|
Client's Name
|
DOB
|
|
UCI
|
Funding Source
|
|
Frequency
|
Authorization Period
|
|
Treating Therapist
|
Supervising Therapist
|
|
Date
|
Time
|
|
Attendance
|
Setting
|
|
Is this a Make Up Session?
|
|
|
Treatment Notes
|
|
|
Home Program Provided
|
|
