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Initial Treatment Plan (Counseling) Form. This is a Idaho form and can be use in Crime Victim Workers Compensation.
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Tags: Initial Treatment Plan (Counseling), Idaho Workers Compensation, Crime Victim
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
IDAHO CRIME VICTIMS COMPENSATION PROGRAM
:
Initial Treatment Plan Calendar No.
:
CV#:
Client’s Name: JUDICIAL SUBPOENA
Plaintiff(s)
Parent/Guardian:
Tax I.D. #:
-against:
Therapist’s Name:
Credentials:
License #:
:
Name of Supervising Therapist (if applicable):
:
Are you a provider under these programs?:
Defendant(s)
! Medicaid
! Medicare
! TriCare :
......................................................
! Blue Cross
! Indian Health Services
! Blue Shield
Do you bill on a sliding fee scale?
! Yes
! No
Other
Rate billed for this client?
THE PEOPLE OF THE STATE OF NEW YORK
Indicate what sources of payment are available to the client:
TO
Date treatment began:
Number of sessions to date:
1. Please describe the presenting symptoms or conditions for which the client is seeking treatment.
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
County client have a history oflocated at mental health treatment? ! Yes ! No
2. Does the of
previous
in room
, on the
, 20
, at
o'clock in the
noon, and at treatment
If so, please indicate approximate day of of treatment, reason for the treatment, duration of the any recessed
dates
or adjourned date, to testify and give evidence as a witness in this action on the part of the
and, the results of the treatment.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
3. Was there prior victimization or psychological trauma? ! Yes ! No
Witness, Honorable
Court in
County,
If so, please describe.
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name the
4. Please provide a brief description of the crime as related to you, including the source ofbelow)
information (i.e. client, parent or other).
Attorney(s) for
5. Please describe any pre-existing conditions that may affect treatment, including any recent
psychological stressors, and to what extent these conditions may have been Address
Office and P.O. exacerbated by the crime.
C:\formdocuments\Initial Treatment Plan - Counseling (8/01)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
6. Indicate percentage of treatment resulting from pre-existing conditions.
%
:
Calendar No.
7. Describe the symptoms/conditions you are treating that are a direct result of the crime.
:
Plaintiff(s)
-against-
JUDICIAL SUBPOENA
:
8. Indicate percentage of treatment resulting from crime-related conditions.
:
(Percentages from #6 and #8 should equal 100%)
%
:
9. Describe the client’s support system and how it will be involved in the treatment.
Defendant(s)
:
......................................................
10. DSM PEOPLE OF THE STATEthe code and the descriptor).
THE IV Diagnosis (indicate OF NEW YORK
Axis I:
Axis II:
TO
Axis III:
Axis IV:
Axis V:
GREETINGS:
11. Estimated duration of treatment:
from
to
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
12. Estimated cumulative cost of treatment:
$
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
13. List adjourned date, to testify and give evidence as a witness in this action on the part of the projected dates to
or below the treatment goals for this client, give specific behavioral measures and
achieve these goals.
Symptom/Condition
Treatment Goal
Method
Target Date
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
14. I certify that the information provided in this treatment plan is true and accurate. I acknowledge
that if the alleged offender is convicted, the Program will request the criminal court to order the alleged
Attorney(s) on
offender to pay restitution to reimburse the Program for expenses paid for behalf of the victim. I further
acknowledge that this document may be submitted as evidence and that I may be called to testify
regarding the mental health treatment outlined in this plan.
Signature of Therapist
Office and P.O. Address
Supervisor’s Signature (if applicable)
C:\formdocuments\Initial Treatment Plan - Counseling (8/01)
Date
Date
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com