denies homicidal ideation yes denies - windstone health
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Practitioner’s Name and Licensure: _____________________________Windstone Behavioral Health Progress Note PsychotherapyContinued Treatment Report Form (PhD/PsyD/LCSW/MFT)
State: _________City: ________________
Phone #: ___________________
Patient’s Name: ____________________________________ Date of Birth: _________________Date of Service: ______________
CPT Code: _________________ Interactive Complexity +90785
Start Time: ___________________ Stop Time: ___________________ Type of Therapy Provided: _______________________
Patient’s Chief Complaint: ___________________________________________________________________________________
If seen in patient's home, give address: ________________________________________________________________________
Person(s) in attendance to session: Self/Alone Other(s) (who): _______________________________________
Suicidal Ideation Yes Denies Homicidal Ideation Yes Denies
History of Present Illness: Indicate the frequency, severity, and duration of symptoms and be specific. Please address if patient has any High Risk Factors such as SI/HI or GD.
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Medical, family and social updates since last session: __________________________________________________________
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Address: ____________________________________________________
Zip: ____________
Fax #: ___________________
Current Medication (dosage/how often): ________________________________________________________________________
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Current Mental Status Exam: Check all that apply: Appearance: Well Groomed Groomed Unkempt Very Poor Demeanor: Cooperative Guarded Withdrawn _____________________ Posture: Normal Limp Rigid _____________________ Movement & Behavior: Alert Slowed Agitated Aggressive Mood: Euthymic Depressed Elated Dysphoric Affect: Appropriate Flat Labile Confused Speech: Normal Slow Rapid Pressured Thought Content: Normal Paranoid Grandiose ______________________ Perception: Normal A/H V/H Thought Process: Normal Circumstantial Loose Association
Tactile _____________________
Orientation: Person Place Time Purpose Cognition: Normal Impaired Disorganized ______________________ Insight: Normal Fair Poor ______________________
Judgment: Normal Fair Impaired Questionable
DSM-5 Diagnoses:
Axis I: Alpha-Numeric Code: ____________________ Description: _________________________________________________
Medical Diagnosis: _________________________________________________________________________________________
Psychosocial Factors check all that apply: Access to Health Care Housing Primary Support Group
Education Occupational Social Environment Other Psychosocial or Environmental
Economic
Legal System/ Crime
Treatment Plan and Goal(s)/Symptom Reduction: ________________________________________________________________
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Practitioner’s Name and Licensure: _____________________________Windstone Behavioral Health
Patient’s Name: ____________________________________ Date of Birth: _________________Date of Service: ______________
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Patient's compliance since last session: Yes No (if no, please explain) _______________________________________
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Axis I: Alpha-Numeric Code: ____________________ Description: _________________________________________________
Axis I: Alpha-Numeric Code: ____________________ Description: _________________________________________________
Change in Diagnosis from prior visit Yes No
Progress Note PsychotherapyContinued Treatment Report Form (PhD/PsyD/LCSW/MFT)
Patient’s Name: ____________________________________ Date of Birth: _________________Date of Service: ______________
Patient’s Prognosis: Excellent Good Fair Poor
Assessment of patient’s ability to adhere to the treatment plan: Excellent Good Fair Poor
Anticipated treatment duration: __________ Weeks / __________ Months / __________ Years
Continued Treatment Report (CTR): Windstone will authorize up to six sessions per request allowing us to communicate with members PCP.
(90832) Individual therapy (30 Minutes)
Next appointment: ________________________
Your request will be processed as a standard request unless specified as URGENT (indicate and document below). All URGENT requests require telephonic notification to 1-888-738-7172 upon submission of this form.
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PCP Name: ______________________________________________________PCP Fax #: _________________________________
OTR/CTR will be submitted to PCP in accordance with Windstone policies and procedures.
Practitioner’s Signature: ___________________________________________________________ Date: ____________________
Please Fax this form to (714) 644-8244
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Windstone Behavioral Health Practitioner’s Name and Licensure: _____________________________
URGENT
# Sessions Requested _________ Frequency _________
# Sessions Requested _________ Frequency _________
# Sessions Requested _________ Frequency _________
(90834) Individual Psychotherapy (45 Minutes)
(90853) Group Therapy
Patient has signed release of information to PCP and this form may be forwarded to PCP? Yes No
If not, why: _________________________________________________________________________________________
Practitioner's Initials: ________________________
Progress Note PsychotherapyContinued Treatment Report Form (PhD/PsyD/LCSW/MFT)