Encore OS — Documentation

Federally required consent for disclosure of substance use disorder (SUD) treatment records under 42 CFR Part 2 § 2.31. Documents informed, voluntary consent specifying recipient, purpose, information disclosed, expiration, right to revoke, and the prohibition-on-redisclosure notice. CL core-owned due to Part 2 sensitivity, submissions stored with CL-level access controls and DS4P Restricted confidentiality coding.Tags: consent, sud, 42-cfr-part-2, disclosure, cl, compliance, phi

Field	Label	Type	Required
`patient_name`	Patient Name	text	Yes
`patient_dob`	Date of Birth	date	Yes
`program_name`	Program/Facility Name	text	Yes
`purpose_of_disclosure`	Purpose of Disclosure	select	Yes
`recipient_name`	Information Will Be Disclosed To	text	Yes
`recipient_address`	Recipient Address	textarea	Yes
`information_to_disclose`	Information to be Disclosed	checkbox_group	Yes
`disclosure_start_date`	Consent Effective Date	date	Yes
`disclosure_end_date`	Consent Expiration Date	date	Yes
`right_to_revoke`	I understand I may revoke this consent at any time	checkbox	Yes
`prohibition_notice`	I understand this information is protected by federal law and cannot be re-disclosed without my consent	checkbox	Yes
`voluntary_consent`	This consent is voluntary and I have not been conditioned on signing	checkbox	Yes
`patient_signature`	Patient Signature	signature	Yes
`signature_date`	Date Signed	date	Yes
`witness_name`	Witness Name	text
`witness_signature`	Witness Signature	signature

Phase Advancement Request Form (operations)

Form for recovery housing residents to request advancement to the next program phase. Collects self-assessment, measurable program-participation evidence, and house manager endorsement. Used with the Phase Advancement workflow.Tags: phase-advancement, recovery-housing, rh, resident, self-assessment, operations

Field	Label	Type	Required
`resident_id`	Resident ID	hidden	Yes
`current_phase`	Current Phase	select	Yes
`requested_phase`	Requested Phase	select	Yes
`time_in_current_phase`	Weeks in Current Phase	number	Yes
`meeting_attendance`	Recovery Meetings Attended (last 30 days)	number	Yes
`employment_status`	Employment Status	select	Yes
`community_service_hours`	Community Service Hours (last 30 days)	number
`ua_results_clean`	All UA results clean in current phase	checkbox	Yes
`house_duties_compliant`	Compliant with house duties	checkbox	Yes
`self_assessment`	Self-Assessment: Why I’m ready to advance	textarea	Yes
`goals_for_next_phase`	Goals for Next Phase	textarea	Yes
`challenges_addressed`	Challenges I’ve Addressed	textarea
`house_manager_endorsement`	House Manager Endorses Advancement	checkbox	Yes
`house_manager_comments`	House Manager Comments	textarea

Residential Intake Form (onboarding)

Comprehensive intake form for recovery housing residents. Collects personal information, emergency contacts, referral details, insurance, brief medical and recovery background, program preferences, and required acknowledgments. Does NOT collect PHI-level clinical data (assessments, diagnoses) — those are handled by CL core templates.Tags: intake, admission, recovery-housing, rh, resident, onboarding

Field	Label	Type	Required
`full_name`	Full Legal Name	text	Yes
`preferred_name`	Preferred Name	text
`date_of_birth`	Date of Birth	date	Yes
`gender`	Gender Identity	select	Yes
`phone`	Phone Number	phone	Yes
`email`	Email Address	email
`emergency_contact_name`	Emergency Contact Name	text	Yes
`emergency_contact_phone`	Emergency Contact Phone	phone	Yes
`emergency_contact_relationship`	Relationship	text	Yes
`referral_source`	How were you referred?	select	Yes
`referral_contact`	Referral Contact Name	text
`insurance_provider`	Insurance Provider	text
`insurance_id`	Insurance ID	text
`ahcccs_id`	AHCCCS ID (if applicable)	text
`medical_conditions`	Current Medical Conditions	textarea
`current_medications`	Current Medications	textarea
`allergies`	Known Allergies	textarea
`substance_history`	Substance Use History (brief)	textarea
`sobriety_date`	Sobriety/Clean Date	date
`previous_treatment`	Previous Treatment Programs	textarea
`program_preference`	Preferred Program Level	select	Yes
`move_in_date`	Requested Move-In Date	date	Yes
`length_of_stay`	Anticipated Length of Stay	select
`house_rules_acknowledged`	I acknowledge and agree to house rules	checkbox	Yes
`consent_to_treatment`	I consent to recovery support services	checkbox	Yes
`financial_responsibility`	I understand my financial responsibilities	checkbox	Yes

Platform Reference

Form Templates Reference