Section 1 of 1 in this document

Quarterly Report - Therapist

Participant's Name:

Therapist's Name & Credentials:

Therapist's Contact Information:

Indicate which quarter this report covers:

1st Quarter: January - March (due 4/20)

2nd Quarter: April - June (due 7/20)

3rd Quarter: July - September (due 10/20)

4th Quarter: October - December (due 1/20)

Dates of therapy sessions during this reporting quarter:

Primary focus in treatment:

Secondary focus in treatment:

Has progress been demonstrated toward their goals? Please explain.

What is the appointment frequency? Do you recommend a change in frequency? Please explain.

Is the participant adherent with your treatment recommendations (i.e. willing participant, attends appointments as scheduled, demonstrates motivation to work toward goals)?

Yes

Does the participant have insight in to their condition? Please explain.

Has there been a change in the participant's diagnosis? If yes, please explain.

Does the current diagnosis affect the participant's ability to practice safely in the field they are licensed in? If yes, please explain.

To your knowledge, has the particpant had any suicidal ideations this quarter? Please explain.

Has the participant signed releases for you to communicate with their medical provider?

Yes

Have you communicated with the participant's medical provider this quarter?

Yes

To your knowledge, has the participant experienced a return to use during this quarter?

Yes

To your knowledge, is the participant adherent with their IPHP contract?

Yes

Unsure

Would you like IPHP staff to contact you?

Yes

Any further Comments, Questions or Concerns?

Your Signature:

First Name

Last Name

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