Exhibit C DCS Unit Consult Log and Verification of Client Services-Clinical-Cnslg.doc

This document is an Exhibit C form from the Arizona Department of Child Safety (DCS), specifically a Unit Consultation Log and Verification of Services form for Clinical/Counseling Services. The form is designed for documenting client service details and is intended to be used by contractors providing mental health services to DCS clients, with the document originating from the Office of Procurement located in Phoenix, Arizona.

The form serves as a service verification document requiring detailed documentation of clinical services, including the contractor's name and contact information, client details, type of service provided (counseling, psychiatric, psychological, or consultation), service dates, start and end times, and client and counselor signatures. The document emphasizes confidentiality by stipulating that one form must be completed per DCS client and maintained in the client's file. The form provides a mechanism for tracking and certifying the delivery of clinical services to children and families involved with the Arizona Department of Child Safety.