Clinician: All blocks must be completed & all notes must be LEGIBLE.
Client Name: (Last)
(First)
Session Date:
Time Spent in Session:
minutes
Current treatment plan — Individual psychotherapy:
per week
Group therapy:
per week
DOB:
Patient Code:
Facility:
Diagnosis / ICD Code:
Vtot:
Clinician: (print name)
Clinician Code:
Current Observable Symptomatic & Functional Impairments & Behaviors / Current Issues:
Certification of client's cognitive ability to actively participate in and benefit from this service:
Therapeutic Goals worked on this session: (Check all as applicable)
Interventions employed: (Check all as applicable)
Positive Clinical Response / Therapeutic Gains noted this session in observable terms:
Ongoing Symptomatic / Functional Impairments & Justification for Continued Treatment (goals to be attained prior to termination of therapy) in observable terms:
Other Notes / Follow-Up:
I hereby certify that the above information is true and correct to the best of my knowledge.