ATTACHMENT 5
Site Coordinator’s Sample Section Abstraction Form Used to Identify Persons Being Treated for PTSD and their Associated PTSD Clinician and Clinician Supervisor
|
Clinician Name |
Clinician’s Degree Type (i.e., MS, PhD) |
Type of Treatment Clinician provides |
Is the Clinician Licensed (yes/no) |
Clinician’s Supervisor Name |
Patient Name |
Patient Therapy Start Date |
# of Sessions Patient Expected to Complete |
Last Session Number Completed |
Patient Home Address |
Notes/Comments |
Eg. |
John Smith |
PhD |
CPT |
Yes |
Joe Somebody |
Jane Smyth |
08/1/2013 |
12 |
3 |
555 Fifth St. #5 Washington, DC 20001 |
On vacation from 12/22/13 -01/05/2014 |
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Site Coordinator’s Sample Section Abstraction Form Used to Identify Persons Being Treated for PTSD and their Associated PTSD Clinician and Clinician Supervisor
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | NPUNUKOLLU |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |