Exhibit E ADJC Verification of Juvenile Services-Clinical-Counseling.doc
DOC document 41 KB Posted
- Attached to
- Master Agreement AZ|CTR064216
- Contract number
- CTR064216
- Issued by
- Arizona
About this file
The document is an Exhibit E Verification Form from the State of Arizona Department of Child Safety, specifically from the Office of Procurement located in Phoenix. This form is designed for documenting juvenile services, specifically psychiatric, psychological, and counseling/consultation services provided to individual juveniles.
The form requires detailed documentation of services, including contractor information, juvenile identification, type of service provided, service dates, start and end times, and requires a signature from the counselor or therapist certifying service delivery. The form emphasizes confidentiality by mandating that one form must be completed per juvenile. While specific contract pricing, terms, or service amounts are not detailed in this exhibit, the document appears to be a standardized tracking and verification mechanism for juvenile service providers working with the Arizona Department of Child Safety.
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Text version
EXHIBIT E
State of Arizona
Department of Child Safety
Office of Procurement
3003 N. Central St, 20th Fl.
Phoenix, AZ 85012
ADJC VERIFICATION OF JUVENILE SERVICES
PSYCHIATRIC, PSYCHOLOGICAL AND COUNSELING/CONSULTATION SERVICES
| CONTRACTOR NAME |
| ADDRESS |
| CITY |
| STATE |
| ZIP |
| JUVENILE NAME (PRINTED) |
| ADJC “K” NUMBER |
| TYPE OF SERVICE PROVIDED |
| PHONE NUMBER |
| DATES OF SERVICE |
| JUVENILE SIGNATURE |
| START TIME |
| END TIME |
FOR REASONS OF CONFIDENTIALITY, ONE FORM PER JUVENILE MUST BE USED.
I HEREBY CERTIFY THAT SERVICES HAVE BEEN PROVIDED TO THE JUVENILE LISTED ABOVE.
PRINT NAME OF COUNSELOR or THERAPIST
CONTRACTOR OR AUTHORIZED SIGNATURE DATE
File details come from the government source that posted it. Updated .