* = Required Information
Company Name (if applicable)
EHR (what Electronic Health record are you using)
Date of Service
Example: Family Training, Family Therapy, Community Support, etc.
(Home, Office, Community (Name & Address)
Group Home Staff
Face to Face
Consumer’s Overall Affect
Were there relevant changes in medical condition and/or medications (health and safety stressor) since last visit?
If Yes, Please explain
Did Consumer Met his/her goal
During your visit what happen?
(Counselor observation, client statements): Observation, thoughts, direct quotes, affect, mood, appearance
(Counselor’s methods (CBT,DBT, demonstration, roleplay) used to address goals and objectives?
Client’s response to the intervention, progress made toward Tx Plan goals and objectives
Plan: Document what is going to happen next?
What in the Tx Plan needs revision?
What is the clinician going to do next?
What is the next session date
I acknowledged that the information above is true and accurate and that I truly provided the services face to face or by phone with the above mentioned client. I also acknowledge that I will not file claim against the transcribing service since this is information given by me.