Recipientname of 5303 Service: ______Program Type (Circle One): REACH FISS WRAP

RecipientName of 5303 Service: ______Program Type (Circle One): REACH FISS WRAP

Month/Year: _____ Provider: ______

Phone Log: All phone calls made or received that qualify for billing need to be documented. Start Time refers to the start of the call.

Travel Log: Your times will not be the same total as your progress notes. Documentation is not included on the log. Signatures are to be obtained at the conclusion of every contact.

Date / Phone Contact
(Check) / Travel
Start
Time / Session Time Frame for all contacts i.e. phone and face to face. / Travel Start & End Time
After
Session / No Show / Reason for Contact/Person Seen (Check all that apply) / Location
Seen (Check or indicate other location seen) / Adult Signature and Relationship to Client / Client Signature / Date sig. obtained
Enter
Date / Check if phone contact / 9:30am / 9:50am- 11:00am / 11:01-
11:16a / _X_Crisis Stabilization
___Crisis Prevention
X_ Crisis Intervention
___ Crisis Supervision / ___Client Home
_X_Community
___Facility
___School
___ Other ______/ Adult signature needed for all contacts upon session conclusion. / Client signature needed for all contacts upon session conclusion. / Enter
Date
___Crisis Stabilization
___Crisis Prevention
___ Crisis Intervention
___ Crisis Supervision / ___Client Home
___Community
___Facility
___School
___Other
______
___Crisis Stabilization
___Crisis Prevention
___ Crisis Intervention
___ Crisis Supervision / ___Client Home
___Community
___Facility
___School
___ Other ______
___Crisis Stabilization
___Crisis Prevention
___ Crisis Intervention
___ Crisis Supervision / ___Client Home
___Community
___Facility
___School
___ Other ______
___Crisis Stabilization
___Crisis Prevention
___ Crisis Intervention
___ Crisis Supervision / ___Client Home
___Community
___Facility
___School
___ Other ______
___Crisis Stabilization
___Crisis Prevention
___ Crisis Intervention
___ Crisis Supervision / ___Client Home
___Community
___Facility
___School
___ Other
Date / Phone Contact
(Check) / Travel
Start
Time / Session Time Frame for all contacts i.e. phone and face to face. / Travel Start & End Time
After
Session / No Show / Reason for Contact/Person Seen (Check all that apply) / Location
Seen (Check or indicate other location seen) / Adult Signature and Relationship to Client / Client Signature / Date sig. obtained
Enter
Date / Check if phone contact / 9:30am / 9:50am- 11:00am / 11:01-
11:16a / _X_Crisis Stabilization
___Crisis Prevention
X_ Crisis Intervention
___ Crisis Supervision / ___Client Home
_X_Community
___Facility
___School
___ Other ______/ Adult signature needed for all contacts upon session conclusion. / Client signature needed for all contacts upon session conclusion. / Enter
Date
___Crisis Stabilization
___Crisis Prevention
___ Crisis Intervention
___ Crisis Supervision / ___Client Home
___Community
___Facility
___School
___Other
______
___Crisis Stabilization
___Crisis Prevention
___ Crisis Intervention
___ Crisis Supervision / ___Client Home
___Community
___Facility
___School
___ Other ______
___Crisis Stabilization
___Crisis Prevention
___ Crisis Intervention
___ Crisis Supervision / ___Client Home
___Community
___Facility
___School
___ Other ______
___Crisis Stabilization
___Crisis Prevention
___ Crisis Intervention
___ Crisis Supervision / ___Client Home
___Community
___Facility
___School
___ Other ______

For Office Use Only:

______

Parent/Guardian Signature – Relationship to Client Date Quality Assurance Staff Date