INTRA-AGENCY TRANSFER REPORT LAST NAME FIRST NAME DELAWARE DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH CONSUMER REPORTING FORM SOFTWARE DEVELOPMENT INSTRUCTIONS • WHEN CREATING ADMISSION DATE, ADD A DAY • BOTH "SOURCE / AGENCY CODE" AND "PRIMARY DESTINATION / AGENCY CODE" WILL BE "T" TRANSFERRED • PULL "MOST RECENT" INFORMATION FOR BOTH ADMISSION AND DISCHARGE RECORDS, FROM THE EPISODE, OR SERVICE TABLE, AS APPROPRIATE • FOR USE BY AUTOMATED AGENCIES ONLY - DO NOT USE IF PAPER ADMISSION AND DISCHARGE CRF FORMS ARE USED, OR IF YOUR AGENCY IS USING THE CIM SOFTWARE M.I. PRIMARY THERAPIST PERSON COMPLETING FORM DATE OF COMPLETION PAGE 1 OF 1 MCI # PRIOR TREATMENT UNIT NAME PRIOR TREATMENT — UNIT ID # TRANSFER DATE / NEW TREATMENT UNIT NAME NEW TREATMENT UNIT ID # 0 0 0 — REASON FOR TRANSFER [ ] FUNDING CHANGE (e.g. OBTAINED/LOST HEALTH INSURANCE) [ ] LOC - LEVEL OF CARE CHANGE (HIGHER LEVEL OF CARE) [ ] LOC - LEVEL OF CARE CHANGE (LOWER LEVEL OF CARE) [ ] RELOCATION (GEOGRAPHICAL MOVE) DISCONTINUATION REASON [ ] G PROGRAM COMPLETED HERE - ALL GOALS [ ] S PROGRAM COMPLETED HERE - SOME GOALS [ ] T TX. CONTINUED IN OTHER PROGRAM MODALITY [ ] MH MENTAL HEALTH [ ] AD ALCOHOL/DRUG [ ] DU CO-OCCURRING (MH & AD) / ID NUMBER ID NUMBER / /