Indicate which quarter this report covers:
Is the participant compliant with treatment (willing participant, attends appointments as scheduled, demonstrates motivation to work toward goals, etc.)?
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.
Has the participant signed releases for you to communicate with their medical provider?
Have you communicated with the participant's medical provider this quarter?
Did the participant experience a return to use during this quarter?
To your knowledge, is the participant adherent with their IPHP contract?
Would you like IPHP staff to contact you?
Your Signature:
Today's Date:
