90 Day Progress Summary Note
Client:
*
First Name
Last Name
Client Date of Birth:
*
-
Month
-
Day
Year
Date
Admission Date
-
Month
-
Day
Year
Date
Authorization Dates
*
Date of most recent Assessment
*
-
Month
-
Day
Year
Date
CPST - Frequency of Services used (Check all that apply):
Weekly
Bi-weekly (every other week)
Monthly
PSR - Frequency of Services used (Check all that apply):
Weekly
Bi-weekly (every other week)
Monthly
Crisis Intervention - Frequency of Services used (Check all that apply):
Weekly
Bi-weekly (every other week)
Monthly
Frequently Used Service Format
*
Individual
Family
Group
Other
Frequently Used Service Format
*
Home
Community
Office
Telehealth
Other
Treatment Compliance:
*
Yes
No/Inconsistent
List all current Diagnosis
*
Goal (Targeted Clinical Area) #1:
*
Goal #1 - Progress Rating:
*
Deterioration
No Significant Changes
Minimal Improvement
Some Improvement
Moderate Improvement
Significant Improvement
Complete Improvement
Goal (Targeted Clinical Area) #2:
Goal #2 - Progress Rating:
Deterioration
No Significant Changes
Minimal Improvement
Some Improvement
Moderate Improvement
Significant Improvement
Complete Improvement
Goal (Targeted Clinical Area) #3:
Goal #3 - Progress Rating:
Deterioration
No Significant Changes
Minimal Improvement
Some Improvement
Moderate Improvement
Significant Improvement
Complete Improvement
Goal (Targeted Clinical Area) #4:
Goal #4 - Progress Rating:
Deterioration
No Significant Changes
Minimal Improvement
Some Improvement
Moderate Improvement
Significant Improvement
Complete Improvement
Specific CPST and PSR interventions & activities used and by whom:
*
Description of progress or lack of progress towards goals (include barriers to progress, functional impairments, stages of change):
*
Recommendation or need for Continued Treatment (include service types, frequency; needs, strengths, needed referrals, etc.)
*
What deviations from the treatment plan occurred since the client's initial treatment plan or treatment plan review? (If the client is only receiving one service, please include an explanation as to why)
*
Describe any changes in the client's medical condition, behavior, or home situation that may indicate a need for a reassessment and changes to the treatment plan.
Please list new Treatment goals being requested:
Medication Information (as applicable)
Name of the prescribing physician:
Date of last psychiatric evaluation /follow up:
-
Month
-
Day
Year
Date
Projected Discharge Date:
-
Month
-
Day
Year
Date
Reason for discharge and recommendations for continuity of care:
Provider name
*
Provider email address
*
example@example.com
Credentials
*
(LPC, LCSW, PLPC, LMFT, MHS, MHP, etc)
Date of submission
*
-
Month
-
Day
Year
Date
Signature
*
LMHP Name
LMHP Credentials
(LPC, LCSW, PLPC, LMFT, MHS, MHP, etc.)
LMHP Signature
Submit
Should be Empty: