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 document is designed to track and verify services provided by contracted clinical service providers to DCS clients, with the department's procurement office located in Phoenix, Arizona.

The form serves as a service documentation record, requiring detailed information including contractor name and contact details, client name and participant ID, type of clinical service provided (such as counseling, psychiatric, psychological, or consultation), service dates, start and end times, and requiring both client and contractor signatures. The form emphasizes confidentiality by mandating that one form must be used per DCS client and maintained within the client's file. The document is structured to provide a professional, standardized method for tracking and verifying clinical services rendered to children and families under the Department of Child Safety's care.