Employee Assistance Network

Summary of Treatment Progress
This Summary of Treatment Progress form is to be used for health plan members with the following employers:  Transylvania Regional Hospital; Sisters of Mercy; and CarePartners Health Services

This document will be used to determine if authorization for continued services is clinically necessary according to the limits of the health plan benefit.

Provider Name & Phone #:______________________________________________________________

Date form completed:_____/____/_____

Client Name:____________________________________________Date of Birth:____/____/______

Current Diagnosis:  Axis I:_______                Axis II:________

Beginning GAF:_____                                      Current GAF:______

Date of Initial evaluation and the number of sessions provided by you since that date:____________/_____

Current and projected frequency of appointments with the client:__________________________________

Current status of suicidal/homicidal ideation or plan and substance use/abuse:_______________________

__________________________________________________________________________________________________________

History of Hospitalizations:______________________________________________________________

Is the client utilizing services from another provider through insurance, such as a psychiatrist who may have also used and billed for services within the plan year?  If so, who is the other provider and how are you coordinating services with that provider?_______________________________________________________________

____________________________________________________________________________________

What adjunct therapies might be beneficial in helping the client reach treatment goals and what steps have been taken to connect the client to those services?_____________________________________________

___________________________________________________________________________________

What is the projected date for conclusion of services?__________________________________________
How is treatment preparing the client for the completion of services?_______________________________

___________________________________________________________________________________

Return Summary of Treatment Progress form to Employee Assistance Network BEFORE the next Request for Additional Services by mail or fax to:                            EAN, 417 Biltmore Ave, Suite 3-C, Asheville NC  28801      FAX:  828.258.1336