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Form46 - Date of last session Number of sessions Scheduled...

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[ FORM 46 —Use the top of this page for your letterhead.] Termination Summary Client: Case: Date: Signature(s) of therapist(s) : A. Reason(s) for termination q Client failed to attend two consecutive appointments without canceling. q Client failed to comply with treatment recommendations. q Client was noncompliant with court order, probation, or other (specify) . q Client could not be reached by phone and did not respond to letters sent. q Planned treatment was completed. q Client refused to receive or participate in services. q Client was unable to afford continued treatment or did not pay bills on time. q Client moved. q There was little or no progress in treatment. q This is a planned pause in treatment. q Client needs services not available here, and so was referred to: q Other: B. Source of termination decision. The decision to terminate was: q Client-initiated q Therapist-initiated q A mutual decision q MCO-affected q Other: C. Treatment sessions Referred on date: Date of first contact:
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Unformatted text preview: Date of last session: Number of sessions: Scheduled: Attended: Cancelled: Did not show: D. Kinds of services rendered q Individual psychotherapy, for sessions q Couple/family therapy, for sessions q Group therapy, for sessions q Other: E. Treatment goals and outcomes (code outcomes as follows: N = no change, S = some or slight [about 25% to 35%], M = moderate [about 50%], V = very good [about 75% to 100%], E = exceeded expectation) Goal Outcome F. Last diagnosis/diagnoses: Other notable aspects of treatment outcome, change, or progress: This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. FORM 46. Termination summary form. From The Paper Office . Copyright 2003 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details)....
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