This data is essential for the formal assessment of the five year pilot program. This evaluation is required by the funders of the program and will be critical in the decision of whether to continue to fund complementary and integrative health services under a Medicaid Waiver or expand these services to additional populations. Honest answers will help the Department of Health Care Policy and Financing (HCPF) understand how to best implement these services.

When to Implement

All forms should be completed at first ever appointment for new clients.

Ongoing - Every appointment (once a week max)

  • Form:  Ongoing Treatment Assessment (download PDF)
  • Form Due: First week of April and first week of October

Variable - At least annually, or whenever the treatment plan is changed

  • Form 5: Care Plan (download PDF)
  • Form Due: First week of April

March (and at outset of treatment)

September (and at outset of treatment, and March-see above)

How to implement forms

The Self-Administered forms should be completed by the participant, unless the participant requires assistance. Participants may complete all forms online or on paper made available by the participant’s primary Complementary and Integrative Health Services Provider.

Ongoing Treatment Assessment

  • Print the form and keep it in the client file to complete at each appointment
  • This form is not available online but the data can be collected electronically in a spreadsheet (that is compatible with your electronic patient records).

Self-Administered Forms 1 to 4

  • Providers may provide a computer, laptop or tablet for the participant to complete the surveys at the links provided above.
  • Providers may alternately print and provide the participant with a paper copy of the forms to fill out. (PDF links are above)

Form 5: Care Plan

  • Print and complete at the initial visit with each participant. This form must be updated at least annually, or as needed when the treatment plan changes. Providers must submit this form to the client’s Case Manager to authorize services and keep a copy in the client’s file. Annually, the first week of April, send all new plans to NRC by fax, FedEx or encrypted email.

How to Submit Forms to NRC

Data from the online forms are sent to NRC automatically when the form is submitted. Paper forms can be scanned and sent to NRC one of two ways:

  • Contact NRC (Sonya Wytinck) for access to a secure dropbox to upload files , scan and upload to dropbox
  • Scan and send by encrypted email to Sonya Wytinck


Additionally, every April, NRC will ask CIHS providers and practitioners, Medicaid case managers and supervisors, and SCI Waiver participants to fill out a survey to assess satisfaction with their SCI Wavier experience.

These will be implemented by NRC, to assure confidentiality.


Please contact us if you have any questions or concerns

Sonya Wytinck
Managing Director at National Research Center, Inc. (NRC)
Phone: 303-226-6989
Fax: 303-444-1145

Lindsay Westlund
Spinal Cord Injury Waiver Specialist at the Colorado Department of Health Care Policy and Financing (HCPF)
Phone: 303-866-5453
Fax: 303-866-2786