PROB 46 (Rev. 06/10) MONTHLY TREATMENT REPORT 1. PROGRAM NAME: 3. CLIENT NAME: 5. PHASE NO. 5a. TIME IN PHASE: 1a. PROVIDER NAME: 3a. PACTS NO. 6. PRETRIAL CLIENT: This form must be completed and submitted with each monthly billing. Additional sheets may be used. 2. DATE OF CURRENT TX PLAN (ATTACH REVISIONS): 4. FOR PERIOD COVERING: 7. CLIENT EMPLOYED: 9 Yes 9 No a. Date b. Service (Name & No.) c. Length of Contact 9 Yes 9 No 9 Student 9 Other e. Copay (amount collected) 8. CONTACTS SINCE LAST REPORT d. Comments (No Shows, Tardiness, Issues Addressed) 9. URINE TESTING RECORD DATE COLLECTED Scheduled Yes No Sample Not Tested Insuf. Qty. Stall Drug Use Admitted No Yes (specify drug) COLLECTED BY SPECIAL TESTS REQUESTED TEST RESULTS (Positive/Negative) Copay (amount collected) 10. COMMENTS REGARDING CLIENT'S TREATMENT PROGRESS a. Describe the treatment goals addressed this month (9 Met 9 Not Met): 9 Negative): b. Describe any steps taken by the client this month toward these goals (9 Positive c. Describe any obstacles or setbacks the client encountered this month: d. Describe one unique way the PO/PSO can assist/support the client in treatment over the next month: e. If continued treatment is recommended, discuss the plan for next month (9 Recommended 9 Not Recommended): f. Discuss your observations of the client's behavior and commitment to treatment (9 Positive 9 Negative): g. Comments: h. Overall Progress: 9 Acceptable 9 Unacceptable DATE SIGNATURE OF COUNSELOR DISTRIBUTION: ORIGINAL CONTRACTOR American LegalNet, Inc. www.FormsWorkFlow.com The vendor shall: Complete a Monthly Treatment Report utilizing the attached format. (See Attachment J.4) Vendors are to submit one MTR that combines information regarding counseling and psychiatric services (if applicable) This form cannot be altered. However, additional sheets may be used. a. Include a second page to the MTR that includes a five axis DSM diagnosis, a list of all psycho-tropic medications prescribed, and includes whether offender has Medi-cal, medicare, SSI, SSDI or any other funding source. b. Ensure that diagnosis listed on the MTR accurately represents diagnoses provided by clinical and psychiatric staff. If there are discrepancies, these are to be explained on the MTR. American LegalNet, Inc. www.FormsWorkFlow.com