Type of Contact Modality

Office Visit Crisis Intervention Behavioral Assistance

Telephone Contact Individual Counseling CSI
Face to Face Group Counseling IFI
Physician Visit / Telephone
Conference
Faily Counseling
Structured Activity Support
Clients Name: Type of Insurance Insurance #
Providers Name: Role of Provider:
Therapist
Date of Service:
Start Time: Location of Service:
Office
County:
McDuffie
nd Time: Duration of Contact !nits: " Service Code:
#$%$&
'oal:
O()ective:
B!
I!
R!
P!
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CLIENTS PROGRESS NOTES