United Behavioral Health Outpatient Treatment Progress free printable template

Outpatient Treatment Progress Report To request further certifications please fax or mail to United Behavioral Health MN-CMC MR MN010-S155 P. O. Box 1459 Minneapolis MN 55440-1459 Phone 1-800-848-8327 Toll Free Minnesota Location or FAX 763 732-6910 MEMBER INFORMATION Member Name First Last Member ID Member Address City/State Print clearly Date of Birth Member Home Phone Provider Name Degree Member Work Phone Phone Address Number of Sessions to date Frequency Date 1st Visit Date Last Visit...Release of information for UBH signed Yes No Yes If Child/Adolescent Is Family Involved No Prior Treatment- Episodes in past year TX Plan or Summary sent to patient s PCP MH of times OutpatientInpatientPHPIOP Member/ Parent/Guardian refused consent for release to PCP Member states they have no PCP Outcome AMA discharge Completed Treatment/still using Completed Treatment/Sober Active in CD Support Group Yes No Current Symptoms Sad Mood Anxiety Worry Elated Hopeless Panic Thought Delusions...Behavior Aggressive Low Energy Fearfulness Hallucinations Truant Poor Concentration Compulsive None Disorganized Speech Runaway Obsessive Sleep Problems Describe DIAGNOSIS Angry Appropriate No Problem Other Distractible Hyperactive Appetite Problems Describe RISK ASSESSMENT TIP Use DSM-IV Codes include all Axes. Axis I - Primary Axis II - Suicidality Secondary Axis III - Axis IV Homicidality Hx Substance Abuse/Dependence Assessed Yes No Ideation Economic problems Problems with accessing health...services Plan Housing problems Problems related to interactions with legal/criminal system Intent w/o means If yes drugs of choice Ideation in past yr Occupational problems Other psychosocial problems Axis V GAF Current Attempt in past yr By Family/Significant Other Family/peer history of completed suicide Other Risk Factors Hx Physical/Sexual Abuse If risk exists Client is able to contract not to harm Self Prescribing MD Child/Elder neglect Anorexia Psychiatrist Name PCP Name CURRENT...MEDICATIONS Include all meds psychiatric and medical Drug Current Dose Duration Progress Update Compliant Progressing and Improving Needs more sessions Compliant Not Progressing or Improving Needs Med referral Not Compliant but at risk How addressed Not Compliant Needs Referral for other Services/ Therapy Current Abuse/Dependence Highest in last 12 months Target Problems/ Symptoms Member has been evaluated for psychiatric meds If Patient needs referral Have you made the referral Can UBH help...you with the referral Would like to consult with a UBH clinician MSW MA PhD MD Expected Outcome and Prognosis Return to normal functioning Frequency of sessions Expect improvement anticipate less than normal functioning Expected LOS Discuss Relieve acute symptoms return to baseline functioning Modality CPT Code Maintain current status/prevent deterioration Clinician s Signature Date This form is to be used for routine outpatient psychotherapy only Bulimia. O. Box 1459 Minneapolis MN 55440-1459...Phone 1-800-848-8327 Toll Free Minnesota Location or FAX 763 732-6910 MEMBER INFORMATION Member Name First Last Member ID Member Address City/State Print clearly Date of Birth Member Home Phone Provider Name Degree Member Work Phone Phone Address Number of Sessions to date Frequency Date 1st Visit Date Last Visit Release of information for UBH signed Yes No Yes If Child/Adolescent Is Family Involved No Prior Treatment- Episodes in past year TX Plan or Summary sent to patient s PCP MH of times...OutpatientInpatientPHPIOP Member/ Parent/Guardian refused consent for release to PCP Member states they have no PCP Outcome AMA discharge Completed Treatment/still using Completed Treatment/Sober Active in CD Support Group Yes No Current Symptoms Sad Mood Anxiety Worry Elated Hopeless Panic Thought Delusions Behavior Aggressive Low Energy Fearfulness Hallucinations Truant Poor Concentration Compulsive None Disorganized Speech Runaway Obsessive Sleep Problems Describe DIAGNOSIS Angry Appropriate...No Problem Other Distractible Hyperactive Appetite Problems Describe RISK ASSESSMENT TIP Use DSM-IV Codes include all Axes. Axis I - Primary Axis II - Suicidality Secondary Axis III - Axis IV Homicidality Hx Substance Abuse/Dependence Assessed Yes No Ideation Economic problems Problems with accessing health services Plan Housing problems Problems related to interactions with legal/criminal system Intent w/o means If yes drugs of choice Ideation in past yr Occupational problems Other...psychosocial problems Axis V GAF Current Attempt in past yr By Family/Significant Other Family/peer history of completed suicide Other Risk Factors Hx Physical/Sexual Abuse If risk exists Client is able to contract not to harm Self Prescribing MD Child/Elder neglect Anorexia Psychiatrist Name PCP Name CURRENT MEDICATIONS Include all meds psychiatric and medical Drug Current Dose Duration Progress Update Compliant Progressing and Improving Needs more sessions Compliant Not Progressing or...Improving Needs Med referral Not Compliant but at risk How addressed Not Compliant Needs Referral for other Services/ Therapy Current Abuse/Dependence Highest in last 12 months Target Problems/ Symptoms Member has been evaluated for psychiatric meds If Patient needs referral Have you made the referral Can UBH help you with the referral Would like to consult with a UBH clinician MSW MA PhD MD Expected Outcome and Prognosis Return to normal functioning Frequency of sessions Expect improvement...anticipate less than normal functioning Expected LOS Discuss Relieve acute symptoms return to baseline functioning Modality CPT Code Maintain current status/prevent deterioration Clinician s Signature Date This form is to be used for routine outpatient psychotherapy only Bulimia.