HEALTH RECOVERY SERVICESDETOX OUTCOMES

Fiscal Year*

Reporting Period*

Mid-Year (Jul 1-Dec 31)

Year-End (Jul 1-Jun 30)

Number of Clients Carried over from Previous Fiscal Year*

List only the number of clients carried over from previous fiscal year

Number of New Clients Served*

List only the number of new clients enrolled in program during current reporting period

Number Discharged*

List total number discharged or ended involvement for any reason - successfully, unsuccessfully, or neutrally

Number of Successful Discharges*

Of the total number discharged, or ended involvement, list how many were successful

Number of Clients Continuing into Next Reporting Period*

List number who continue to be engaged and will receive services in next reporting period

Are you on target to meet projections?*

Yes

No

Numbers Served by County

Please indicate numbers served by county of residence below. Totals for all counties should equal Number of Clients Carried over from Previous Fiscal Year + Number of New People Served

Number Who Are Athens County Residents*

Number Who Are Hocking County Residents*

Number Who Are Vinton County Residents*

Number Served who Reside OUTSIDE of AHV Counties*

Additional Program Outcomes

Number of Clients who are Successfully Discharged and who are Available for Follow-up Reports Maintaining Sobriety 30 days Post-Discharge*

Number of Clients Engaged in Services*

Defined by client attending and completing detox

Number of Clients who were Fully Board supported*

Number of Clients who were Partially Board Supported*

Number of Clients who have Private Insurance that Contributed to Payment*

Total Number of Bed Nights*

Total Number of Bed Nights for AHV Residents*

Narrative

Program Achievements*

Briefly describe achievements for reporting period

Program Challenges*

Briefly describe program challenges for reporting period

Program Improvements*

Briefly describe program improvements made during the reporting period

Significant Differences Last Year to this Year*

Were there any significant differences between last year and this year? If so, please describe

Additional Noteworthy Remarks

Optional field to share additional info such as a story demonstrating how people have benefited from program

File Upload

Optional: Use file upload to attach and include any supporting documents

Drag and drop files here or

Agency Contact

Agency Representative Providing Data*

List name of staff member providing data on this form

Email Address for Person Providing Data*

List email address of staff member providing data on this form

Phone Number for Person Providing Data*

List phone number for staff member providing data on this form

Phone

Year End Reporting Only

Projections

Use this section to project total number served, number who ended involvement, and number who will continue in the next fiscal year: July 1-June 30.

Number carried over from previous fiscal year*

Project number of new people who will be served*

Project discharges*

Total number who will be discharged or end involvement for any reason (successfully, unsuccessfully or neutrally)

Project successful discharges*

Of the total number of discharge or those ending involvement, how many will be successful

Project number who will continue to be engaged and receive services*

Briefly describe what additional results might be achieved if extra resources were available*

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