Practitioner’s Name and Licensure: _____________________________Windstone Behavioral Health Progress Note PsychotherapyContinued Treatment Report Form (PhD/PsyD/LCSW/MFT)

State: _________City: ________________

Phone #: ___________________

Patient’s Name: ____________________________________ Date of Birth: _________________Date of Service: ______________

CPT Code: _________________ Interactive Complexity +90785

Start Time: ___________________ Stop Time: ___________________ Type of Therapy Provided: _______________________

Patient’s Chief Complaint: ___________________________________________________________________________________

If seen in patient's home, give address: ________________________________________________________________________

Person(s) in attendance to session: Self/Alone Other(s) (who): _______________________________________

Suicidal Ideation Yes Denies Homicidal Ideation Yes Denies

History of Present Illness: Indicate the frequency, severity, and duration of symptoms and be specific. Please address if patient has any High Risk Factors such as SI/HI or GD.

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Medical, family and social updates since last session: __________________________________________________________

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Address: ____________________________________________________

Zip: ____________

Fax #: ___________________

Current Medication (dosage/how often): ________________________________________________________________________

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Current Mental Status Exam: Check all that apply: Appearance: Well Groomed Groomed Unkempt Very Poor Demeanor: Cooperative Guarded Withdrawn _____________________ Posture: Normal Limp Rigid _____________________ Movement & Behavior: Alert Slowed Agitated Aggressive Mood: Euthymic Depressed Elated Dysphoric Affect: Appropriate Flat Labile Confused Speech: Normal Slow Rapid Pressured Thought Content: Normal Paranoid Grandiose ______________________ Perception: Normal A/H V/H Thought Process: Normal Circumstantial Loose Association

Tactile _____________________

Orientation: Person Place Time Purpose Cognition: Normal Impaired Disorganized ______________________ Insight: Normal Fair Poor ______________________

Judgment: Normal Fair Impaired Questionable

DSM-5 Diagnoses:

Axis I: Alpha-Numeric Code: ____________________ Description: _________________________________________________

Medical Diagnosis: _________________________________________________________________________________________

Psychosocial Factors check all that apply: Access to Health Care Housing Primary Support Group

Education Occupational Social Environment Other Psychosocial or Environmental

Economic

Legal System/ Crime

Treatment Plan and Goal(s)/Symptom Reduction: ________________________________________________________________

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Practitioner’s Name and Licensure: _____________________________Windstone Behavioral Health

Patient’s Name: ____________________________________ Date of Birth: _________________Date of Service: ______________

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

Patient's compliance since last session: Yes No (if no, please explain) _______________________________________

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Axis I: Alpha-Numeric Code: ____________________ Description: _________________________________________________

Axis I: Alpha-Numeric Code: ____________________ Description: _________________________________________________

Change in Diagnosis from prior visit Yes No

Progress Note PsychotherapyContinued Treatment Report Form (PhD/PsyD/LCSW/MFT)

Patient’s Name: ____________________________________ Date of Birth: _________________Date of Service: ______________

Patient’s Prognosis: Excellent Good Fair Poor

Assessment of patient’s ability to adhere to the treatment plan: Excellent Good Fair Poor

Anticipated treatment duration: __________ Weeks / __________ Months / __________ Years

Continued Treatment Report (CTR): Windstone will authorize up to six sessions per request allowing us to communicate with members PCP.

(90832) Individual therapy (30 Minutes)

Next appointment: ________________________

Your request will be processed as a standard request unless specified as URGENT (indicate and document below). All URGENT requests require telephonic notification to 1-888-738-7172 upon submission of this form.

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PCP Name: ______________________________________________________PCP Fax #: _________________________________

OTR/CTR will be submitted to PCP in accordance with Windstone policies and procedures.

Practitioner’s Signature: ___________________________________________________________ Date: ____________________

Please Fax this form to (714) 644-8244

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Windstone Behavioral Health Practitioner’s Name and Licensure: _____________________________

URGENT

# Sessions Requested _________ Frequency _________

# Sessions Requested _________ Frequency _________

# Sessions Requested _________ Frequency _________

(90834) Individual Psychotherapy (45 Minutes)

(90853) Group Therapy

Patient has signed release of information to PCP and this form may be forwarded to PCP? Yes No

If not, why: _________________________________________________________________________________________

Practitioner's Initials: ________________________

Progress Note PsychotherapyContinued Treatment Report Form (PhD/PsyD/LCSW/MFT)