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Follow up Treatment
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Patient Name
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Date of service
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Appointment time ( From / To )
/
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Appointment time duration ( Minutes )
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Information Reviewed
• • •
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Review of recent history and compared with assessment
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Mental Exam
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Appearance
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Speech
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Orientation
• • •
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Mood
• • •
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Sensory and motor
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Other
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Goal/Plan of treatment
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Therapy
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Dr Cruey
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Neurofeedback
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BST
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Psychosocial Rehab
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Other
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Neurofeedback provider assigned to client
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Present
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Proposed protocol
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Neurofeedback Provider/Supervisor discussed the process/plan of Neurofeedback treatment to patient/caregiver?
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Evaluation of mental health assessment discussed with a patient/caregiver
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Notes
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Discussed with
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Evaluation of the EEG report discussed with a patient/caregiver
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Notes
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Discussed with
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Dr. Signature
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Patient/Guardian
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