36C24118Q0304-00001003.pdf
PDF 516 KB Posted
- Attached to
- Farmington Readjustment Counseling Services
- Solicitation number
- 36C24118Q0304
About this file
36C24118Q0304 00001 Quarterly request_COTR.pdf
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C24118C0073-000.docx | DOCX document | |
| 36C24118Q0304-00001001.pdf | ||
| 36C24118Q0304-00001000.docx | DOCX document | |
| 36C24118Q0304-00001004.pdf | ||
| 36C24118Q0304-00001002.pdf | ||
| 36C24118Q0304-001.pdf | ||
| 36C24118Q0304-000.docx | DOCX document |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Fee Contract Quarterly Request For Additional Services
Veteran Name: Number: Date:
1. What issues or problems have been addressed in the last quarter?
2. What new problems or issues have become the focuses of treatment in the last quarter?
3. What will be the focus of treatment for the next quarter and what results do you expect to achieve during that time?
4. With what have you consulted about this veteran?
Name Date
a. Vet Center Staff
b. Prescribing Physician
c. Other
5. Number of Sessions requested:
Individual Group Family
6. Number of Sessions approved
Individual Group Family
COTR Signature
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
| Date: |
| Veteran Name: |
| Number: |
| undefined_2: |
| Text38: |
| Check Box46: Off |
| Check Box47: Off |
| Check Box48: Off |
| Check Box49: Off |
| Text50: |
| 0: |
| 1: |
| 2: |
| 3: |
| Family: |
| Individual_2: |
| Group_2: |
| Text43: |
| Text44: |
| Text45: |
| Text39: |
| undefined: |
| Name: |
| Date_2: |
File details come from the government source that posted it.