Submit this document to: Crime Victims Compensation Program CVCP TREATMENT Department of Labor & Industries REPORT: FORM IV Post Office Box 44520 Olympia, Washington 98504-4520 This formmu st be submitted by the 31st session for adults/41st session for ch Prildreen. authorization for payment of additional sessions up to 50 sessions for adults/60 sessions for children, is contingent on the detail pro. vided in this form Bill Procedure Code 0125C For This Report. Victims Name Cvcp Claim Number Family Members Name (if counseling is for a family member of a sexual assault or homicide victim) Date treatment began Time Period this Report Coversfr (om month/day/yearto month/day/year) Date Form Completed Clinicians Name Clinicians Provider Number (if known) Number of sessions to date Clinicians Address Clinicians Phone Number ( ) City State Zip+4 Please review the CVCP guideline 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) What were the diagnoses at treatment onset? Axis I: Axis II: Axis III: Axis IV: Axis V/Current GAF: Highest GAF past Year: Turn page to continue 4of1 eagP 0420-1 ve r4 rmfo, ortept rentmea trpccv )FPDF( 000-380-008F >>>> 22) What are the current diagnoses (if different from those listed above)? Axis I: Axis II: Axis III: Axis IV: Axis V/ Current GAF: Highest GAF past year: 3) Request for extended sessions (Complete either A, B or C, whichever is applicable) A. Substantial progress toward treatment goals has been made. Explain: Please explain the proposed plan for treatment and number of sessions you are requesting. Please also list who, in addition to the victim, you expect to include in treatment sessions e.g., parent(s), significant others. Turn page to continue FORM IV Page 2 of 4 Rev 1/13/04 >>>> 3 B. Partial progress toward treatment goals has been made. Explain: Please explain the proposed plan for treatment and number of sessions you are requesting. Please also list who, in addition to the victim, you expect to include in treatment sessions e.g., parent(s), significant others. Turn page to continue FORM IV Page 3 of 4 Rev 1/13/04 >>>> 4 C. Little/no progress toward treatment goals has been made. Explain: Please explain the proposed plan for treatment and number of sessions you are requesting. Please also list who, in addition to the victim, you expect to include in treatment sessions e.g., parent(s), significant others. FORM IV Page 4 of 4 Rev 1/13/04