Exhibit E ADJC Verification of Juvenile Services-Clinical-Counseling.doc

The document is an official verification form (Exhibit E) from the State of Arizona Department of Child Safety (ADJC), specifically from the Office of Procurement located in Phoenix. The form is designed for documenting juvenile services, specifically psychiatric, psychological, and counseling/consultation services provided to individual juveniles by contracted service providers.

The verification form is structured to capture critical service delivery details, including the contractor's name and contact information, the juvenile's name and ADJC identification number, type of service provided, service dates, start and end times, and requires signature verification by the counselor or therapist. The form emphasizes confidentiality by mandating that one form must be completed per juvenile, and serves as a formal certification of services rendered, with space for the contractor's authorized signature and date of service confirmation.