Indicate which quarter this report covers:
Has there been a change in the participant's diagnosis and/or treatment? If yes, please explain.
Does the current diagnosis affect the participant's ability to practice in the field they are licensed in? If yes, please explain.
Do you recommend any changes to the participant's treatment requirements, including the frequency of services, need for re-evaluation, work restrictions, etc.? If yes, please explain.
To your knowledge, is the participant adherent with their IPHP contract?
Has the participant signed releases for you to communicate with their therapist and/or aftercare provider?
Have you communicated with the participant's therapist and/or aftercare provider this quarter? If yes, please explain.
SUBSTANCE USE CASES ONLY: Do you have any concerns about the participant's ability to travel outside of the U.S. or to a location where drug screen monitoring is not available during this next reporting quarter based on their status at the time of this report?
To your knowledge, has the participant experienced a return to use during this quarter?
Would you like IPHP staff to contact you?
Your Signature:
Today's Date:
