Record #: Person’s Name (First MI Last): Person or Family/Guardian Declined/Deferred/Referred Out Rationale(s) (Explain why Person Family/Guardian Declined to work on Need Area; List rationale(s) for why Need Area(s) is/are Deferred/Referred Out below). None 1. 2. 3. 4. 5. Person’s Service Preferences, of Care/ Indicated Services Recommendation: Will person’s family be involved with treatment Yes No. If yes, specify (include family’s response to recommendations, the involvement of family in the assessment process, agency involvement and other supports).: Person’s Signature Date: Parent/Guardian Signature Date: (Optional, if clinically appropriate) (If appropriate): Clinician/Provider - Print Name/Credential: Date: Supervisor - Print Name/Credential (if needed): Date: Date: Clinician/Provider Signature: Date: Supervisor Signature (if needed): Psychiatrist/MD/DO (If Date: Next Appointment: required): Date: Time: am pm Date of Provider Loc. Mod Total Diagnostic Code Start Time Stop Time Service Number Code 1 Time Code
Person’s Name (First MI Last): Record #: Person or Family/Guardian Declined/Deferred/Referred Out Rationale(s) (Explain why Person Family/Guardian Declined to work on Need Area; List rationale(s) for why Need Area(s) is/are Deferred/Referred Out below). None 1. 2. 3. 4. 5. Person’s Service Preferences, of Care/ Indicated Services Recommendation: Will person’s family be involved with treatment Yes No. If yes, specify (include family’s response to recommendations, the involvement of family in the assessment process, agency involvement and other supports).: Person’s Signature (Optional, if clinically appropriate) Date: Parent/Guardian Signature (If appropriate): Date: Clinician/Provider - Print Name/Credential: Date: Supervisor - Print 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 Code Mod 1 Start Time Stop Time Total Time Diagnostic Code