[Insert Contractor Letterhead Here] SAFETY PLAN SERVICES (SPS) 15-DAY SUMMARY REPORT Referral Date and Time State ID Contractor Response Date and Time Case ID Referral Worker Name Billing Name Referral Worker Email Family Address Referral Worker Contact Number Family Phone Number (Phone/Cell) Care Coordinator Name/Author Financial County Date of 15-Day Summary Report Date 15-Day Summary Report provided to Referring Worker Reason for Referral DATES OF SERVICE PROVISION Type of Date of Met Contact Requirement E-Mail sent within 24 hours for initial contact on Contact Contact 1st referral and then by end of the next calendar day of each contact 1 INITIAL FACE-TO- YES NO YES NO FACE CONTACT 2 FACE-TO-FACE YES NO YES NO PHONE 3 FACE-TO-FACE YES NO YES NO PHONE 4 FACE-TO-FACE YES NO YES NO PHONE 5 FACE-TO-FACE YES NO YES NO PHONE 6 FACE-TO-FACE YES NO YES NO PHONE 7 FACE-TO-FACE YES NO YES NO PHONE 8 FACE-TO-FACE YES NO YES NO PHONE 9 FACE-TO-FACE YES NO YES NO PHONE 10 FACE-TO-FACE YES NO YES NO PHONE 11 FACE-TO-FACE YES NO YES NO PHONE 12 FACE-TO-FACE YES NO YES NO PHONE 13 FACE-TO-FACE YES NO YES NO PHONE 14 FACE-TO-FACE YES NO YES NO PHONE
[Insert Contractor Letterhead Here] SAFETY PLAN SERVICES (SPS) 15-DAY SUMMARY REPORT Referral Date and Time State ID Contractor Response Date and Time Case ID Referral Worker Name Billing Name Referral Worker Email Family Address Referral Worker Contact Number (Phone/Cell) Family Phone Number Care Coordinator Name/Author Financial County Date of 15-Day Summary Report Date 15-Day Summary Report provided to Referring Worker Reason for Referral DATES OF SERVICE PROVISION Type of Contact Date of Contact Met Contact Requirement E-Mail sent within 24 hours for initial contact on 1st referral and then by end of the next calendar day of each contact 1 INITIAL FACE-TO- FACE CONTACT YES NO YES NO 2 FACE-TO-FACE PHONE YES NO YES NO 3 FACE-TO-FACE PHONE YES NO YES NO 4 FACE-TO-FACE PHONE YES NO YES NO 5 FACE-TO-FACE PHONE YES NO YES NO 6 FACE-TO-FACE PHONE YES NO YES NO 7 FACE-TO-FACE PHONE YES NO YES NO 8 FACE-TO-FACE PHONE YES NO YES NO 9 FACE-TO-FACE PHONE YES NO YES NO 10 FACE-TO-FACE PHONE YES NO YES NO 11 FACE-TO-FACE PHONE YES NO YES NO 12 FACE-TO-FACE PHONE YES NO YES NO 13 FACE-TO-FACE PHONE YES NO YES NO 14 FACE-TO-FACE PHONE YES NO YES NO
SPS%20_5-Day_Rpt_1.17.docx