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Substance use treatment services forms

Substance use treatment consent form

To register a youth who needs substance use treatment or to authorize care, the youth must sign this consent form. All associated service providers must be included on the form. Please have both the consent and the explanation available for the youth to view.

Substance use treatment consent and release form is now available

This consent form is used exclusively by substance use providers and intensive in-community (IIC) assessors who specialize in substance use. It is used to disclose information to PerfomCare for referral and/or treatment. This is limited to:

  • Substance use treatment providers contracted by DCF/CSOC
  • IIC assessors who have LCADC credentials submitting the Needs/BPS substance use assessment
  • Probation, parole, and juvenile court representatives sending PerformCare substance use information or assessments (this does not include juvenile detention center representatives)

All other providers and community partners should continue using the standard consent/release form.

Substance use treatment service-related documents that require faxing to PerformCare must be submitted via this dedicated, toll-free fax line: 1-877-949-6590. Do not use any other fax number associated with PerformCare for substance use treatment documents.

Information and instructions

Initial Assessment for Substance Use Treatment

As part of the new substance use authorization process, substance use treatment providers are required to use the new Substance Use Treatment Initial Assessment form (PDF). All documents should be faxed to the PerformCare substance use provider fax number at 1-877-949-6590. The 42 Code of Federal Regulations (CFR) consent forms must be faxed on the first day of admission, and the initial clinical assessments should be faxed within the first 30 days of admission. The clinical documents must provide clinical justification for the youth's treatment at the requested intensity of service.

Intensity of service dispute form

 For instances when providers wish to dispute PerformCare's Intensity of Service (IOS) determination.

Service desk request form

 An online form that can be completed to address CYBER technical issues, eligibility questions, provider information, etc.