Detox Data Form

Human Services Block Grant Data Tracking
Detox Data Required
Provider Name
Select Month
Select Year
Number of patients that completed detox
Number of clients ( of total #1) that began follow up treatment within 7 days
Percentage (%) of completed detox clients that began follow up treatment within 7 days
Submitter Name
Submitter Email
Submitter Phone


Instructions: 1. Number of clients that completed detox – completed is defined as medically stable and not leaving against medical advice. 2. Number of clients (from # 1) that began follow-up treatment within 7 days – follow-up treatment is defined as engaged in a level of care as assessed via PCPC or a lessor level of care requested by the client and agreed to by the provider. If slightly beyond 7 days due to bed or appointment availability this can be included as within seven days). 3. Percentage (%) that completed detox and began follow-up treatment with 7 days – The percentage is calculated by dividing #2 (Number of clients that began follow-up treatment within 7 days by #1 (Number of clients that completed detox).