CVCP Progress Note Form III {F800-082-000}

Submit this document to: Crime Victims Compensation Program CVCP PROGRESS NOTE: Department of Labor & Industries FORM III Post Office Box 44520 Olympia, Washington 98504-4520 This formmu st be submitted by session 16. Preauthorization for payment of additional senossit toons e, xceed 30 for adults and 40 for chil, is drecontin ngent on the detail provided in this form. You should begin to consider whether or not you will need more than the 30/40 sessions, and the rationale behind the need. Bill Procedure Code 0124C For This Report. Victims Name Cvcp Claim Number Family Members Name (if counseling is for a family member of a sexual assault or homicide victim) Date treatment began Time Period this Report Covers (from month/day/yearto month/day/year) Date Form Completed Clinicians Name Clinicians Provider Number (if known) Number of sessions to date Clinicians Address Clinicians Phone Number ( ) City State Zip+4 Please review the CVCP guideline on Initial Response, Assessment and Documentation Procedures and provide answers to the questions listed below. You may copy and complete this form, or send a narrative report that contains all of the points listed below. 1) Is there substantial progress toward recovery from the crime related condition(s)? Yes (continue on to question #2) No (continue on to question #3) 2) If yes, do you expect that treatment will be completed within the allocated 30 sessions for adults/ 40 sessions for children? Yes No (please continue on to question #3) 3) What complicating or confounding issues are hindering recovery? F( 000-208-008Ff 1 o1 gePa 0420-1 vre 3m for, steno ssegropr pccv )FPD