Person’s Signature (Optional, if clinically Date: Parent/Guardian Signature (If Date: appropriate) appropriate): Clinician/Provider - Print Date: Supervisor - Name/Credential (if Date: Name/Credential: needed): Date: (if needed): Clinician/Provider Signature: Date: Supervisor Signature Psychiatrist/MD/DO (If required): Date: Next Appointment: Date: - Time am pm Date of Provider Mod Diagnostic Loc. Code Prcdr. Code Time Stop Time Total Time Service Number 1 Code
Person’s Signature (Optional, if clinically appropriate) Date: Parent/Guardian Signature (If appropriate): Date: Clinician/Provider - Print Name/Credential: Date: Supervisor - Name/Credential (if needed): Date: Clinician/Provider Signature: Date: Supervisor Signature (if needed): Date: Psychiatrist/MD/DO (If required): Date: Next Appointment: Date: - Time am pm Date of Service Provider Number Loc. Code Prcdr. Code Mod 1 Time Stop Time Total Time Diagnostic Code