Drug Testing or completing this form is an administrative only activity and is not claimable
Drug Test Report
Client:
InSyst #	Last Name	First Name
Location:	Episode Opening Date:
Agency:	RU:
Services were provided in:	by ☐ interpreter or ☐ clinician
Drug Testing
Test Results Report Date:
Test Type:	☐ UA	☐ Quick Test	☐ Breathalyzer	☐ Other:
☐ Illicit	☐ Prescribed	☐ Both	☐ Not Tested
Drug Tested	THC	METH	COC	AMP	OPI	BAR	BNZ	HALL	ETOH	MDMA (Ecstasy)	OXY	PCP	OTHER
Positive	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐
Negative	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐
Dilute	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐
Altered	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐
Not Tested	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐	☐
Description
LPHA/SUD Counselor Signature	Printed Name/Credentials	Date