Encounter Form

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Name*

Date of Session:*

Time In:*

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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

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Encounter Form

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