Monitors & Reporting

MPHP Report & Intake Forms/Policies & Guidelines

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Monitor Responsibilities:
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Communication with members of an MPHP participant's treatment team and/or worksite is imperative. The MPHP's Release of Information Form gives the MPHP permission to speak with treatment providers and other monitors to ensure that all parties have the information necessary to document the recovery and/or monitoring process. Releases are required for all monitors (i.e. employers, clinical providers, attorneys, etc.).  

What are we looking for from Monitors?  Experience and research shows that there are warning signs that place a person at risk for relapse. These warning signs include missed meetings or appointments, behavioral issues at work or in an individual's personal life or in therapy. 

​The information monitors are asked to report include the following:

• Frequency of visits with provider/monitor.
• Knowledge of abstinence from alcohol and other mind-altering substances.
• Appropriate use of prescribed medications if applicable.
• Continued commitment to recovery if applicable.
• Issues that could compromise those in recovery.
• Changes in employment, diagnosis, medications, etc.
• Changes in treatment providers.
• Any additional information that relates to health, treatment and/or recovery.

​Report Forms (monthly/quarterly): are due on the 1st day of the month.
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Click on each form to open - print and scan to send via email or mail

• Therapist Report  
• Worksite/Peer Monitor Report 
• Prescriber Report​
• Self Assessment
• Meeting Attendance Tracking Sheet Verification​

Intake Forms:

• Informed Consent
• HIPAA Release Form
• Intake Demographic Form
• Intake Questionnaire
• MPHP Payment Plan Form - Fillable Form​
• AC-OK Tool - Fillable Form
• PHQ-9 Tool - Fillable Form

MPHP Policies & Guidelines:

• MPHP Fee Policy
• Worksite/Peer Monitor Guidelines & Agreement
• General Guidelines for MPHP Evaluations

Monitor Roles:
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• Treatment Providers  The MPHP relies on the compassionate and insightful services provided by the many therapists, psychologists, psychiatrists, primary care physicians, treatment programs, workplace monitors and others who evaluate and treat program participants.  Communication between treatment providers and the MPHP clinical coordinator is imperative.  In addition to providing the required reports, it is important for  participants to consult with their clinical coordinator about any changes to their recovery program.  It is the participant’s responsibility to assure that reports from treatment providers are submitted in a timely manner.
• Primary Care Provider  Participants are encouraged to meet regularly with a primary care provider for general health care needs.  Participants are asked to refrain from self-treating or treating family members or practice partners except in emergency situations.  If a participant is affected by chronic pain, and controlled substances are considered necessary, the participant should be referred to a physician specializing in chronic pain for evaluation and treatment. Generally, monitor reports are not required from primary care providers but is determined on a case by case basis.
• Therapist  Participants may be expected to attend sessions with a therapist.  The therapist works with the participant to develop strategies for maintaining a strong recovery/mental health program.  The therapist will be asked to submit regular reports (either monthly or quarterly) that reflect on the participant’s attendance at therapy and progress in treatment.  Therapists help participants recognize threats to recovery and/or their mental health and detect early signs of potential relapse/resumption of behavior. MPHP clinical coordinators may periodically speak directly with therapists. 
• Psychiatrist/Prescriber  Every participant with mental health and/or dependency issues must have a mental health treatment provider. For the most part this will mean a psychiatrist.  Those with a substance misuse disorders should have an addiction medicine practitioner to provide clinical guidance with respect to their recovery program and safe use of prescription medications that could compromise their recovery when indicated.
• Worksite/Peer Monitor  Participants working in their profession may be expected to identify an individual in the workplace (approved by the clinical coordinator) to familiarize them with their MPHP Monitoring Agreement, and their worksite monitor reporting requirements.  Workplace monitors are expected to be supportive of the participant and their monitoring.  Work monitors will be reporting their observations of the participant’s behavior in the workplace setting, and will identify any concerns on a monthly/quarterly basis depending on the terms of the participant's Monitoring Agreement.  

Have questions?  Feel free to call or email at any time.  MPHP Question and Answer forms may also contain information needed.

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GET HELP TODAY - CONTACT MPHP at [email protected] or (207) 623 - 9266

Medical Professionals Health Program ~ 16 Association Drive ~ Manchester, ME 04351 ~ (207) 623-9266 ~ Fax: (207) 430-8386