DELAWARE HEALTH & SOCIAL SERVICES
DIVISION OF DEVELOPMENTAL DISABILITIES SERVICES
COUNSELING APPOINTMENT INFORMATION RECORD
Name:
MCI #:
Date:
Is this an (check one): Initial Appointment
or
Return Visit
1.
Presenting problem:
2.
Current findings:
3.
Proposed Treatment Plan (length, frequency and number of visits requested): Initials
Next Appointment:
Therapist Signature & Title
DELAWARE HEALTH & SOCIAL SERVICES
DIVISION OF DEVELOPMENTAL DISABILITIES SERVICES
COUNSELING APPOINTMENT INFORMATION RECORD
Name:
MCI #:
Date:
Is this an (check one): Initial Appointment
or
Return Visit
1.
Presenting problem:
2.
Current findings:
3.
Proposed Treatment Plan (length, frequency and number of visits requested): Initials
Next Appointment:
Therapist Signature & Title