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Status at Intake:
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CC at Intake:
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Diagnosis at Intake:
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GAF at Intake:
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Treatment Summary:
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Services Utilized by Client:
• • •
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If Other, then specify:
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Summary:(Services provided, interventions and their efficacy, progress toward treatment goals):
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Length of Treatment with Lumate:
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Date of First visit [MM/DD/YYYY]:
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Number of sessions:
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Types of services provided:
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Interventions Provided by the Therapist:
• • •
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Please specify other:
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Notes:
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Current Status:
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Medical Conditions or concerns:
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Psychosocial Stressors:
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If other, then specify:
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GAF Score:
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Notes:
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Clinical Global Impression:
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Severity
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Severity (Select)
• • •
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Improvement
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Improvement (Select)
• • •
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Termination of Treatment:
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Reason(s) for termination (select all that apply):
• • •
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Other, then specify:
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Discharge plan:
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The following is a summary of the plan developed at time of discharge to assist patient in sustaining or achieving improvements
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Prognosis:
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Based on the pt.’s commitment to treatment and improvement in problems, is likely to
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Client’s medication(s) following termination of treatment with Lumate will be managed by:
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N/A:
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Patient’s primary care provider:
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Enter provider's name:
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External psychiatry provider:
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Enter external psychiatry provider’s name:
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Other:
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Enter other provider's name:
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Referral given to patient for medication management. Client was referred to:
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Referral 1:
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Referral 2:
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Referral 3:
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