Risk Assessment	09-24-20	Printable	Fillable
In-House Substance Use ITP	01-16-24	Printable	Fillable
In-House Substance Use Prior Authorization	09-24-20	Printable	Printable
In-House Substance Use Statement of Confidentiality	09-24-20	Printable	Printable
Sliding Scale Fee Schedule	04-12-18	Printable	N/A
WITS Admission	06-16-17	Printable	N/A
WITS Discharge	06-16-17	Printable	N/A

Medication Management Forms

Form	Revision Date	Printable	Fillable
Chart Entry	03-11-08	Printable	N/A
CSR Form Atrezzo (Med Management)	02-02-24	Printable (PDF)	Printable (DOCX)
Dominion Release Form		Printable	N/A
*Unit Request	06-06-19	Printable	N/A
In-House Med Management ITP	01-16-24	Printable	Fillable
In-House Med Management Progress Note	03-23-21	Printable	Fillable
Medication Instructions Information Consent Form	09-24-20	Printable	Fillable
Lab Request	03-11-08	Printable	N/A

Supervision Forms

Form	Revision Date	Printable	Fillable
Admin Group Supervision Sheet	10-18-21	Printable	N/A
Affiliate Mental Health Individual Supervision Sheet	10-18-21	Printable	N/A
Affiliate Substance Use Individual Supervision Sheet	10-18-21	Printable	N/A
Clinical Group Supervision Sheet	10-18-21	Printable	N/A

DHHS Mandatory Reporting Training

Form	Revision Date	Printable	Fillable
Instructions for Accessing DHHS Mandatory Reporting Training		Printable	N/A

OHH and MAT

Form	Revision Date	Printable	Fillable
Acehelosu OHH Individual Treatment Plan	01-16-24	Printable	Fillable
Audit Corrections Fax Coversheet	09-24-20	Printable	N/A
Clinical Opiate Withdrawal Scale	Jun '03	Printable	N/A
Health Info Net - Agree to Share		Printable	N/A
Health Info Net - Revoke Sharing		Printable	N/A
Health Info Net - Start Sharing after Revoking		Printable	N/A
Mainecare Treatment Authorization Form	Sep '19	Printable	N/A
MAT and OHH Addendum to the Discharge Summary	09-24-20	Printable	N/A
MAT and OHH Addendum to the Initial Assessment	10-05-20 06-21-21	Printable	Fillable
MAT and OHH Adolescent ACOK	09-24-20 06-21-21	Printable	Fillable
MAT and OHH Adult ACOK	09-24-20 06-21-21	Printable	Fillable
MAT and OHH Annual HIPAA Signature Page	12-07-22	Printable	Fillable
MAT and OHH Annual Summary	11-21-22	Printable	Fillable
MAT and OHH Consolidated Demographic	09-24-20 06-21-21	Printable	Fillable
MAT and OHH Crisis Safety Plan	09-24-20 06-21-21	Printable	Fillable
MAT and OHH Discharge Summary	09-24-20 06-21-21	Printable	Fillable
MAT and OHH Initial Co-Occurring Assessment	09-24-20 06-21-21	Printable	Fillable
MAT and OHH PCP Cover Letter	06-21-21	Printable	Fillable
MAT and OHH PCP Release	09-24-20	Printable	N/A
MAT and OHH Program List and Acknowledgement	09-01-21	Printable	N/A
MAT and OHH Provider Signature Attestation Form	01-18-19	Printable	N/A
MAT and OHH Release of Information	09-24-20 06-21-21	Printable	Fillable
MAT Individual Treatment Plan	01-16-24	Printable	Fillable
MAT Program Client Informational Handout	09-01-21	Printable	N/A
MAT Program Statement of Confidentiality		Printable	N/A
Pharmacy Consent		Printable	N/A
Therapeutic Agreement for Treatment with Buprenorphine		Printable	N/A
Urine Cup Screen Checklist		Printable	N/A