Treatment Provider Update

For Treatment Providers

Treatment Provider Update

Submit a monthly update on a client Hope Council referred to your agency.

Start Update

Tx Provider Update

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Your information The provider completing this report.

Reporting agency name*

Your first name*

Your last name*

Credentials / license (e.g. SAC, CSAC, LPC)

Work email*

Work phone*

Client information

Client first name*

Client last name*

Client date of birth*

Last 4 digits of client SSN

Reporting period

Date of this report*

Date client admitted to program

As of (date client last seen)*

Next scheduled treatment appointment

Program involvement

Total number of sessions

Individual counseling sessions

Group therapy sessions

Services involved (check all that apply)

Continuing care

IOP

MAT

12-step meeting attendance

Tobacco cessation

Outpatient Individual/Group

Other

Other — describe

Client status

The client is

Following recommended course of treatment

In partial compliance

Re-admitted to program

Discharged in compliance

Discharged in non-compliance

Discharged in compliance except money owed (do not complete client until further notice)

Prognosis

Degree of use If partial or continued use is indicated, please add detail in the notes below.

Client self-reports

Full abstinence

Partial abstinence

Continued use

Attach report

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB, Max. files: 2.

Notes

Client goals and progress

Common Questions

Who is allowed to submit this form?dooley2026-07-14T19:12:40-05:00

Who is allowed to submit this form?

Only the licensed treatment provider a client was referred to. The verification step matches your work email and the client’s last-4 SSN and date of birth against the referral on file — so client treatment updates can’t be submitted by anyone else.

How often do I submit an update?dooley2026-07-14T19:12:59-05:00

How often do I submit an update?

Monthly. Monthly reports are mandatory for clients referred through the Intoxicated Driver Program. If there’s a significant change in status between reports, notify Hope Council immediately.

What if the client’s information doesn’t verify?dooley2026-07-14T19:13:17-05:00

What if the client’s information doesn’t verify?

The update stays locked and Hope Council staff are notified of the attempt. If you believe you have an active referral that isn’t matching, call 262-658-8166 to confirm the client’s details on file.

Where does the completed report go?dooley2026-07-14T19:13:31-05:00

Where does the completed report go?

Directly to Hope Council’s IDP coordinator (coordinator@hopecouncil.org). It is handled under the same federal and state confidentiality protections as all Hope Council client records.

For Treatment Providers