5. Intake Interview Demographics Referral History of Present Illness Medical History Social/Family History Mental Status Exam Diagnostic Impression
6. Report Format Demographics Referral History of Present Illness Medical History Social/Family History Mental Status Exam Tests Administered Test Results Diagnostic Impression Summary Recommendations Closing remarks
7. Treatment Plan Demographics Diagnosis Treatment Plan Short Term Goals Long Term Goals Expected Level of Functioning at Discharge Total Number of Sessions Required Number Seen To Date Number Requested to Complete Treatement Frequency of visits requested