Levels 3.5 (LT), 3.5 (ST), and 3.7

Human Services Block Grant / Comparative Effectiveness Research (CER) Data Tracking

Information must be submitted for ALL Dauphin County residents, regardless of funding source. If you do not have any Dauphin County residents in treatment, you must enter zeros.

Person submitting form - Contact information

First Name

Last Name

Phone

Provider Name

Select Month

Select Year

For the chosen month, please enter the number of individuals that successfully completed inpatient residential treatment.

Successfully completed is defined as completed due to stability and goal completion, and not leaving against facility advice.

For the chosen month, please enter the number of individuals that were unsuccessfully discharged from inpatient residential treatment.

Unsuccessfully discharged is defined as non-compliance, discharged against medical advice, or discharged due to a program violation, infraction, or behavior.

Please enter the number of individuals (from entry made in box #1) that began follow-up treatment within 7 days.

Follow-up treatment is defined as the recommended treatment level of care assessed via ASAM, or a different level of care requested by the individual and agreed to by the provider.