Progress Note/ Billing Form
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1
2Progress Note/
Billing Form
NAME / MRN
Service Date:
_____________
RU: _____________
Staff #:
_____________
Hours* _______
Mins ______
# in Group: _______
Co-Staff #:
_____________
Hours* _______
Mins ______
Total Travel Time: Hours ______
Mins ______
* Service duration must include travel time, if applicable
Services:
(Check one)
Location of Services:
(Check one)
1 Office
5 School
11 Faith-based
15
Licensed Care Fac. (Adult)
19 Residential Tx
2 Field
8 Correctional Facility
12 Healthcare
16 Mobile Service
Center (Child)
3 Phone
9 Inpatient
13
Age-Specific Center
17 Non-Traditional Location
20 Telehealth
4 Home
10 Homeless/Shelter
14 Client’s Job-site
18 Other
21 Unknown
Service Strategies:
(Check up to three, if applicable)
50 Peer/Family Services
53 Supportive Education
56 With Social Services
59 With Develpmt Disabled
51 Psycho-Education
54 With Law Enforcement
57 With Substance Abuse
60 Ethnic-specific Services
52 Family Support
55 With Health Care
58 With Aging Providers
61 Age-specific Services
99 Unknown
Is the client pregnant?
Yes
No
(If yes, please document how service was pregnancy-related)
Interpreter Name of Interpreter:
Language service provided in other than English:
Spanish
Other
____________
Chart to: Goals/Strategies on plan; impairment related to diagnosis; progress and/or barriers to recovery; or unplanned
events.
1a. Treatment goal(s) addressed, if appropriate.
1b. Description of Current Situation/Reason for
DSM-5
ICD-10
Code:
____________________ Code
Contact:
(Status update, needs, clinical impressions)
_____________________
MHC017-9 (Rev 05-2017) Progress Note/Billing Form
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