Monthly Summary Report

MONTHLY SUMMARY (FOR REFERRAL SOURCES/CAREGIVERS)

Consumer Name: Parent/Caregiver Name: Date of Report: Service Delivered: IFI TEAM Services

CORE Services

Wrap Around Services

Referral Source/Agency: _________________________/_________________________________ Signature of Staff/Title:

______________________________________________ ______________________________________________ ______________________________________________

DSM IV Diagnosis AXIS I (Primary):

AXIS I (Secondary):

Name of Psychiatrist & last date seen? List Medication 1. 2.

Dosage

Medication Compliance Issues? (If yes, please specify IN BOX): None

Frequency

Yes

Not on medication

No

N/A

Current GOAL(S):

SUMMARY & RECOMMENDATIONS Overall Behavior(s) of Consumer (at home, school, peers, and community; Mental Status):

Interventions Implemented by Staff:

Responses and Progress Made To the Interventions:

1 of 2 Jireh Counseling And Consulting Services, Inc./ June 2008

Changes Made in Tx Plan and/or Intensity in Services:

Risks & Concerns/Barriers Observed:

Plans To Continue Services:

Community Resources/Support and Linkages Made:

Invitations offered by referral source or caregiver to panels, court hearings, FTM’s, MDT’s, SST Meetings, Other? Yes No N/A Attended panels, court hearings, FTM’s, MDT’s, SST Meetings, Other?

Yes

No

N/A

(Please specify or explain below):

Supervisor’s Signature/Credentials:__________________/___________ Printed Name:

2 of 2 Jireh Counseling And Consulting Services, Inc./ June 2008

Date Signed: ___________