Encounter Form

"*" indicates required fields

Name*

Date of Session:*

Time In:*

Time Out:*

Service Type:*

Intake Assessment

Medication Check

Psychiatric Evaluation

Individual Session

Family Session with Client

Family Session without Client

I certify that the information shown on this invoice is true, correct, and accurate. I understand that payment and satisfaction of this claim will be from federal and state funds, and that any false claims, statements of documents, or concealment of material facts, may be prosecuted under applicable federal and state law.

Provider MA#: 100760841-0003

Client Signature:*

Date*

Phone

This field is for validation purposes and should be left unchanged.

Encounter Form

Stay connected with ACE