Submit this document to: Crime Victims Compensation Program CVCP TREATMENT Department of Labor & Industries REPORT: FORM V Post Office Box 44520 Olympia, Washington 98504-4520 This form must be submitted by the 51st session for adults/61st session for child. Prreneauthorization for payment of additional sessions, up to 70 sessions for adults/80 sessions for children is contingent on the detail provided in this form. NOTE: Use this form for additional 20 sessions increments beyond 70/80 sessions. Bill Procedure Code 0126C 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 Covers (from 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 4 of1 gePa 004-2 1vre 5 rmfo, rtporet entmrea tpvc c)FPDF( 000-408-080F >>>> 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 V 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 V 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 V Page 4 of 4 Rev 1/13/04