|
EIN/ NPI
|
Total # of sessions
|
|
Treatment
|
Start Date
|
|
End Date
|
Efficacy
|
|
Initial Scores
|
|
|
QIDS-SR:
|
PHQ-9:
|
|
GAD-7:
|
WHO-5:
|
|
FTND:
|
Cravings:
|
|
Final Scores
|
|
|
QIDS-SR:
|
PHQ-9:
|
|
GAD-7:
|
FTND:
|
|
WHO-5:
|
Cravings:
|
|
Diagnostic Impression:
|
DI: Major Depressive Disorder
• • •
|
|
DI: Other Disorders
• • •
|
DI: Eating Disorders
• • •
|
|
DI- ADHD
• • •
|
DI: Bipolar
• • •
|
|
DI: (If not listed as favorite above)
|
Disposition:
|
|
Plan
• • •
|
Preventative/ Ancillary Services recommended:
• • •
|
|
Follow Up
|
Additional Plan Notes:
|
|
Smoking Cessation Follow Up
|
|
