Partners for Children Family Counseling/Bereavement Services Log

State of California—Health and Human Services AgencyDepartment of Health Care Services

Partners for Children Family Counseling/Bereavement Services Log

This log is to be used by the counselor to track the use of Family Counseling/Bereavement services. The family must meet with their counselor at least once before the death of the participant. The Agency can then bill for the lump sum payment allowed for up to 22 hours (including the initial visit) of continued counseling.

Instructions:

Complete a separate log for each Participant/Family receiving Family Counseling/Bereavement Services.

Agency: Enter the name of the Agency responsible for providing the service.

County: Enter the name of the County in which the participant/family resides.

Page: If more than one page is needed to log all visits, enter the page number of each sheet.

Participant: Enter the name of the PFC participant.

Birth Date: Enter the participant’s birth date.

CCS#: Enter the participant’s 7 digit CCS number.

Medi-Cal #: Enter the participant’s Medi-Cal number.

Date Service Started: Enter the date the family first met with their counselor.

Date of Death: Enter the date of the participant’s death.

Complete one line of the log for each counseling visit.

Individuals Presentat Visit: Enter the name, relationship to participant and age of each individual present.

If the individual is a caregiver but not a family member indicate that they are part of the circle of support (COS).

Hours Used: Enter the number of hours used for this the visit.

Service Date: Enter the date the visit.

Time of Day: Enter the time of the appointment, for multiple visits on one date of service use separate lines.

Provider: Enter the name, title, and discipline of the individual providing the service.

SAMPLE:

Individuals Presentat Visit / Hours Used / Service Date / Time of Visit / Provider
Mother-Name (30), Father-Name (30), Brother-Name (8), Sister-Name (9), COS-Name (21) / 2 / 11/11/09 / 9-11 am / Pat Doe, PhD, Clinical Psychologist
Mother-Name (30), Sister-Name (10), COS-Name (21) / 1 / 01/06/10 / 9-10 am / Pat Doe, PhD, Clinical Psychologist

Civil Code Section 1798.17 provides that the individual will be notified of the intended purpose and use of personal information being collected. Information on this document will be used exclusively by the Department of Health Care Services and affiliates of the Partners for Children program for the purposes of monitoring and providing quality services to PFC participants.

Agency: / County: / Page:
Participant: / CCS#: / Date Services Started:
Birth Date: / Medi-Cal #: / Date of Death:
Individuals Present at Visit / Hours Used / Service Date / Time of Visit / Provider
Page Total:

MC2359 (1/10)