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VISIT TYPE
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Appointment Type
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Telemedicine
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Emergency Only: Verbal Telemed Consent
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Visit Comment
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Crisis Visit
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Visit Comment
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Vivitrol Injection
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Pre-Injection UDS
• • •
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Name and Title of Injector (MA or above)
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Lot Number
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Expiration Date
/
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Injection Site (Must Alternate)
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Post-Injection Side Effects
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Comments
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Others Involved in Session?
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List All People Involved in Session (>2)
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Verbal Consent for Other's Involvement
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Supportive Psychotherapy/Edu
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Time spent with patient for therapy/edu (16-37 minutes)
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Psychotherapy Comments
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