Submit this document to: Crime Victims Compensation Program Department of Labor and Industries PO Box 44520 Olympia WA 98504-4520 CVCP TERMINATION REPORT: FORM VI This form must be submitted within 60 days of the client's last session and you are no longer conducting treatment. Include a complete description of the client's diagnosis at the time of termination. This information will assist the CVCP should the client submit a reopening application at a later date. Bill Procedure Code 0127C For This Report. Victim's Name Family Member's Name (if counseling is for a family member of a sexual assault or homicide victim) Time Period this Report Covers (from month/day/year to month/day/year) Clinician's Name Clinician's Address Street City State Clinician's Provider Number (if known) CVCP Claim Number Date Treatment Begun Date Form Completed Number of sessions to date Clinician's Phone Number ( ) ZIP+4 Does your patient have insurance other than CVCP? If so what insurance is available____________________________ It is your responsibility to verify your patient's insurance coverage and ensure its rules are being followed. Please review the CVCP guidelines 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) Date of last session: ___________________________________ 2) Diagnosis at the time client stopped treatment: Turn page to continue F800-085-000 CVCP Termination Form IV 6-2011 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 3) Reason for termination (check all that apply): Current goals achieved Client choice to terminate treatment Therapist choice to terminate treatment Parent/guardian choice to terminate treatment Client relocated Client unavailable Client referred to other services Other _____________________________ F800-085-000 CVCP Termination Form IV 6-2011 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com