Clinical Review Form - Life Recovery Center

Clinical Review Form

Please submit this form each day for any new assessments, treatment plan reviews, or treatment plan updates.
Please submit this form each day for any new, reviewed or updated treatment plans. All forms for the week need to be submitted by noon on Friday. Please send all treatment plans on the same form once per week. If you have more than 5 to submit, use a second form.

Suggestion: Start an ongoing hand-written list in the morning and add the information to it throughout the day. At the end of the day input the data from the list into the form and submit it.
Date*

MonthDayYear
Date
Counselor*
Email
example@example.com
1. Client Name
Date of Tx Plan

MonthDayYear
Date
Client Payor Source

Self-PayMedicaidRecovery WorksIPGAPOther
Type

Initial treatment planTreatment plan review only; no updatesTreatment plan review with updatesOther
2. Client Name
Date of Tx Plan

MonthDayYear
Date
Type

Initial treatment planTreatment plan review only; no updatesTreatment plan review with updatesOther
Client Payor Source

Self-PayMedicaidRecovery WorksIPGAPOther
3. Client Name
Date of Tx Plan

MonthDayYear
Date
Type

Initial treatment planTreatment plan review only; no updatesTreatment plan review with updatesOther
Client Payor Source

Self-PayMedicaidRecovery WorksIPGAPOther
4. Client Name
Date of Tx Plan

MonthDayYear
Date
Type

Initial treatment planTreatment plan review only; no updatesTreatment plan review with updatesOther
Client Payor Source

Self-PayMedicaidRecovery WorksIPGAPOther
5. Client Name
Date of Tx Plan

MonthDayYear
Date
Type

Initial treatment planTreatment plan review only; no updatesTreatment plan review with updatesOther
Client Payor Source

Self-PayMedicaidRecovery WorksIPGAPOther
Should be Empty: