RE-ENGAGEMENT

RE-ENGAGEMENT
Writer [select name="engaged" value=" |Called|Visited"] [select name="Location" value="Client's Home|Client's School|Homeless Shelter"] to re-engage client in treatment due to [select name="reason" value=" |24 hour|72 hour|7 day"] absence from program.
[checkbox name="variable_2" value="Call could not be completed due to number not being on file.
|Call could not be completed due to number being out of service.|Call was not answered and a message was left for client to call clinic.|Call was connected but message could not be left due to voicemail box.|Call connected and was answered by"][comment memo="Add information here if call was answered or leave blank"][textarea name="variable_3" default=""]

DROP-IN
Client presented at drop-in center to [select name="Reason" value=" |obtain resources for|address barriers to receiving"] [select name="Type" value=" |Mental Health services|Substance Abuse services"]. Writer [select name="Service" value=" | provided the following information:|resolved the following barriers:"] [textarea name="variable_1"]. Client was [select name="response" value="satisfied|unsatisfied"]with outreach.

FOLLOW-UP:
[checkbox name="variable_4" value="Writer will attempt re-engagement x2 more.|Writer will attempted re-engagement x1 more.|Writer will prepare and send re-engagement letter to address on file.|Writer will staff client to determine if contact information is accurate."] [comment memo="If other follow-up is needed use text box to explain, or leave blank if not needed"][text name="variable_5" default=""]
RE-ENGAGEMENT
Writer to re-engage client in treatment due to absence from program.
Add information here if call was answered or leave blank

DROP-IN
Client presented at drop-in center to . Writer . Client was with outreach.

FOLLOW-UP:
If other follow-up is needed use text box to explain, or leave blank if not needed

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.75, 14 form elements, 25 boilerplate words, 1 text boxes, 2 text areas, 2 checkboxes, 7 drop downs, 2 comments, 19 total clicks
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