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EAN Summary of Treatment Progress This Summary of
Treatment Progress form is to be completed and faxed to EAN for health plan
members of the following employers: Client Name:_______________________________________________________DOB:_______________ 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 ________________________________________________________________________________________________________________________________________________________________________________________ Have you addressed the
plan limit with the client and how best to use those sessions according to
treatment goals?________ If the client will need
continued treatment beyond their plan limits, what plan have you developed
with him or her for _________________________________________________________________________________________________________________________________________________________________________________________
Return Summary of
Treatment Progress to EAN before the next Request for Additional
Services by mail or fax to: |