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32:T535,

Presenting condition

Reason for seeking services

Client states: "I would like to get help getting my life together"

33:Te42,

34:T61ff,

Treatment history detail

Do you have any prior Medical, Surgical, Mental Health, or Substance Use treatment history?

Yes

Medical/surgical treatment history

Condition

Date

Provider

Treatment and response

Mental health/substance use treatment history

Reason for treatment

Provider/facility name

Start date of treatment

End date of treatment

35:T810,

36:T1be9,

Intake summary

Summary of assessment findings

Example Summation.

Intake status

Approved

Wait list

Denied

Referral needed

Summary of placement decisions

Placed in outpatient program.

37:Tef9,

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