Telehealth Service Encounter Form
Client Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Non Binary
Prefer Not To Answer
Other
Cyber ID Number
*
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Diagnosis Code
*
Please Select
F43.20 ADJUSTMENT DISORDER
F41.1 GENERALIZED ANXIETY DISORDER
F32.90 MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED
F91.30 OPPOSITIONAL DEFIANT DISORDER
F84.0 AUTISTIC DISORDER
F90.0 ATTENTION- DEFICIT HYPERACTIVITY DISORDER
F50.9 EATING DISORDER
F34.81 DISRUPTIVE MOOD DYSREGULATION DISORDER
F40.11 SOCIAL PHOBIA
F43.11 MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE
OTHER
Services Delivered
*
Please Select
INTENSIVE IN COMMUNITY - MASTERS
INTENSIVE IN COMMUNITY - LICENSED
BEHAVIORAL ASSISTANCE'
RESPITE
PARENT COACHING
BIOPSYCHOSOCIAL ASSESSMENT
Location of Service
*
Please Select
COMMUNITY
HOME
TELEHEALTH
Name of Therapist or Behavior Assistant
*
First Name
Last Name
Tele-Health Platform used for services: (example: zoom)
*
Service Date
*
-
Month
-
Day
Year
Date
Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Duration of Service
*
Please Check
*
I request payment of government benefits either to myself or to the party who accepts assignment.
Please Check
*
I authorize the release of any medical or other information necessary to process claims associated with services delivered as documented on this form.
Please Check
*
I authorize payment of medical benefits to the supplier(s) identified at numbers 13 through 17 on this form for services described on this form.
Please Check
*
I am the parent or legal guardian and I certify that the child received services as documented on this form.
Name of Responsible Party for Child
*
Relationship to the Child
*
Signature
*
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