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OOH Student Database
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Initial Contact Date
MM
/
DD
/
YYYY
Assessment Date
MM
/
DD
/
YYYY
Authorization Approved Date
MM
/
DD
/
YYYY
Track Type(s)
Your answer
Client's Name
Your answer
M#
Your answer
SSN
Your answer
DOB
MM
/
DD
/
YYYY
Diagnostic Code
Your answer
Treatment Duration / Discharge
30 Days Up OOH Only
60 Days Up
Discharge to RAC
Clear selection
Last Use Date
MM
/
DD
/
YYYY
Number of Kids
Your answer
Age of First Usage
Your answer
Race
Your answer
Highest Grade
Your answer
MH
Yes
No
Clear selection
Phone Number
Your answer
Email Address
Your answer
Referral Org / POC
Your answer
Emergency Contact Name
Your answer
Emergency Contact Number
Your answer
For more information,
OOH Training Department : 443.805.8927
OOH Main Office 1.855.9. OOHHOPE (1.855.966.4467)
PW@OrganiationOfHope.org
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