HDC Case Activity Form

Human Development Company, Inc. 1930 Bishop Lane, Suite 603 Louisville, KY 40218

Make Check Payable to:

Tax ID #:

Mailing Address:

Email:

example@example.com

Telephone #:

Client's Name:

Dates of Service and Activity Codes.

Please choose from one of the following activity codes: In Person, Telehealth, SAP, No Show, Training, CISD.

Activity Code: Date of Service: How long was the session:

Did anyone attend session with client? If so, list dates and relationship (spouse, partner, dependent):

Primary Assessed Problem:

Secondary Assessed Problem:

Please evaluate the client's condition at the close of your last session.

Risk Management: 0-No Impairment 1-Mild 2-Moderate 3-Severe

Risk to self:

Risk to others:

Substance Use:

Job Function:

Social Function:

Impulsive Behavior:

Mood:

Current Problem Status:

ResolvedImprovingNo ChangeDeclining

Referred to (if referral was made):

Fees and Signature By submission of this request for reimbursement, the undersigned represents that services have been performed as described on dates and times specified. The undersigned agrees to maintain clinical notes for those services. The undersigned agrees

to submit this form no more than two weeks after the last date of service. The

undersigned agrees to a fee reduction based on late submission as follow: Submissions between 91 and 120 days after last date of service produces 50% of contracted rates. Submissions 121 days after last date of service forfeits payment. The undersigned agrees not to seek reimbursement for any services from any payor (including the client and/or any insurer) other than HDC.

Clinician Signature:

Clear

Date:

Date