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Client: Curtis Harrison DOB: October 7, 1983

Completed Tasks:


Amount Paid: [1244] Tender: [1246] Ck#[1248]


Date of Service: January 7, 2016 Appointment Time: 9:30 AM Arrival Time: [1222] Check-in Date: January 7, 2016 Check-in Time: 


POS: Clinician: Joseph L. Follette, Jr., M.Div., M.S., LMFT Purpose: Counseling


Other family members: 

Aware of fee: Yes


Contact Updates

Phone: Email:  Address:  City, State, Zip: 


Insurance Company Insurance:   ID Number: Group Number Insurance:  Authorization: 


Subjective: 

Objective: 

Observations: 

Diagnosis Version: 

1-[1230] 2345678910

Assessment Note: 

Procedures:

1– 2– 3– 4– 5678910

Procedure Notes:

Treatment Goals:

Treatment Plan:

Instructions/Followup:


Documents: