Form Voucher Informatio Voucher Informatio Voucher Information and Transaction

ATTACHMENT A

Voucher Information and VOUCHER
Transaction tools

Form Approved

OMB No.

Expiration Date

VOUCHER INFORMATION

ACCESS TO RECOVERY PROGRAM

Public reporting burden for this collection of information is estimated to average 2 minutes per response including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1045, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-0266..

voucher information

Client ID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Grant ID: __ __ __ __ __ __ __

Voucher ID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Voucher Issue Date: |___|___| / |___|___| / |___|___|___|___|

Month Day Year

Voucher Amount:: $__ __ __ __ __. __ __

Voucher Service Type: (Check all that apply)

_______________________________________________________________

Clinical Treatment Services		Medical Services
	1. Screening/assessment		21. Medical Care
	2. Brief Intervention		22. Alcohol/Drug Testing
	3. Treatment Planning		23. HIV/AIDS Medical Support & Testing
	4. Individual Counseling		24. Other Medical Services
	5. Group Counseling	After Care/Recovery Support Services
	6. Family/Marriage Counseling
	7. Co-occurring Treatment Services		25. Continuing Care
	8. Pharmacological Interventions		26. Relapse prevention
	9. HIV/AIDS Counseling		27. Recovery Coaching
	10. Other Clinical Services		28. Self-help and Support Groups
Case Management/Recovery Support Services			29. Spiritual Support
			30. Other After Care Services
	11. Family Services (including marriage education, parenting and child development services)	Education/Recovery Support Services
	12. Child Care		31. Substance Abuse Education
	13. Employment Services		32. HIV/AIDS Education
	14. Pre-employment Services		33. Other Education Services
	15. Employment Coaching	Peer-to-Peer Recovery Support Services
	16. Individual Services Coordination
	17. Transportation		34. Peer Coaching or Mentoring
	18. HIV/AIDS services		35. Housing Support
	19. Supportive transitional drug-free housing services		36. Alcohol- and Drug-Free Social Activities
	20. Other Case Management Services		37. Information and Referral
			38. Other Peer-to-Peer Recovery Support Services

Form Approved

OMB No.

Expiration Date

VOUCHER TRANSACTION INFORMATION

ACCESS TO RECOVERY PROGRAM

Public reporting burden for this collection of information is estimated to average 2 minutes per response including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1045, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-0266.

voucher TRANSACTION information

Client ID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Grant ID: __ __ __ __ __ __ __

Voucher ID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Transaction ID: __ __ __ __ __ __ __ __ __ __

Provider ID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Faith-Based Provider Yes No

Voucher Redemption Date: |___|___| / |___|___| / |___|___|___|___|

Month Day Year

Amount Redeemed: $__ __ __ __ __.__ __

Number of Sessions: __ __ __ __ __

Voucher Service Type: (Indicate which service the client received for this transaction from the list below)

_________________________________________________________________________________________

Clinical Treatment Services		Medical Services
	1. Screening/assessment		21. Medical Care
	2. Brief Intervention		22. Alcohol/Drug Testing
	3. Treatment Planning		23. HIV/AIDS Medical Support & Testing
	4. Individual Counseling		24. Other Medical Services
	5. Group Counseling	After Care/Recovery Support Services
	6. Family/Marriage Counseling
	7. Co-occurring Treatment Services		25. Continuing Care
	8. Pharmacological Interventions		26. Relapse prevention
	9. HIV/AIDS Counseling		27. Recovery Coaching
	10. Other Clinical Services		28. Self-help and Support Groups
Case Management/Recovery Support Services			29. Spiritual Support
			30. Other After Care Services
	11. Family Services (including marriage education, parenting and child development services)	Education/Recovery Support Services
	12. Child Care		31. Substance Abuse Education
	13. Employment Services		32. HIV/AIDS Education
	14. Pre-employment Services		33. Other Education Services
	15. Employment Coaching	Peer-to-Peer Recovery Support Services
	16. Individual Services Coordination
	17. Transportation		34. Peer Coaching or Mentoring
	18. HIV/AIDS services		35. Housing Support
	19. Supportive transitional drug-free housing services		36. Alcohol- and Drug-Free Social Activities
	20. Other Case Management Services		37. Information and Referral
			38. Other Peer-to-Peer Recovery Support Services