Exhibit E Progress Report CSO-1139A.doc

CSO-1139A (9-15) – Page 2

CONTRACTOR

REPORTING PERIOD

Monthly Report FORMCHECKBOX Discontinuation of Services for DCS: FORMCHECKBOX Counseling FORMCHECKBOX Day Support Services

CASE NAME (Last, First, M.I.)

CASE ID NO.

AUTHORIZATION PERIOD

REFERRED BY / TITLE

PHONE NO.

DEPARTMENT

APPOINTMENT SUMMARY

Participant's Name (First, Last) and ID No.

Scheduled Appointment Date and Time

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*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 related to underlying trauma):

Changes in the client and family information:

Other significant client and family information:

Review and update of service/treatment plan, including type and frequency of therapy and changes in the service/treatment plan:

Therapeutic areas of concern:

Recommendations / comments:

Reason(s) for discontinuation of service(s), if applicable:

NAME OF SERVICE PROVIDER (Please print)

LICENSE / TITLE

PROVIDER/THERAPIST’S SIGNATURE (Original signature required)

DATE

INSTRUCTIONS

Return to Form

A. PURPOSE:

1. To report and document the provisions of ADCS counseling and/or day support services for eligible clients;

2. To facilitate planning;

3. 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 ADCS-funded counseling services and/or ADCS-funded day support services.

C. ITEM EXPLANATIONS:

1. REASONS FOR MISSED APPOINTMENTS: Indicate by category (NS = No-show, CC = Client cancelled, TC = Therapist cancelled) the number of missed appointments during the reporting period, with an explanation of circumstances.

2. TYPE OF SESSIONS: Indicate the type of session (I = Individual, F = Family, G = Group) for each appointment (more than one box may be checked).

3. NUMBER OF SESSIONS: Indicate the total number of times the client has been seen for counseling/day support per type of session since the service began.

4. Information provided in the remaining items must relate to each client listed in the appointment summary.

5. Include discussion of client's motivation and rapport with therapist, as appropriate.

D. ROUTING: The original is sent to the assigned ADCS Child Safety Specialist. The provider retains a copy.

E. 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, call 602-255-2500; TTY/TDD Services: 7-1-1. • Free language assistance for Department services is available upon request.