Outpatient Treatment Progress Report Form PDF Details

At the forefront of ensuring effective and continued care in the realm of outpatient psychotherapy lies the Outpatient Treatment Progress Report form. Integral to the process, this document serves a multifaceted role, streamlining communication between healthcare providers and United Behavioral Health. It is meticulously designed to capture a comprehensive snapshot of the patient's journey, starting with basic details that include the patient's name, ID, and contact information, progressing through the intricacies of treatment details such as the number of sessions, frequency, and involvement of family in cases of child or adolescent treatment. The thoroughness is further exemplified in sections devoted to the patient's current symptoms and diagnosis, where mood, anxiety, thought patterns, and behavior are systematically cataloged alongside pertinent diagnosis codes. Risk assessments are vigorously addressed, offering insights into potential suicidality or homicidality, substance abuse, and other psychosocial problems, ensuring that every aspect of the patient's well-being is considered. The form also delves into treatment progress, evaluating compliance, the efficacy of the current medication regime, and the anticipated outcomes, which aids in determining the necessity for further sessions or modifications to the treatment plan. By capturing a broad and detailed overview of the patient’s status, the Outpatient Treatment Progress Report fosters a seamless and efficient route towards optimal treatment outcomes.

QuestionAnswer
Form NameOutpatient Treatment Progress Report Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesintent outpatient form, intent outpatient template, treatment progress report template, united behavioral progress

Form Preview Example

Outpatient Treatment Progress Report

To request further certifications, please fax or mail to: United Behavioral Health MN-CMC

 

MR:MN010-S155, P.O. Box 1459, Minneapolis, MN 55440-1459

Phone:

1-800-848-8327 (Toll Free Minnesota Location) or FAX (763)732-6910

MEMBER INFORMATION

 

 

 

Member Name*: (First & Last)

 

Member ID#:

Date of Birth*

 

 

 

Member Address: (City/State)_________________________________________

Print clearly

 

Member Home Phone:

 

Provider Name: _________________________________Degree _________

Member Work Phone:

 

Phone :________________________Address: ______________________________

Number of Sessions to date: __________Frequency ___________________

 

 

 

 

 

 

 

 

 

 

 

 

Date 1st Visit __________ Date Last Visit _____________

 

 

 

 

 

 

 

 

 

 

 

 

 

Release of information for UBH signed: __Yes __No

 

 

 

 

If Child/Adolescent: Is Family Involved?

Yes

No

 

 

 

 

Release of information for PCP signed:

Yes

 

No

 

Prior Treatment- Episodes in past year:

 

 

 

 

 

 

__TX Plan or Summary sent to patient’s PCP

 

 

 

 

 

MH # of times Outpatient_____Inpatient____PHP____IOP_____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__Member/ Parent/Guardian refused consent for release to PCP

 

 

CD: # of times Outpatient_____Inpatient____PHP____IOP_____

 

 

 

 

__Member states they have no PCP

 

 

 

 

 

 

Outcome: AMA discharge _________Completed Treatment/still using______________

 

 

 

 

 

 

 

 

 

 

 

 

 

Completed Treatment/Sober ________Active in CD Support Group? __Yes __ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Symptoms:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mood:

Sad,

Elated,

 

Hopeless,

Low Energy,

Poor Concentration,

Angry,

Appropriate,

No Problem,

Other________________

 

 

 

Anxiety:

Worry,

Panic,

Fearfulness,

Compulsive,

None,

 

Other__________________

 

 

 

 

 

 

 

 

Thought:

Delusions,

Hallucinations,

Disorganized Speech,

Obsessive,

Distractible,

No Problems

Other____________________

 

 

 

Behavior:

Aggressive,

 

Truant,

Runaway,

Disorganized behavior,

Compulsive,

Hyperactive

Other_____________________

 

 

 

Sleep Problems, Describe:________________________

Appetite Problems, Describe: _____________________________________

 

 

 

DIAGNOSIS

★ TIP: Use DSM-IV Codes; include all Axes.

 

 

 

RISK ASSESSMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Axis I - Primary ____________________

Axis II -______________________

 

 

Suicidality:

Homicidality:

 

Hx Substance

 

 

 

Secondary __________________

Axis III - _____________________

 

 

None

 

 

None

 

Abuse/Dependence:

 

Axis IV

 

 

 

 

 

 

 

 

 

 

 

 

 

Ideation

 

Ideation

 

Assessed __ Yes __ No

 

Economic problems

 

Problems with accessing health services

 

 

 

Plan

 

 

Plan

 

Problem ?

Yes

No

Housing problems

 

Problems related to interactions with legal/criminal system

 

Intent w/o means

 

Intent w/o means

If yes, drugs of choice:

 

Occupational problems

 

Problems related to social environment/school

 

Intent with means

Intent with means

__________________________

Other psychosocial problems

 

 

 

 

 

 

 

 

 

Ideation in past yr

Ideation in past yr

Current Abuse/Dependence

Axis V (GAF) Current _____

 

 

 

 

 

 

 

 

 

Attempt in past yr

 

 

By Family/Significant

Highest in last 12 months___________ Target Problems/ Symptoms: _____________

 

 

 

 

 

 

Other

 

 

 

______________________________________________________________________

 

Family/peer history of completed suicide

Other Risk Factors:

 

______________________________________________________________________

 

 

 

 

 

 

Hx Physical/Sexual Abuse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If risk exists: Client is able to contract not to harm

Child/Elder neglect

 

Self

Others

Anorexia

Bulimia

Member has been evaluated for psychiatric meds?

Yes

No Prescribing MD:

Psychiatrist Name:

PCP Name:

CURRENT MEDICATIONS Include all meds psychiatric and medical

Drug

Current Dose

Duration

Drug

Current Dose

Duration

Progress Update

Compliant, Progressing and Improving –Needs more sessions

Compliant, Progressing and Improving- Plan for discharge When?___________

Compliant, Not Progressing or Improving – Needs Med referral______________

Not Compliant, but at risk How addressed?_______________________________

Not Compliant, Needs Referral for other Services/ Therapy

If Patient needs referral

Have you made the referral? Yes No

Can UBH help you with the referral?

Would like to consult with a UBH clinician? MSW MA PhD MD

 

Expected Outcome and Prognosis

 

 

 

Return to normal functioning

Frequency of sessions: ___________________________

 

 

 

 

Expect improvement, anticipate less than normal functioning

Expected LOS: __Discuss_____________________________

 

 

Relieve acute symptoms, return to baseline functioning

Modality CPT Code: ________________________________

 

 

Maintain current status/prevent deterioration

 

 

Clinician’s Signature __________________________________________________________ Date_____________________________

This form is to be used for routine outpatient psychotherapy only

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