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Chief Complaint
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Reason for seeking care:
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Symptom Tracking
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Symptom
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Change Status
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Symptom severity since last session
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Additional Symptom 1
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Symptom
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Change Status
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Symptom severity since last session
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Additional Symptom 2
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Symptom
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Change Status
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Symptom severity since last session
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Additional Symptom 3
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Symptom
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Change Status
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Symptom severity since last session
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Additional Symptom 4
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Symptom
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Change Status
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Symptom severity since last session
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Additional Symptom 5
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Symptom
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Change Status
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Symptom severity since last session
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Additional Symptom 6
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Symptom
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Change Status
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Symptom severity since last session
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Additional Symptom 7
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Symptom
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Change Status
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Symptom severity since last session
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Additional Symptom 8
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Symptom
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Change Status
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Symptom severity since last session
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Additional Symptom 9
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Symptom
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Change Status
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Symptom severity since last session
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INTERVENTION--Neurofeedback Protocol
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Neurofeedback Protocol 1
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Channel 1
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Amplitude Settings
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Reward Percentage
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Sustained Reward Criterion
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Duration of Protocol
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Channel 2
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Channel 2
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Amplitude Settings
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Reward Percentage
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Sustained Reward Criterion
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Duration of Protocol
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Channel 3
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Channel 3
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Amplitude Settings
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Reward Percentage
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Sustained Reward Criterion
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Duration of Protocol
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Channel 4
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Channel 4
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Amplitude Settings
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Reward Percentage
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Sustained Reward Criterion
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Duration of Protocol
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Neurofeedback Protocol 2
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Neurofeedback Protocol 2
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Channel 1
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Amplitude Settings
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Reward Percentage
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Sustained Reward Criterion
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Duration of Protocol
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Channel 2
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Amplitude Settings
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Reward Percentage
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Sustained Reward Criterion
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Duration of Protocol
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Channel 3
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Amplitude Settings
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Reward Percentage
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Sustained Reward Criterion
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Duration of Protocol
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Channel 4
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Amplitude Settings
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Reward Percentage
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Sustained Reward Criterion
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Duration of Protocol
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CLIENT RESPONSE
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Client response to session:
• • •
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Client Response Comments:
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PLAN
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Treatment Plan Progress:
• • •
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Tx Plan Progress Comments:
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Plan Review:
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Plan Review Comments:
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Medical Necessity
• • •
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Medical Necessity Comments:
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