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Summary Placement  Form

Summary Placement Form

Use a Summary Placement template to make your document workflow more streamlined.

Needs. Dimension I Intoxication/ Withdrawal II Biomedical III Emotional/ Behavioral/ Cognitive IV Readiness for Change V Relapse and Continued Use VI Recovery Environment Severity Rating  0  1  2  3  4 = Crisis  0  1  2  3  4 = Crisis  0  1  2  3 = SC + R&B  4 = Crisis  0  1  2  3 = SC  4 = SC + R&B  0  1  2  3 = SC  4 = SC + R&B  0  1  2  3 = SC  4 = SC + R&B Service Coordination (if required above) Room & Board, if not paid for through the CCDTF (if required above) Page 1 of 2 Provider...
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