Exhibit B Progress Report CSO-1139A.doc
DOC document 77 KB Posted
- Attached to
- Master Agreement AZ|CTR064216
- Contract number
- CTR064216
- Issued by
- Arizona
About this file
This document is a monthly progress report form (CSO-1139A) issued by the Arizona Department of Child Safety (DCS) for tracking counseling and day support services. The form is designed for contract providers and therapists to document service delivery, client progress, and appointment details for DCS-funded counseling and support services. The document outlines instructions for completion and emphasizes non-discrimination policies under various federal civil rights acts.
The report captures comprehensive service information including appointment summaries, session types (individual, family, group), number of sessions, client and family functioning, treatment plan updates, and reasons for potential service discontinuation. While no specific contract pricing or renewal terms are detailed in this document, it serves as a standardized reporting mechanism for tracking client services, therapist interactions, and treatment progress within the DCS counseling and support services program. The form requires original signatures and is intended to be submitted monthly to the assigned case manager, with a copy retained in the client's case record.
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Text version
FW-212 (10-06) – Page 1 CLIENT’S NAME (Last, First, M.I.)
ADD BLANK CONTRACTOR - STATUS RPT
CASE MANAGER’S NAME
REFERRING DEPARTMENT CASE MANAGER
CSO-1139A (9-14)
FW-212 (7-12)
ARIZONA DEPARTMENT OF CHILD SAFETY
FORMCHECKBOX
MONTHLY PROGRESS/ FORMCHECKBOX
DISCONTINUATION OF SERVICES REPORT
FOR DCS FORMCHECKBOX
COUNSELING/ FORMCHECKBOX
DAY SUPPORT SERVICES
STATUS REPORT (MO. & YR)
GOTOBUTTON Instructions View Instructions CLIENT’S NAME (Last, First, M.I.)
ADD BLANK CONTRACTOR - STATUS RPT
CHILD SAFETY REPRESENTATIVE’S NAME
REFERRING DEPARTMENT CASE MANAGER
APPOINTMENT SUMMARY
| NAME (First, Last) |
| DATE OF SCHEDULED |
APPOINTMENTS
(Circle Date Attended)
*REASON
FOR MISSED
APPOINTMENTS
**TYPE OF
SESSIONS
NO. OF SESSIONS
TO DATE
| I |
| F |
| G |
| NS |
FORMCHECKBOX
CC
FORMCHECKBOX
TC
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
ADD COLUMN
| FORMCHECKBOX |
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
FOR EXPLAN
| FORMCHECKBOX |
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
| FORMCHECKBOX |
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
| FORMCHECKBOX |
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
FORMCHECKBOX
*NS = No show; CC = Client cancelled; TC = Therapist cancelled
** I = Individual; F = Family; G = Group
PROGRESS (or lack of) TOWARD GOALS AS RELATED TO THE SERVICE (treatment) PLAN
(Please include symptoms and progress realted to underlying trauma)
CHANGES IN THE CLIENT AND FAMILY’S FUNCTIONING AND DEVELOPMENT
OTHER SIGNIFICANT CLIENT AND FAMILY INFORMATION
REVIEW AND UPDATE OF TREATMENT PLAN INCLUDING TYPE AND FREQUENCY OF THERAPY AND CHANGES IN THE TREATMENT PLAN
RECOMMENDATIONS/COMMENTS
REASON(S) FOR DISCONTINUATION OF SERVICE(S), IF APPLICABLE
ADD LINE FOR PROVIDER TO PRINT NAME, LICENSE/TITLE
PROVIDER/THERAPIST’S SIGNATURE
Original Signature Required!
DATE
See reverse for EOE/ADA/LEP/GINA disclosures.
MONTHLY PROGRESS/DISCONTINUATION OF SERVICES
REPORT FOR DEPARTMENT OF CHILD SAFETY (DCS) COUNSELING/DAY SUPPORT SERVICES
A. Purpose: To report and document the provisions of DCS counseling and/or day support services for eligible clients;
To facilitate planning;
To document discontinuation of counseling and/or day support services and reason(s) for this action.
B.
Completion: This form is completed monthly by the contract provider/therapist for each client receiving DCS funded counseling services and/or DCS funded day support services.
All items are self-explanatory except:
REASONS FOR MISSED APPOINTMENTS: Indicate, by category, the number of missed appointments during the reporting period. Codes are indicated on the form.
TYPE OF SESSIONS: Check all that apply for each client. More than one box may be checked.
NUMBER OF SESSIONS: Indicate the total number of times the client has been seen for counseling/day support since the service began.
Information provided in the remaining items must relate to each client listed in the appointment summary.
Include discussion of client’s motivation and rapport with therapist, as appropriate.
C.
Routing: The original is sent to the assigned case manager. The provider retains a copy.
D. Retention: A copy is retained in the case record until the record is destroyed.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for department services is available upon request. • Ayuda gratuita con traducciones relacionadas con los servicios del departamento está disponible a solicitud del cliente.
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